Psychological and Behavioral Elements of Success for Exercise and Physical Activity

1. Psychological and Behavioral Elements of Success for Exercise and Physical Activity Patricia M. Dubbert, PhD Geriatric Research, Education and Clinical Center. CAVHS South Central VA MIRECC Department of Psychiatry , UAMS

2. Disclosure of Interest • Dr Dubbert has signed a document stating that she has NO disclosures.

3. Objectives • Describe current public health recommendations for physical activity • List mental health benefits of physical activity • Discuss behavioral and psychological interventions that help promote exercise and physical activity

4. “Physical activity” is... … “any bodily movement produced by skeletal muscles that results in energy expenditure” Caspersen, Powell, & Christenson, 1985, Public Health Reports

5. Physical activity includes… • Self care such as bathing and dressing • Walking leisurely such as shopping • Meal preparation and clean up • Care giving such as for children, elderly • Household cleaning and repairs • Yard work and gardening • Occupational activities • Walking/cycling for transportation • Sports and exercise

6. “Exercise” is... ... a subset of physical activity defined as “planned, structured, and repetitive bodily movement done to improve or maintain one or more components of physical fitness” Caspersen, Powell, & Christenson, 1985, Public Health Reports

7. Exercise includes… • Training for athletics and sports • Structured bouts of physical activity to increase fitness and health risk factor management • Rehabilitative training following illness and injury

8. “Physical fitness” is... … “a set of attributes that people have or achieve that relates to the ability to perform physical activity” Caspersen, Powell, & Christenson, 1985, Public Health Reports

9. Types of Health-related Physical Fitness • Cardio-respiratory fitness (maximal aerobic power and ability to sustain sub maximal effort) • Muscular fitness (strength & endurance) • Flexibility • Motor fitness (postural control) • Bone strength (mineral density) • Body composition (fat content & distribution) • Metabolic fitness (endocrine, lipid, etc.) Bouchard et al., 1994

10. Physical Activity Dosing Dimensions • F Frequency • I Intensity • T Time • T Type of activity • To get fitness benefits, the dose of physical activity and exercise must be at the right levels of FITT.

11. Public health guidelines with specific recommendations for PA were updated in 2007. Haskell et al., 2007, Medicine & Science in Sports & Exercise, 39:1423-1434

12. Physical Activity and Public Health: Updated Recommendation for Adults American College of Sports Medicine & American Heart Association (2007) • Maintain a physically active lifestyle. • Moderate intensity aerobic PA 30 min on 5 days/week or vigorous PA 20 min 3 days/week. • May combine these activities but must be in addition to light intensity PA in daily life. • PA can be accumulated in 10 min bouts. • Muscle strengthening exercises at least twice a week. • Exceeding these recommendations may produce additional benefits. Haskell et al., 2007, Medicine & Science in Sports & Exercise, 39: 1423-1434

13. Light Physical Activity At the light intensity level, you can talk and sing during the activity.

14. Moderate Physical Activity At the moderate intensity level, you can talk but you can’t sing during the activity.

15. Hard/Vigorous Physical Activity At the hard or vigorous intensity level, you can’t talk or sing during the activity.

16. Sedentary Behavior • Sedentary time may increase risk of poor health independent of physical activity • Sitting for long periods of time without activity breaks is associated with poorer metabolic fitness • With increasing evidence, future guidelines may suggest taking breaks from sedentary behavior. Pate et al., 2008, Exercise and Sport Sciences Reviews, 36 (4): 173-178

17. Exercise and Physical Activity Reduce Stress and Anxiety; Improve Quality of Life

18. Reduced Stress and Anxiety after 12 Months of Walking: Aging Veterans In Primary Care Clinics • 60-80 year old Veterans from PC clinics were counseled by a nurse • Fitness improvements (6 min walk) were correlated with self reported walking • Depression scores (in non-depressed range at baseline) did not change • Anxiety and perceived stress score changes were associated with improved fitness (6 min walk performance) Dubbert et al. (2002), Journal of Gerontology:MEDICAL SCIENCES, 57A, M733-M740

19. Changes in Anxiety and Stress with Improved Fitness: Aging Veterans in Primary Care Clinics State Anxiety Scores Perceived Stress Scales

20. Dose Response to Exercise in Postmenopausal Women • Randomized trial of 50%, 100%, 150% of public health recommendation for PA on QoL • Dose was 4, 8, or 12 kcals exercise/kg body weight per week • 430 women, BMI 25-43, 35% nonwhite • Exercised on laboratory treadmill and recumbent bike for 6 mo • Outcome measure: change in SF-36 subscales Martin et al., 2009, Arch Intern Med, 169: 269-78

21. Dose Response to Exercise in Postmenopausal Women (DREW) Study SF-36 MH and RE Responses SF-36 SF and VT Responses Martin et al., 2009, Arch Intern Med, 169: 269-78

22. Physical Activity and Exercise Can Help Maintain Brain Health in Aging Men and Women

23. Walking Benefits for Aging Men and Women • Men aged 71-93: walking < .25 mi/day had 1.8 X risk of dementia compared with walking > 2 mi/day* • Women aged 70-81: PA equivalent to walking at easy pace 1.5 h/wk resulted in better cognitive scores than equivalent of walking < 40 min/wk† *Abbott et al., 2004, JAMA, 292: 1447-1453; † Weuve et al., 2004 , JAMA, 292: 1454-1461

24. PA and Sub Clinical Cerebral Infarcts in African Americans: The ARIC Study • 944 African Americans from Jackson, MS or Forsyth County NC • 6 years later completed MRI • Aged 45-64 at Visit 1; completed PA survey • 64% female • 57% with hypertension • 15% diabetes • 28% smokers • PA scores for Sport were inversely related to MRI infarcts in models including other risk factors Dubbert et al., 2009, Journal of the Neurological Sciences

25. ARIC: Sport Participation and OR for MRI Cerebral Infarct Physical activity scores for Sport were inversely related to presence of MRI infarcts in models including other risk factors Dubbert et al., 2009, Journal of the Neurological Sciences

27. Factors Associated with Participation in Exercise and Physical Activity

28. Factors Associated with More Exercise and Physical Activity • Education • Male gender • Enjoyment, expectation of benefit • Self-efficacy, stage of change • Activity history and lack of injury • Healthy diet habits • Physician, friend and family social support

29. Factors Associated with Less Exercise and Physical Activity • Identified self as racial/ethnic minority • Perceived lack of time • Depressed mood • Perceived effort • Lack of safe and appealing places to exercise in neighborhood • Living in rural area • Season/climate

30. Major Barriers to Provider Physical Activity and Exercise Counseling • Time constraints • Lack of training and skills • Lack of confidence in value of taking time for counseling • Lack of organizational support • Little or no reimbursement

31. How Can Providers Help Patients with Lifestyle Modification? • Identify patients who can benefit • Explain benefits • Evaluate readiness to make changes • Recommend intervention appropriate to patient’s readiness to change

32. Identify Patients Who Can Benefit • Active but doing less than the recommended amount of physical activity • Health conditions that benefit from regular physical activity • Some leisure activity but sedentary for long periods during the day • Not doing any exercise or leisure physical activity

33. Explain Benefits of Lifestyle Modification • Talk to patients to learn their beliefs and misconceptions • Have educational materials available • Utilize all available members of the health care team • Involve family and other supportive persons

34. “Ask, Tell, Ask” Model for Patient Teaching • When teaching patients, “Ask, Tell, Ask” • Ask patients what they already know • Tell the patient the recommended actions • Ask the patient again about their understanding, and elicit their concerns and questions Keller & Carroll, Patient Education& Counseling, 1994, 23: 131-140

35. Offer Interventions Appropriate to Patient’s Readiness to Change

36. Overcoming Patient Barriers to Lifestyle Modification

37. Assess Readiness To Change • Only a minority of patients are ready to make recommended changes at any given visit (maybe 10%) • Gentle, repeated assessment can elicit the right time for action (try at every visit) • Give every patient advice to help him/her progress toward the goal

38. Questions to Assess Readiness for Lifestyle Modification • Do you see this as something you are willing to consider at this time… • Have you been thinking about trying to… • Have you tried to make some changes already… • How confident are you that you can… • Are you ready to…

39. Cognitive-Behavioral Strategies Used In Effective Exercise Promotion Programs • Tailored instructions/promotion material • Self-monitoring (exercise/activity diaries) • Feedback • Review of diaries, pedometer logs, measures of fitness improvement • Telephone contacts • Tailoring of interventions to participant readiness to change

40. Example Study of Exercise and Physical Activity Promotion in Aging Veterans

41. Seniors Telephone Exercise Primary Care Study (STEPS) • 224 elderly male VA Primary Care patients with physical functional impairment • Nurse and physical therapy assistant provided 30-60 min of clinic counseling at 2 visits, one month apart to increase walking and strength exercise • 1-3 phone calls from nurse to check on progress and problem solve if needed • Patients marked exercise days on calendar and brought in to clinic visits to discuss with provider Dubbert et al, Archives of Internal Medicine, 2008168(9): 979-986

42. Seniors Telephone Exercise Primary Care Study (STEPS) • Primary outcomes • Time spent walking each week and • Time spent performing strength exercises • Secondary outcomes: physical performance measures of strength, balance and speed; accelerometer activity; perceived health quality of life Dubbert et al, Archives of Internal Medicine, 2008168(9): 979-986

43. STEPS Exercise Outcomes:Walking for Exercise, Minutes Per Week

44. STEPS Exercise Outcomes:Strength Exercise, Minutes Per Week

45. STEPS Fitness Outcomes: 6 Minute Walk, Distance in Feet

46. STEPS QoL Outcomes Associated with Strength Exercise: Changes in SF-36 Scores at 10 months Dubbert et al., 2008, Archives of Internal Medicine, 168(9): 979-986

47. Summary • Public health recommendations indicate the types and amounts of physical activity necessary for good health at all ages • Physical activity at the recommended level promotes brain health and quality of life as well as physical health • Matching physical activity counseling to patient readiness to change is efficient and effective for promoting increased activity • Setting individual goals, keeping activity diaries or calendar records, making exercise a social event and continuing encouragement from health care providers can help older people stay physically active

48. Let’s help everyone enjoy physical activity !