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. 2026 Feb 7;15(1):60–66. doi: 10.4103/jfmpc.jfmpc_582_25

A traffic light approach to lifestyle change: Health building guideline for NCD outpatients in India

Rakesh Sarwal 1,✉, Anil K Pandey 2, Suruchi Sood 3, Deepa Negi 4
PMCID: PMC12975079  PMID: 41816145

ABSTRACT

Aim:

To develop and describe a simple, culturally appropriate, evidence-based lifestyle intervention tool and administration protocol for stable NCD outpatients.

Methods:

A multidisciplinary team synthesized global (WHO) and national (ICMR-NIN) guidelines, behaviour-change principles (COM-B, Health Belief Model, self-efficacy), and patient/provider feedback to create a one-page bilingual handout containing 21 evidence-based recommendations classified using a traffic-light system (red: avoid; green: consume safely; yellow: lifestyle actions). A structured 7-step protocol was designed for administration by nurses/dietitians, physicians, and yoga instructors, incorporating motivational interviewing, lifestyle scoring (0–21), goal setting, practical demonstration, and follow-up.

Results:

The “Health Building Lifestyle Guideline” and protocol were successfully piloted in an integrative health clinic serving industrial workers. Patients and providers reported high acceptability, improved comprehension, and enthusiasm for the visual traffic-light format, numeric lifestyle score, and team-based reinforcement.

Conclusion:

This novel, low-cost, replicable traffic-light lifestyle guideline with a structured 7-step delivery protocol effectively bridges the knowledge–practice gap and empowers NCD outpatients to adopt and sustain healthier behaviours. Wider implementation and formal outcome evaluation are recommended.

Keywords: Behaviour change, lifestyle intervention, noncommunicable diseases, nutrition education, primary care, traffic-light labelling, India

Introduction

Noncommunicable diseases (NCDs) such as cardiovascular disease, cancer, chronic respiratory diseases, and diabetes are leading causes of morbidity and mortality worldwide.[1] Unhealthy diets, sedentary lifestyles, and tobacco and alcohol consumption are primary contributors to these conditions.[2] The global marketing and advocacy of high-fat, high-sugar, and low-fiber fast foods and soft drinks is likely to result in an epidemic of obesity and noncommunicable diseases (NCDs), thus requiring an equally forceful response at all levels. Given the ongoing global nutrition transition, there is an urgent need for an integrated, preventive approach to target these health risks.[2] India, in particular, is experiencing a rising burden of NCDs, largely driven by lifestyle factors such as unhealthy diets, physical inactivity, and urbanization.[3]

Lifestyle management is defined as a flexible and multifocused program based on detecting individual health risks, barriers, and goal development through motivational interviewing and clinical coaching.[4] Many studies have shown the effectiveness of lifestyle intervention for the prevention of NCDs, showing commendable improvements.[5] Evidence suggests that lifestyle interventions integrating dietary changes, physical activity, and behavioral modifications can significantly reduce NCD risk and improve health outcomes.[4] An outpatient visit presents an opportunity for lifestyle intervention, which has been found to be effective for mental health issues.[6,7,8,9] as well as in overweight or obese children and adolescents.[10,11]

Despite the growing recognition of lifestyle management as a critical component in preventing and managing NCDs, structured interventions in outpatient settings remain underutilized. We looked for available communication material that could be administered in a hospital setting to stable outpatients of all ages and genders suffering from noncommunicable diseases (NCD). Since we did not find much material, we compiled one. Relying on existing models of behavior change, we developed a communication handout and an administration protocol, together called “Health Building Lifestyle Guideline” for all stable patients of NCDs attending the outpatient integrative health clinic. The goal was to help patients better self-manage their condition, prevent escalation, and possibly reverse the progression of their disease. Here, we present the guideline-building process and results for wider testing and adoption.

The context

Faridabad is an industrial town of the National Capital Region of Delhi, with a population of 2 million, of which a quarter are workers. The ESIC Medical College and Hospital caters to around 1 million workers and 4 million members of their families across a large area of the National Capital Region of Delhi. Workers in organized occupations drawing a lower band of salary are covered under the contributory Employees State Insurance (ESI). An integrated health clinic was started in September 2024 to manage stable cases of NCD using the best therapy available in different systems of medicine (allopathy, ayurveda, and yoga) along with dietary and lifestyle advice. Over the last 6 months of its existence, the most common conditions encountered have been arthritis, diabetes mellitus (Type-2), hypertension, obesity, sciatica, gastrointestinal disorders, migraine hemorrhoids, asthma, fatty liver and spondylitis. While operating this clinic, the need for a comprehensive, forceful, and concise communication material that would be convincing to the patients and encourage a positive, lasting change in behavior was felt.

Methods and Protocol

We did a web search to synthesize the essential elements of a clinic-based lifestyle intervention. We then reviewed available literature in PubMed, PubMed Central to identify studies on “communication” of “Healthy Lifestyle” for “ NCD” in “Outpatient Clinics”, using the respective MeSH terms. While PubMed resulted in one result,[12] PMC had 30 results, none of which contained the communication material. We discuss the two PMC articles

We relied, in particular, on the WHO Global Action Plan for the Prevention and Control of NCDs 2023-2030,[13,14] building around the risk factors listed there, namely tobacco and alcohol use, obesity, physical inactivity, unhealthy diets containing an excess of salt, sugar, and fats. In matters of diet and in view of its contextual relevance, the Dietary Guidelines for Indians issued by ICMR-NIN[15] were relied upon. Our subsequent search was purposive and used the snowball method, originating with the mother references of WHO on risk factors and lifestyle advice[16] and ICMR dietary guidelines.

Our team of authors, who are experts in nutrition sciences, physiology, modern medicine, public health, behavior change communication, and yoga, took on the task to design a culturally acceptable, contextually relevant, evidence-based, and comprehensive lifestyle guideline. The team deliberated at length on all aspects of lifestyle affecting health and came up with a consensus-based, consolidated, one-page handout containing easily understandable information. The team used the following criteria in selecting the advice and its recommendations:

  • Availability, access to food, and lifestyle choices

  • Ease of preparation of the menu item

  • Affordability

  • Minimalist and close to nature

  • Ease of comprehension by the workers and their families. We considered the low educational and socioeconomic background of the target population (workers) attending our clinics to make the guideline simple, understandable, and doable.

  • Providing choices and options for the patients to choose from based on their taste and background, instead of dictating a particular set of food or lifestyle choices.

As the lifestyle handout was developed, feedback from experts of other disciplines, namely in internal medicine, respiratory medicine, obstetrics and gynecology and peers in nutritional sciences was obtained on its content and style, which was used to further refine the handout. In addition, feedback, views, and preferences of patients attending our clinic were also elicited, largely on the language to be used so that the message is understood as intended. This step was helpful in tailoring our content to what is understood and can be conveniently practiced by our target population.

Our research did not involve any study of or on human subjects as participants. Nor was this a clinical trial, case report, or covered by the ICH Good Clinical Practice Guideline. There were no study participants, adult or minor, as such. Hence, there was no need for participant consent or ethical approval.

Results

Concepts underlying behavior changing

Our synthesis of lifestyle interventions revealed that lifestyle education faces numerous challenges with numerous barriers and facilitators. We summarize the key learning from the evidence on the subject.

A systematic review of the barriers and facilitators to diet, physical activity, and behavior intervention concluded that lifestyle interventions that foster self-regulatory skills, opportunities for social engagement, and personalization of goals may improve behavior adherence.[17] An integrated understanding of the perceived barriers and enablers of lifestyle change can help facilitate planning for psychological, social, and environmental support for this population.[18] The Capability, Opportunity, Motivation - Behavior (COM-B) model of behavior change identifies three necessary components for any behavior to occur, namely, capability (C), opportunity (O), and motivation (M).[19] The Health Belief Model of Behavior Change consists of six primary cognitive constructs that influence behavior, namely, perceived susceptibility, perceived severity, perceived benefits, perceived barriers, self-efficacy, and cues to action.[20] The presence or absence of knowledge on healthy behaviors has been assessed as the most common enabler or barrier for diet, lifestyle, and physical activity.[21] A synthesis of lifestyle interventions targeting weight loss in primary care identified support, the role of the general practitioner, the structure of the lifestyle intervention program, logistics, and psychological factors as the most important factors to conclude that a strong support system and a personalized lifestyle intervention are essential components for successful implementation.[22] A review of lifestyle advice for people with Polycystic Ovarian Disease (PCOD) concluded that it is best delivered by a multidisciplinary team, including dietitians, and should be individualized.[23] A review of barriers and facilitators to a healthy lifestyle in postpartum women identified social support from healthcare providers as an opportunity.[24] Studies highlight the importance of healthcare provider involvement and structured interventions in supporting behavior change.[22,23] Another review on adherence to physical exercise in patients with chronic diseases and older adults identified 14 key factors, such as initial exploration of participants’ characteristics, barriers, and facilitators, participants’ education, adequate expectations, and knowledge about risks and benefits.[25] Individualized care, education, and knowledge have been identified as facilitators in managing multiple chronic conditions.[26]

A meta-analysis of lifestyle interventions targeting weight loss in primary care emphasized the need for structured programs, regular follow-ups, and healthcare provider involvement.[22] The knowledge-attitude-behavior health education model has been found to be useful in the acquisition of disease-related knowledge and self-management behavior by patients with chronic diseases.[27] Pender’s Health Promotion Model notes that each person has unique personal characteristics and experiences that affect subsequent actions. The set of variables for behavior-specific knowledge and effect has important motivational significance. These variables can be modified through nursing actions.[28]

A number of studies have identified self-efficacy to be a potential influencer in behavior change for the adoption of healthy lifestyle practices.[29] Self-efficacy was a better predictor of behavior than perceived behavioral control.[30] Self-efficacy can be achieved by better understanding the concept with the help of patience and motivational counseling.[31] Interventions that included feedback on past or others’ performance produced the highest levels of self-efficacy in a systematic review to promote lifestyle and recreational physical activity.[32]

Culturally tailored health communication strategies are essential for effective lifestyle interventions. The use of visual tools, such as color-coded dietary recommendations based on traffic light symbols, has been shown to improve patient comprehension and adherence.[6] Studies on lifestyle interventions for mental health patients highlight the effectiveness of nurse-led counseling and interactive educational materials in sustaining behavioral changes.[7,8] For the effective delivery of health education to patients, structured, culturally appropriate, and patient-specific teaching have been found to be better than ad hoc teaching or generalized teaching.[33] Health education-based yoga and naturopathy lifestyle interventions have been found to be effective on the personality of patients with NCDs.[34]

Literature review on lifestyle interventions in clinical settings

Our search yielded nil articles in PubMed, and 30 articles in PubMed Central, none of which revealed any health education clinical protocol for NCD patients that takes a holistic approach by combining lifestyle and diet in a culturally acceptable manner. Our search yielded two articles in PubMed Central, one on a protocol for a community-based care model for lifestyle change, called LOFIT (Lifestyle Front Office For Integrating Lifestyle Medicine in the Treatment of patients),[12] while the other was a systematic review and meta-analysis of the components and efficacy of the format of empowerment interventions designed for persons living with chronic disease.[35] It concluded that none of the 39 studies reviewed incorporated all four fundamental components of the WHO framework on empowerment, namely (1) patient participation and understanding of their role; (2) patient acquisition of enough knowledge so they can engage with their health care provider; (3) patient skills; and (4) the creation of a facilitating environment.[35]

Our team did note the Front of Pack Labelling (FOPL) system for processed foods to inform consumers on the excess of sugars, total fats, saturated fats, trans fats, and sodium. One of the FOPL models is color-coded like Multiple Traffic Lights (MTL) to guide consumers, which has been effective.[36] Studies have recommended that an effective front-of-pack labeling system should be Food-Directive (instead of Diet-Directive) and be displayed on both healthy and unhealthy foods.[37] Our study covered both unhealthy and healthy choices, not only in food but also in lifestyle, presented as a continuum for use by all patients visiting our clinic.

Health building lifestyle guideline

Our team came up with a list of 21 items for the handout, each of which was referenced with the best available evidence through standard APA style citation. Six references relate to dietary risks like high in fat, sugar, and salt (HFSS)[15,38,39,40,41,42] that we color in red, four references relate to healthy diets[43,44,45,46] that we color in green, and two references relate to lifestyle[16,47] that we color in yellow in the reference section [Figure 1]. Our advice is similarly clubbed into three categories: food items to be avoided, food items that can be safely consumed, and suggested lifestyle actions. The analogy of universally understood traffic lights was used to color the three groups: red for forbidden items, green for safe items, and yellow for lifestyle advice.

Figure 1.

Figure 1

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Health building lifestyle guideline

The handout was translated into the local language (Hindi), and feedback was obtained from patients on their comprehension of the terms used. This handout served as a starting point for motivational interviewing by the dietitian/nurse with the patient to explore information on health risks and benefits, explore barriers and opportunities, and develop goals.

We devised a seven-step protocol for implementing the “Health Building Lifestyle Guideline”, namely:

  • (a) Lifestyle, including nutritional assessment of the patient. Context setting is achieved by first engaging the test patients to elicit their views on the general theme of the role of lifestyle and nutrition in health and disease.

  • (b) Presenting the health-promoting lifestyle recommendations under broad heads colored by universally understood analogies of traffic lights to guide their behaviors. An assessment to test patients’ knowledge, attitude, and beliefs on each of the 21 listed items in the handout under the three groups. Open discussion on the evidence in support of the suggested action, the rationale, choices, and consequences.

  • (c) Test patients were asked to grade their practice of the 21 suggested lifestyle advice. A simple addition of the results on 21 items yielded a “lifestyle score” for each patient at the initial assessment out of a perfect score of 21.

  • (d) Exploring barriers and opportunities to adoption. Affirmation by the patient on the amends they would willingly make in their lifestyle henceforth. Goal setting by the patient in terms of a target score that they would work to achieve in the next few weeks.

  • (e) The patient then met the physician, who reviews the affirmation by the patient and, besides providing other care, re-emphasizes the importance of lifestyle.

  • (f) The patient is then led to the next station of a yoga instructor who guides them on the best practice for their condition through a live demonstration and hand-holding to introduce them to the exercise/posture.

  • (g) Subsequently, after a gap of a few weeks, the effect of lifestyle counseling is assessed through a call to all patients to assess the extent of compliance with committed and agreed lifestyle amendments and their effect on the patient’s condition.

This guideline was administered to a few test patients attending our clinic over a 2-month period in 2024 by trained nursing personnel after obtaining patients’ vitals, in blood pressure, weight, height, BMI, and pulse. Our guideline is intended for use by healthcare providers (nurses, doctors, and dietitians) with stable cases of NCDs in outpatient settings, aimed at a change in their lifestyle and diet. We propose the use of this guideline at the time of the first visit of the patient and at every follow-up visit to maintain a log of changes in “lifestyle score” over time.

Since reporting guidelines of the EQUATOR network have not been developed for quality improvement studies in nutritional sciences,[48] we used the AGREE Reporting Checklist, 2016, for clinical practice guidelines[49] for this study. (Supplementary material) “Health Building Lifestyle” [Figure 1].

Discussion

Our handout and protocol address the common issues in the successful transmission of lifestyle messages, namely clarity, consistency, motivation, cultural sensitivity, and captivating using an intuitive mode of presentation. The journey of lifestyle amendment by the patients was supported by a clinical team through multiple channels, starting from knowledge exploration, fact sharing, open discussion, provision of a written handout, practical demonstration, and reinforcement. Our handout and counseling protocol offer the following advantages:

  1. Is concise, consistent, direct, decisive, and evidence-based, providing references for each piece of advice.

  2. Comprehensive, holistic, combining lifestyle and dietary issues

  3. Simplicity: Places foods into two categories for simplification: those to be shunned and those that can be safely taken, leaving those to be occasionally taken to the reader’s choice.

  4. Uses the commonly understood analogy of traffic light colors, which simplifies complex lifestyle and dietary information into an easy-to-follow guide. This helped in understanding the deterministic consequences of our lifestyle choices to motivate a positive change.

  5. Is illustrative, giving examples of menu choices for three meals a day, based on local, ethnic preferences.

  6. Is bilingual for better comprehension. Also combines pictures of a colorful food plate for image-based cognition and better comprehension.

  7. Is administered orally, through written hard copy, and also made available digitally on test patients’ mobile phones.

Our communication addresses the knowledge, skills, and abilities gap to engage, motivate, and empower the patients to take charge of their lifestyle and reverse the drift. We capitalize on the opportunity presented by the visit of patients with chronic diseases to our integrative clinic to first introduce, and over time, emphasize the need for a lifestyle change to reverse the course of the NCDs and also to prevent complications. We use the strength of groups of cases with lifestyle conditions to bring social support and encourage discussion on the need for a reboot of lifestyle. Our follow-up by trained nursing staff helps assess comprehension and compliance and helps monitor self-administered goals, which improves patients’ self-efficacy. By including lifestyle counseling as an essential part of patients’ experience in our clinic, we have built a microculture of health promotion, thus building a social norm. Our counselor raised the patient’s awareness, while the yoga trainer next door provided access to the practice, all in an integrated manner. The number of items on our handout matches the well-known 21-day rule in building a new habit. The response of test patients attending our clinic to this protocol has been enthusiastic. Both the providers and the patient report satisfaction with the engagement. The multidisciplinary approach, which combined dietary advice, yoga coaching, and physician reinforcement, was well-received. When multiple healthcare professionals reinforced the importance of lifestyle changes, patients were more likely to follow recommendations.

The “Health Building Lifestyle Guideline” is a living document that will be revised based on experience with patients and suggestions of the providers. Our Health Building Guideline can be further developed by the inclusion of Ayurvedic dietary principles and personalized care frameworks like Prakriti-based profiling Given the National Health Policy 2017’s emphasis on mainstreaming AYUSH systems, embedding Ayurvedic health promotion and disease management strategies into such lifestyle counseling can improve both patient adherence and long-term outcomes.

By suggesting a handout and protocol for informing and engaging patients for behavioral changes and adherence to lifestyle modifications, this study aims to contribute to the growing evidence base for structured lifestyle interventions in outpatient settings, with potential implications for scaling such models globally. Addressing dietary habits, promoting physical activity, and implementing culturally tailored health education can help mitigate these risks and improve long-term health outcomes.

Possible limitations of our guideline could be its overwhelming nature, though it was built consciously to make it comprehensive. We overcome this possibility by encouraging a gradual adoption by the test patients as per their choice and at their own pace. Given its advisory nature and by placing the patient as the driver of change, we do not foresee any possible harm from the use of the suggested guideline. A theoretically possible harm from our guideline could arise from over-aggressive practice or compliance. We guard against possible harm through follow-up calls and reviewing its practice in all subsequent visits of the patient. Future research should explore the long-term sustainability of such interventions and their impact on patient outcomes.

Conclusion

Patients with chronic NCDs are prime candidates for changing lifestyles, including diets. Such patients are reasonably motivated and are likely to derive long-term, sustainable benefits from adopting healthy lifestyles. Our “Health Building Lifestyle Guideline” uses a culturally relevant, visually engaging guide coupled with structured counseling and follow-up protocol to achieve high levels of patient engagement and behavior change. Our multi-provider method is more likely to convey the message in a convincing fashion and is likely to prompt effective behavior change. A numeric lifestyle score on a scale of 0 to 21 enables goal setting and monitoring. When fully implemented, our guidelines would cover all four fundamental components of the WHO framework on empowerment.[35]

The effectiveness of our guideline in changing lifestyle behaviors among patients with NCDs would be the subject of further empirical research.

Conflicts of interest

There are no conflicts of interest.

Acknowledgment

The authors would like to thank our colleagues for their help and support in this work. Dr. Manas Kamal Sen (Pulmonary Medicine), Prof. Jagdish Chander Sharma (Obs. and Gyne), Dr. Rajesh Manocha (Internal Medicine), Ms. Aparajita (Dietary Sciences), Radhika Bhardwaj, and Neetu Sharma. (Nursing Orderlies).

Funding Statement

Nil.

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