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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. Disclosure of Interest.

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Psychological and behavioral elements of success for exercise and physical activity

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


Disclosure of interest
Disclosure of Interest Exercise and Physical Activity

  • Dr Dubbert has signed a document stating that she has NO disclosures.


Objectives
Objectives Exercise and Physical Activity

  • 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


Physical activity is
“Physical activity” is... Exercise and Physical Activity

… “any bodily movement

produced by skeletal muscles that results

in energy expenditure”

Caspersen, Powell, & Christenson, 1985, Public Health Reports


Physical activity includes
Physical activity includes… Exercise and Physical Activity

  • 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


Exercise is
“Exercise” is... Exercise and Physical Activity

... 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


Exercise includes
Exercise includes… Exercise and Physical Activity

  • Training for athletics and sports

  • Structured bouts of physical activity to increase fitness and health risk factor management

  • Rehabilitative training following illness and injury


Physical fitness is
“Physical fitness” is... Exercise and Physical Activity

… “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


Types of health related physical fitness
Types of Health-related Physical Fitness Exercise and Physical Activity

  • 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


Physical activity dosing dimensions
Physical Activity Dosing Dimensions Exercise and Physical Activity

  • 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.


Public health guidelines with specific recommendations for PA were updated in 2007.

Haskell et al., 2007, Medicine & Science in Sports & Exercise, 39:1423-1434


Physical PA were updated in 2007.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


Light physical activity
Light Physical Activity PA were updated in 2007.

At the light intensity level, you can talk and sing during the activity.


Moderate physical activity
Moderate Physical Activity PA were updated in 2007.

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


Hard vigorous physical activity
Hard/Vigorous Physical Activity PA were updated in 2007.

At the hard or vigorous intensity level, you can’t talk or sing during the activity.


Sedentary behavior
Sedentary Behavior PA were updated in 2007.

  • 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



Reduced stress and anxiety after 12 months of walking aging veterans in primary care clinics
Reduced Improve Quality of LifeStress 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


Changes in anxiety and stress with improved fitness aging veterans in primary care clinics
Changes in Anxiety and Stress with Improved Fitness: Aging Veterans in Primary Care Clinics

State Anxiety Scores

Perceived Stress Scales


Dose response to exercise in postmenopausal women
Dose Response to Exercise in Postmenopausal Women Veterans in Primary Care Clinics

  • 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


Dose response to exercise in postmenopausal women drew study
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


Physical activity and exercise can help maintain brain health in aging men and women
Physical Activity Studyand Exercise Can Help Maintain Brain Health in Aging Men and Women


Walking benefits for aging men and women
Walking Benefits for Aging Study 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


Pa and sub clinical cerebral infarcts in african americans the aric study
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


Aric sport participation and or for mri cerebral infarct
ARIC: Sport Participation and OR for MRI Cerebral Infarct The ARIC Study

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



Factors associated with more exercise and physical activity
Factors Associated with More Exercise and Physical Activity 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


Factors associated with less exercise and physical activity
Factors Associated with Less Exercise and Physical Activity 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


Major barriers to provider physical activity and exercise counseling
Major Barriers Physical Activityto 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


How can providers help patients with lifestyle modification
How Can Providers Help Patients with Lifestyle Modification? Physical Activity

  • Identify patients who can benefit

  • Explain benefits

  • Evaluate readiness to make changes

  • Recommend intervention appropriate to patient’s readiness to change


Identify patients who can benefit
Identify Patients Who Can Benefit Physical Activity

  • 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


Explain benefits of lifestyle modification
Explain Benefits of Lifestyle Modification Physical Activity

  • 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


Ask tell ask model for patient teaching
“Ask, Tell, Ask” Model for Physical ActivityPatient 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




Assess readiness to change
Assess Readiness To Change 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


Questions to assess readiness for lifestyle modification
Questions to Assess Readiness for Lifestyle Modification Change

  • 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…


Cognitive behavioral strategies used in effective exercise promotion programs
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



Seniors telephone exercise primary care study steps
Seniors Telephone Exercise Primary Care Study (STEPS) Aging Veterans

  • 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


Seniors telephone exercise primary care study steps1
Seniors Telephone Exercise Primary Care Study (STEPS) Aging Veterans

  • 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


Steps exercise outcomes walking for exercise minutes per week
STEPS Exercise Outcomes: Aging VeteransWalking for Exercise, Minutes Per Week


Steps exercise outcomes strength exercise minutes per week
STEPS Exercise Outcomes: Aging VeteransStrength Exercise, Minutes Per Week


Steps fitness outcomes 6 minute walk distance in feet
STEPS Fitness Outcomes: Aging Veterans6 Minute Walk, Distance in Feet


Steps qol outcomes associated with strength exercise changes in sf 36 scores at 10 months
STEPS Aging VeteransQoL 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


Summary
Summary Aging Veterans

  • 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



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