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NCPD Article

Wellness Coaching: An Intervention to Increase Healthy Behavior in Breast Cancer Survivors

Daniela L. Stan
Susanne M. Cutshall
Tammy F. Adams
Karthik Ghosh
Matthew M. Clark
Kaisa C. Wieneke
Esayas B. Kebede
Bonnie J. Donelan Dunlap
Kathryn J. Ruddy
Jennifer K. Hazelton
Alissa M. Butts
Sarah M. Jenkins
Ivana T. Croghan
Brent A. Bauer
CJON 2020, 24(3), 305-315 DOI: 10.1188/20.CJON.305-315

Background: Regular physical activity after breast cancer diagnosis improves survival rates and quality of life (QOL). However, breast cancer survivors rarely meet guidelines for recommended levels of physical activity. Wellness coaching interventions (WCIs) have improved exercise and health behaviors in other patient populations.

Objectives: This study assessed the feasibility and effectiveness of WCIs for increasing physical activity in breast cancer survivors; secondary measures included changes in dietary habits, weight, and QOL.

Methods: 20 obese or overweight breast cancer survivors who recently completed active breast cancer treatment were recruited into a single-arm, 12-week WCI pilot feasibility study. The intervention was comprised of one in-person wellness coaching visit followed by four telephone calls over 12 weeks and 12 weekly emails containing wellness recommendations.

Findings: Significant improvements from pre- to postintervention were seen in physical activity level, dietary habits, and in some aspects of QOL. Forty percent of participants achieved the 3% postintervention weight-loss goal, but this was not sustained at 30 weeks.

Earn free contact hours: Click here to connect to the evaluation. Certified nurses can claim no more than 0.75 total ILNA points for this program. Up to 0.75 ILNA points may be applied to Oncology Nursing Practice OR Survivorship OR Psychosocial OR Health Promotion OR Care Continuum. See www.oncc.org for complete details on certification.

There are currently more than three million breast cancer survivors in the United States, and their numbers are expected to increase by another million by 2030 (Miller et al., 2019). Healthy lifestyle habits, particularly regular physical activity, have been shown to be positively correlated with breast cancer survival (Holick et al., 2008; Holmes et al., 2005). Guidelines recommend that cancer survivors engage in at least 150–300 minutes of moderate activity weekly and include at least two days per week of strengthening exercises (Campbell et al., 2019; National Comprehensive Cancer Network, 2019; Rock et al., 2012). Other factors associated with positive breast cancer outcomes include a low-fat diet (Chlebowski et al., 2006), a diet rich in fruits and vegetables (Pierce et al., 2007), and having a positive quality of life (QOL) (Epplein et al., 2011). In addition, overweight women and those who gain weight after cancer diagnosis (50%–96% of patients) (Vance et al., 2011) have a higher rate of recurrence and mortality from breast cancer (Chan et al., 2014; Chlebowski et al., 2002; Playdon et al., 2015; Vance et al., 2011). These outcomes may be related to the negative microenvironment associated with excess adiposity, such as increased proinflammatory markers, increased estrogen secretion, and hyperinsulinemia, or underdosing of chemotherapy and radiation therapy in obese patients (Picon-Ruiz et al., 2017). Evidence suggests that approximately one-third of women receiving chemotherapy gain weight, and one-third gain weight during the five years of endocrine therapy (Gandhi et al., 2019; Raghavendra et al., 2018). Given the prevalence of weight gain, being overweight, and obesity in this population, effective strategies are needed to help women understand the implications of body weight for their breast cancer prognosis and to help them achieve an ideal body weight.

The development of new models of cancer survivorship care is a priority in oncology (Halpern et al., 2016); wellness interventions are at the core of these models (Rowland, 2008). Clinicians have limited time to address wellness issues; therefore, collaboration with nurse coaches specifically trained to educate and motivate patients on wellness behaviors may help to bridge this gap. Nurses are considered the most trusted role in health care, and nurse coaching is a natural role extension for nurses (American Hospital Association, 2019). Coaching patients is a core competency in patient care and a foundation of nursing practice, but the role of the nurse coach, specifically, is new (Ross et al., 2018). Nurse coaching has been acknowledged by the American Nurses Association since 2012 (Hess et al., 2013).

Health and wellness coaches facilitate and empower patients to develop and achieve self-determined wellness goals and assist patients to use their insight, personal strengths, goal-setting ability, action steps, and accountability toward achieving healthy lifestyle changes (International Consortium for Health and Wellness Coaching, 2018). Nurse coaching is defined as a skilled wellness coaching interaction provided by a RN to the patient for the purposes of promoting health and well-being (Erickson et al., 2016; Hess, 2011; Hess et al., 2013). Nurse coaching is grounded in the principles and core values of holistic nursing.

Coaching has been shown to improve mental, physical, emotional, and spiritual well-being in healthcare employees (Clark et al., 2014; Mettler et al., 2014), in people with chronic diseases (DeJesus et al., 2018; Dorough et al., 2014; Kivelä et al., 2014), and in the general population (Clark et al., 2016; Leahey et al., 2014). Other small studies of wellness coaching in breast cancer survivors showed potential benefits for weight, physical activity, and healthy diet choices (Lawler et al., 2017; Park et al., 2012).

In the past few years, nurses have begun to describe the role of the nurse coach and integrate nurse coaches into clinical practice. In an integrative review, Vincent and Sanchez Birkhead (2013) summarized 13 studies analyzing the impact of nurse coaching interventions among patients with various chronic diseases. Eleven of the 13 studies reported significant improvements in treatment adherence, hospital readmission rates, and improved biomarkers. Because of these positive outcomes, the authors concluded that nurse coaching can be an accepted enhancement to standard clinical care (Vincent & Sanchez Birkhead, 2013). Another study evaluated the benefits of nurses coaching patients with chronic obstructive pulmonary disease. Study results indicated improvements in dyspnea, fatigue, emotional function, and QOL (Rehman et al., 2017). From the qualitative evaluation regarding the benefits of coaching in clinical practice, several themes emerged: participants (a) viewed conversations as motivating and encouraging, (b) showed increased accountability, and (c) gained awareness of health and health behaviors.

A study of nurse coaching for patients with diabetes mellitus living in rural communities reported significantly higher self-efficacy scores in the intervention group and slightly higher satisfaction (Young et al., 2014). A study by Tiede et al. (2017) used telehealth technology to offer telephone nurse coaching to patients with heart failure. The intervention group reported a significantly higher level of physical activity, lower intake of nonprescribed drugs, and lower levels of stress than the control group. A study by Delaney and Bark (2019) on the experience of holistic nurse coaching among patients with chronic diseases indicated that nurse coaches increased patient self-care abilities and assisted patients with self-management of chronic conditions.

Such coaching among patients with breast cancer could be offered by nurses at a survivorship visit, which occurs after completing active breast cancer treatments (surgery, chemotherapy, or radiation therapy). At the Mayo Clinic in Rochester, MN, a survivorship visit is conducted by an advance practice provider whose role is to finalize the survivorship care plan. The purpose of this article was to examine the feasibility and effectiveness of a nurse wellness coaching intervention (WCI) coordinated with a cancer survivorship visit among overweight or obese breast cancer survivors who have recently completed active breast cancer treatments.

Methods

This was a single-arm pilot study of patients receiving care at a breast cancer survivorship visit in a breast diagnostic clinic at a tertiary care center. The survivorship visit occurred 2–10 months after the completion of active breast cancer treatments. The study was approved by the Mayo Clinic Institutional Review Board, and participants provided written informed consent.

Participants

Women were eligible for the study if they were English-speaking breast cancer survivors, aged 18 to 70 years, treated surgically at the Mayo Clinic, and had a body mass index (BMI) of 25 kg/m2 or higher, exercised less than 150 minutes per week, and had access to telephone and email services. Potential participants were identified from the list of appointments in the survivorship clinic and were contacted by the study coordinator. A total of 56 patients with breast cancer were screened, and 43 were eligible for the study. Of the 43 eligible, 21 (49%) were enrolled and, of these 21, 1 withdrew (0.5%). The 20 remaining patients were enrolled after obtaining written informed consent. Mean age of participants was 55 years (range = 39–68 years), mean BMI was 33 kg/m2 (range = 27–51 kg/m2), and 19 were White or Caucasian (see Table 1). Enrollment began in March 2016 and ended in August 2016. The study was completed in March 2017.

Intervention

A screening study visit took place approximately two weeks before the baseline health and WCI study visit, during which participants were given wellness-focused patient education brochures and an electronic scale for home weight tracking.

The WCI consisted of the baseline face-to-face coaching study visit, followed by four coaching telephone calls during the next 12 weeks and 12 weekly reminder and educational emails (see Table 2). The face-to-face visit was delivered by one of two nurses who had been trained in health and wellness coaching. The goal of this visit was to shift the patient’s attention to healthy behaviors on the basis of her strengths and opportunities, to identify personal wellness goals, and to develop an individualized behavioral plan, including a strategy for ensuring accountability. The focus was on regular physical activity and a balanced diet, but other concerns were addressed, such as stress management, sleep habits, strength, and flexibility. Coaches used a visit fidelity checklist to provide a similar structure to coaching visits so the experience could be standardized (see Figure 1).

The four coaching telephone calls took place at weeks 2, 4, 8, and 12, with goals of reviewing patient-identified wellness goals and physical activity plans, recording the frequency of physical activity and healthy dietary changes implemented over the previous week, determining the patient’s perceived level of motivation and confidence, and identifying the next health and wellness goals. An in-person follow-up coaching session was offered, if preferred.

The weekly emails were reminders of the regular exercise and healthy diet goals and included a link every week to a new habit of The 12 Habits of Highly Healthy People (12 for Health, 2020). These habits are part of the Mayo Clinic’s comprehensive wellness program and include physical activity, forgiveness, portion size, preventive healthcare testing, adequate sleep, trying something new, strength and flexibility, laughter, family and friends, addressing addictive behaviors, quieting your mind, and gratitude.

Measurements

The main study outcome was feasibility—recruitment and attrition rate, time spent with the patient by wellness coach, and adherence to the telephone calls. Feasibility was defined as a recruitment rate greater than 50% of eligible patients and an attrition rate of less than 20%. Durations of patient contact considered feasible were 60 minutes for the coaching study visit and 30 minutes per coaching telephone call (total of 120 minutes per patient for the telephone calls). Participation in at least three of the coaching telephone calls was considered adequate adherence.

Implementation, motivation, and confidence with regular physical activity and healthy diet were assessed through one-item linear analog scale assessment (LASA) questions, all using a scale from 0 (lowest) to 10 (highest). These items have been shown to be valid and clinically appropriate (Locke et al., 2007; Singh et al., 2014) and have been used to evaluate patients with cancer (Solberg Nes et al., 2012) and wellness coaching participants (Clark et al., 2014; DeJesus et al., 2018). Patient adherence to regular physical activity and healthy diet were assessed by recording the number of days of regular exercise or adherence to a healthy diet during the previous week (see Figure 2). An increase of 1 point or more on the LASA items was considered a clinically meaningful improvement. Physical activity was assessed at baseline and weeks 2, 8, and 12, and diet was assessed at baseline and weeks 4 and 12.

Weight was measured at the screening and baseline visits and was self-reported at weeks 2, 4, 8, 12, and 30. Before the study was designed, weight trends were reviewed among a randomly selected cohort of patients (n = 52) who attended a survivorship visit and a six-month follow-up visit. This review showed a weight gain of approximately 0.5 kg at six months after the survivorship visit in these 52 patients; on the basis of this finding, a goal of 3% weight loss at 12 weeks in the current study was classified as a significant clinical improvement. Although 5% weight loss is considered clinically significant in obesity studies (Jensen et al., 2014; Swift et al., 2016), these studies often used supervised exercise interventions or severe caloric restrictions and generally had a longer duration than this study. A weight loss of 6 lbs was seen in the intervention arm of a large study of breast cancer survivors, which demonstrated that a low-fat diet is associated with improved relapse-free survival (Chlebowski et al., 2006).

QOL was assessed at baseline and at week 12 using the Functional Assessment of Cancer Therapy–Breast (FACT-B), a multidimensional questionnaire that includes the domains of physical, social, emotional, and functional well-being and a breast cancer–specific subscale (Cella et al., 1993). The FACT-B has shown excellent validity and reliability (Beaulac et al., 2002; Coster et al., 2001).

Study surveys (FACT-B and LASA items) were administered verbally during in-person study visits and telephone visits and electronically through a secure REDCap Survey electronic email link outside of these visits.

Statistical Analysis

For the items assessing physical activity and dietary intake (series of LASA items), the averages at each time point and the average difference from baseline were calculated. The regular physical activity and healthy diet items were summarized similarly (days per week achieving 30 or more minutes of exercise, days per week eating five or more servings of fruits and/or vegetables per day, and days per week eating fast food or junk food).

For the FACT-B assessing QOL, the average at each time point and the average difference from baseline were calculated. For all outcomes, the statistical significance of average change from baseline was assessed with paired t tests. The percentage of participants meeting the American Cancer Society (ACS) guidelines (Rock et al., 2012) for exercise of five or more days per week was compared at each time point versus baseline with McNemar tests (Statistics Solutions, 2019). In any cases of missing data, a last-observation-carried-forward approach was used for imputation, noting that most participants had complete data for each visit. P values less than 0.05 were considered statistically significant, with no correction for multiple testing in this small pilot study. All analyses were performed using SAS, version 9.4, and figures were generated using R.

Results

The mean number of telephone calls per participant was 3.85, which represents a 96% adherence rate. Eighteen women (90%) participated in all four scheduled telephone calls, one had three calls, and one had two calls. Many participants were unavailable during business hours, which required flexibility in the coaches’ schedule for evening telephone calls. The mean initial in-person coaching visit duration was 59 minutes (range = 45–90 minutes), and the mean duration of the telephone calls was 26 minutes (range = 15–50 minutes). On average, the wellness coach dedicated 160 minutes per participant during the 12-week study period.

Physical activity habits (level and frequency) significantly improved from baseline to week 12. The perceived self-reported level of physical activity during the previous week increased from an average of 3.8 on the 10–point scale at baseline to an average of 6.5 at week 12 (p = 0.002). The number of days performing at least 30 minutes of physical activity during the previous week increased consistently from a mean of 3.1 at baseline to 5.2 at week 12 (p = 0.003) (see Table 3). The number of participants meeting ACS guidelines for exercise for cancer survivors was 5 (25%) at baseline, 8 (40%) at week 2 (p = 0.26 versus baseline), 11 (55%) at week 8 (p = 0.06 versus baseline), and 12 (60%) at week 12 (p = 0.02 versus baseline). Self-reported motivation to perform regular physical activity increased from 6.5 to 7.4 (p = 0.11), and the confidence for physical activity improved from 6.6 to 7 (p = 0.4); these increases were not statistically significant.

Most diet habit outcomes improved significantly from baseline to 12 weeks: ability by 2 points (p < 0.001) and confidence by 1.1 points (p = 0.02) (see Table 4). The number of days per week the participants had at least five servings of fruits and vegetables increased from an average of 3.3 at baseline to 4.9 at 12 weeks (average change = 1.6 days; p = 0.03), and the number of days per week eating fast food decreased from an average of 4.2 at baseline to 2.3 at 12 weeks (average decrease = 1.9 days; p = 0.01).

Weight increased from the screening to the baseline visit from a mean of 88 kg to 88.5 kg (0.6% change; p = 0.002) and, thereafter, decreased throughout the intervention period, from a mean of 88.5 kg at baseline to a mean of 87.3 kg at weeks 2 and 4, 87 kg at week 8, and 86.8 kg at week 12 (−2%; p = 0.01). Mean weight increased again to 87.4 kg at week 30 (−1.5% from baseline; p = 0.3). The clinical significance of 3% body weight loss from the baseline weight (on average) was not reached for the entire study population, but eight participants (40%) lost at least 3% of their baseline weight.

The overall QOL (FACT-B total) increased significantly by a mean of 6.3 points (p = 0.01) from pre- to postintervention, mainly driven by increases in physical well-being (mean increase = 2.7 points; p = 0.009) and breast cancer–specific concerns (mean increase = 29 points; p = 0.006) (see Table 5).

Overall, 88% of patients reported that wellness coaching was extremely helpful. Study participants commented on the benefits of the coaching relationship, including emotional support, putting behavior change into action, and accountability.

Discussion

In this study of 20 breast cancer survivors participating in a WCI, the proportion of participants who met the ACS guidelines for physical exercise (Rock et al., 2012) increased significantly from baseline to the end of the intervention (25% to 60%; p = 0.02). Perhaps the most important finding is that the number of days performing at least 30 minutes of physical activity during the previous week increased from a mean of 3.1 at baseline to 5.2 at week 12. Participants also increased their motivation and confidence for exercise. Given the importance of maintaining a physically active lifestyle for breast cancer survivors (Holick et al., 2008; Holmes et al., 2005; Rock et al., 2012), these initial pilot findings warrant further investigation.

This study had a reasonable recruitment rate (49%) and very low attrition (0.5%). The 95% completion rate might suggest that breast cancer survivors are highly motivated to implement lifestyle changes conducive to better cancer outcomes, possibly because of the wealth of resources and publications on breast cancer. It could also be a reflection of the resources used and the individualized nurse coaching–based model of the study.

On average, coaches spent 160 minutes per participant during the 12-week intervention, indicating that the intervention is feasible and only requires moderate resources. Adherence to the telephone calls was very high (96%), although challenges occurred in reaching patients during business hours, and nurses repeated calls to patients to contact them.

Although feasible as a component of nursing clinical practice, incorporation of coaches into practice as standard of care will remain challenging, given that such interventions are time consuming, not routinely covered by medical insurance, and possibly not recognized by providers and patients seeking weight loss and exercise interventions.

Most coaching studies have shown improvements in physical activity levels and weight, but the effects on dietary habits and QOL vary (Cadmus-Bertram et al., 2016; Hawkes et al., 2013). Participants in this study reported improvements in their motivation and confidence for healthy diet changes, number of days eating fruits and vegetables, and days not eating fast food. This study confirmed previous reports of improved eating self-efficacy and healthy eating behaviors, as well as decreases in energy intake, body weight, and BMI derived from coaching in healthy or obese populations (Clark et al., 2016; Shahnazari et al., 2013). In a previous telephone-based WCI, however, dietary improvements in breast cancer survivors did not reach statistical significance (Lawler et al., 2017). This outcome deserves additional exploration because dietary changes substantially affect weight and possibly breast cancer survival (Chlebowski et al., 2006).

Throughout the intervention period, participants had gradual weight loss, reaching a maximum of 2% loss, on average, between baseline and week 12; 40% of participants reached the goal of 3% average weight loss, which was defined as clinically significant. In other wellness intervention studies, average weight loss ranged from 5% during six months (Shahnazari et al., 2013) to 4.4% over 12 weeks (Gabriele et al., 2011) or was reported as 35% of participants losing 5% or more of their baseline weight at six months (Block et al., 2015). In addition, the average weight in this study returned to almost baseline levels at week 30 (18 weeks postintervention), suggesting that weight loss is difficult to maintain without continued or at least prolonged external motivation.

However, this study’s weight loss data should be interpreted in the context of a consistently demonstrated tendency for weight gain after breast cancer treatments (Gross et al., 2015; Vance et al., 2011), including in 52 patients in the practice who demonstrated an average increase of 0.5 kg in the six months after the survivorship visit. Although weight gain has been clearly shown in patients receiving chemotherapy, studies vary regarding weight changes during endocrine therapy. One study suggested a greater than 5% weight gain in 37% of patients after five years of endocrine therapy, which was more likely in premenopausal women and those receiving tamoxifen versus aromatase inhibitors (Raghavendra et al., 2018). In the current study, only three patients had received chemotherapy, and the numbers were too small to compare weight changes between premenopausal and postmenopausal women or by type of endocrine therapy. Future studies targeting weight loss or weight gain prevention in premenopausal breast cancer survivors are warranted. Longer interventions might achieve more sustained habit changes that can be maintained without external intervention, which is the ultimate goal of a coaching intervention.

For participants in this study, overall QOL improved significantly, mainly reflecting improvements in physical well-being and breast cancer–specific concerns. A previous study showed significant benefits in all domains of QOL in healthy employees undergoing a WCI (Clark et al., 2014), although less benefit has been seen in breast cancer survivors—improved mental QOL but not physical QOL (Lawler et al., 2017)—and no effects on QOL in colorectal cancer survivors (Hawkes et al., 2013). The more modest QOL benefits in cancer survivors most likely reflects additional mental, social, and physical stressors resulting from a cancer diagnosis and its treatment adverse effects. This suggests that cancer survivors might benefit from interventions targeted to cancer-related distress incorporated in the WCIs.

Limitations

This study was limited by the small sample size and the lack of a control group, making it difficult to attribute the effects to the intervention versus to the time elapsed since completing treatments, or possibly to the attention effect. In addition, the main outcomes data were patient reported and not objectively measured and, therefore, might be influenced by patient recollection and propensity to please the providers. In addition, study participants were primarily White or Caucasian, so the applicability of these results to more diverse or underserved populations is unknown. The study also did not distinguish between aerobic versus strengthening components of physical activity, given the small sample size. To evaluate compliance with the guidelines for physical activity in cancer survivors, future studies should measure the time spent on aerobic, strengthening, and stretching exercises. Conducting coaching visits was sometimes challenging because of occasional difficulties contacting participants despite a planned call. Also, some participants underwent reconstructive surgery during the study, which affected their physical activity and diet.

Implications for Research

Future studies should include demographically and ethnically diverse breast cancer survivors randomly assigned to coaching versus standard care or to different styles of coaching (e.g., group versus individualized, in-person versus telephone) and undergoing objective monitoring of physical activity, diet, and weight. This would help determine the overall significance of coaching for this population. Cost analysis studies will be needed to justify this additional staffing expense. Health and wellness coaches with a medical background may fit better within current reimbursement models and can guide patients through their medical care.

Implications for Nursing

The results of the study support previous research indicating benefits of coaching, specifically nurse coaching. Although many disciplines have begun to offer health coaching, nurses have been leaders in setting standards and developing a scope of practice for nurse coaching. Several themes were identified in this study: (a) patients need help seeking guidance to navigate life’s challenges; (b) coaching enters a safe, sacred place; and (c) with coaching, patients feel empowered and accountable, develop strategies to access different ways of knowing, find answers within, make health behavior changes, form a new caring relationship with self, and transform to a new approach to life. Nurse coaching remains a way to help patients address and improve health behaviors by providing an approach that honors the patient as an expert and the coach as a facilitator, helping the patient to discover ways of making lasting change. With additional training to enhance coaching competencies, nurses can impact the outcomes of breast cancer survivorship care.

Conclusion

The addition of nurse health and wellness coaching to survivorship visits for patients with breast cancer is feasible, with high recruitment and low attrition rates, and moderate wellness coaching resources. This study resulted in improved physical activity level, dietary intake, and QOL. Additional studies of WCIs are needed to improve overall health and well-being for breast cancer survivors and could potentially improve the patient experience and enhance weight and QOL outcomes over time. Additional research is needed to examine the influence of nurse coaching on health outcomes for breast cancer survivors.

About the Author(s)

Daniela L. Stan, MD, and Susanne M. Cutshall, DNP, APRN, CNS, are both assistant professors of medicine in the Division of General Internal Medicine, Tammy F. Adams, RN, is an educator in the Cancer Education Program, Karthik Ghosh, MD, is the chair of the Division of General Internal Medicine, Matthew M. Clark, PhD, LP, is a psychologist in the Department of Psychiatry and Psychology and a psychologist in the Division of Endocrinology, Diabetes, Metabolism, and Nutrition, Kaisa C. Wieneke, MPH, is the assistant director of employee well-being in the Department of Physical Medicine and Rehabilitation, Esayas B. Kebede, MD, is a physician in the Division of General Internal Medicine, Bonnie J. Donelan Dunlap, CCRP, is a certified clinical research coordinator in the Department of Medicine Research, Kathryn J. Ruddy, MD, is a professor of oncology in the Division of Medical Oncology, and Jennifer K. Hazelton, APRN, CNS, is a clinical nurse specialist in the Division of General Internal Medicine, all at the Mayo Clinic in Rochester, MN; Alissa M. Butts, PhD, LP, is a neuropsychologist at the Medical College of Wisconsin in Milwaukee; and Sarah M. Jenkins, MS, is a statistician in the Department of Health Sciences, Ivana T. Croghan, PhD, is a professor of medicine in the Department of Health Sciences and a research vice chair in the Division of Primary Care Internal Medicine, and Brent A. Bauer, MD, is a professor of medicine and the director of research for the Integrative Medicine Program in the Division of General Internal Medicine, all at the Mayo Clinic in Rochester, MN. The authors take full responsibility for this content. The study was supported in part by the Mayo Clinic Department of Medicine and the Mayo Clinic Integrative Medicine Research Council. The data entry system used was REDCap, supported in part by the Center for Clinical and Translational Science award (UL1 TR000135) from the National Center for Advancing Translational Sciences (NCATS). Wieneke has a financial relationship with a commercial product version of The 12 Habits of Highly Healthy People. The article has been reviewed by independent peer reviewers to ensure that it is objective and free from bias. Stan can be reached at stan.daniela@mayo.edu, with copy to CJONEditor@ons.org. (Submitted September 2019. Accepted January 13, 2020.)

 

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