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Psychological and Behavioral Elements of Success for Exercise
and Physical Activity
Patricia M. Dubbert, PhDGeriatric Research, Education and Clinical Center. CAVHS
South Central VA MIRECCDepartment of Psychiatry , UAMS
Patricia M. Dubbert, PhDGeriatric Research, Education and Clinical Center. CAVHS
South Central VA MIRECCDepartment of Psychiatry , UAMS
Disclosure of Interest
• Dr Dubbert has signed a document stating that she has NO disclosures.
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
• 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...
… “any bodily movementproduced by skeletal muscles that resultsin energy expenditure”
Caspersen, Powell, & Christenson, 1985, Public Health Reports
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
“Exercise” is...
... a subset of physical activitydefined as “planned, structured, and repetitive bodily movement done to improveor maintain one or more components ofphysical fitness”
Caspersen, Powell, & Christenson, 1985, Public Health Reports
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
“Physical fitness” is...
… “a set of attributes that people have orachieve that relates to the ability toperform physical activity”
Caspersen, Powell, & Christenson, 1985, Public Health Reports
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.)
• 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
• 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.
Haskell et al., 2007, Medicine & Science in Sports & Exercise, 39:1423-1434
Public health guidelines with specific recommendations for PA were updated in 2007.
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
Light Physical Activity
At the light intensity level, you can talk and sing during the activity.
Moderate Physical Activity
At the moderate intensity level, you can talk but you can’t sing during the activity.
Hard/Vigorous Physical Activity
At the hard or vigorous intensity level, you can’t talk or sing during the activity.
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
Exercise and Physical Activity Reduce Stress and Anxiety; Improve
Quality of Life
Exercise and Physical Activity Reduce Stress and Anxiety; Improve
Quality of Life
Reduced Stress and Anxiety after 12 Months of Walking: Aging Veterans In Primary Care ClinicsReduced 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
Changes in Anxiety and Stress with Improved Fitness: Aging Veterans in Primary Care Clinics
State Anxiety Scores
-2.5
-2
-1.5
-1
-0.5
0
0.5
1
1.5
Change in Anxiety Score
1 2 3
Walking (Fitness) Improvement Tertiles
Perceived Stress Scales
-1.4
-1.2
-1
-0.8
-0.6
-0.4
-0.2
0
Change in PSS Stress Scores
1 2 3
Walking (Fitness) Improvement Tertiles
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
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 and Exercise Can Help Maintain Brain Health in Aging
Men and Women
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
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
Sp
ort
Q1 S
po
rt Q
2
Sp
ort
Q3
0.00
0.20
0.40
0.60
0.80
1.00
1.20
1.40
1.60
Baecke Sport Quartile
Ad
just
ed*
OR
an
d 9
5%
CI
ARIC: Sport Participation and OR for MRI Cerebral Infarct
Dubbert et al., 2009, Journal of the Neurological Sciences
Physical activity scores for Sport were inversely related to presence ofMRI infarcts in models including other risk factors
Factors Associated with Participation in Exercise and Physical Activity
Factors Associated with Participation in Exercise and Physical Activity
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
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
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
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
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
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
“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
Offer Interventions Appropriate to Patient’s Readiness to Change
Readiness to Change Interventions
Not interested, not even considering change
Education on benefits to self and others, avoid confrontation
Considering change but not ready
Education with encouragement to try small changes, problem-solve barriers
Recent attempts to begin changes
Reinforce attempts, assist in planning, refer to program, class
Achieving target but for only few weeks, less than 6 months
Encouragement, skills training, problem-solving
Lifestyle modification achieved and maintained > 6 months
Praise, recognition, always cautious about and ready to deal with relapse
Overcoming Patient Barriers to Lifestyle Modification
Barrier Example Solutions
Lack of perceived benefits Explain health benefits of even small changes
Lack of time Accumulate 5-10 minute periods of exercise
Lack of motivation Write a “prescription” for specific behavior change goals, monitor progress
Lack of support Encourage seeking friend or co-worker support, let health care team give encouragement
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
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…
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
Example Study of Exercise and Physical Activity Promotion in Aging
Veterans
Example Study of Exercise and Physical Activity Promotion in Aging
Veterans
Seniors Telephone Exercise Primary Care Study (STEPS)
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
Seniors Telephone Exercise Primary Care Study (STEPS)
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
STEPS Exercise Outcomes:Walking for Exercise, Minutes Per Week
0
10
20
30
40
50
60
70
80
90
BL 5Mo 10Mo
EDUC
EXC
STEPS Exercise Outcomes:Strength Exercise, Minutes Per Week
0
10
20
30
40
50
60
BL 5Mo 10Mo
EDUC
EXC
STEPS Fitness Outcomes: 6 Minute Walk, Distance in Feet
1420
1440
1460
1480
1500
1520
1540
1560
1580
1600
1620
BL 5Mo 10Mo
EDUC
EXC
STEPS QoL Outcomes Associated with Strength Exercise: Changes in SF-36 Scores at 10 months
-6 -4 -2 0 2 4 6 8
Physical Function
Role Physical
Role Emotional
Vitality
Mental Health
Social Function
Body Pain
General Health
No Strength Exc Strength Exc
Dubbert et al., 2008, Archives of Internal Medicine, 168(9): 979-986
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
Let’s help everyone enjoy physical activity !