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

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Change in Anxiety Score

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Walking (Fitness) Improvement Tertiles

Perceived Stress Scales

-1.4

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-0.8

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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

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Baecke Sport Quartile

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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

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STEPS Exercise Outcomes:Strength Exercise, Minutes Per Week

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STEPS Fitness Outcomes: 6 Minute Walk, Distance in Feet

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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 !