Behavior Analytic Approach to Increase Exercise Behavior in Overweight and Obese Adults Contemporary Developments in Behavior Analysis Boston, March 12th, 2011 Gretchen A. Dittrich Michael Cameron What is behavioral medicine? вЂў Behavioral medicine involves the application of behavior analytic principles to the prevention, treatment, and rehabilitation of medical and health disorders. вЂў Behavioral medicine evaluates the relation between behavior and biology, and provides methods to shift these relations to improve overall health in individuals, populations, and communities. A sizeable epidemic: вЂў 2 out of 3 Americans are overweight (BMI в‰Ґ 25) вЂў 1 out of 3 Americans are obese (BMI в‰Ґ 30) вЂў Obesity prevalence is accelerating in the U.S. (Ogden, & Carroll, 2010) вЂў Prevalence of extreme morbid obesity has increased by 75% (Sturm, 2007) вЂў The epidemic is not limited to America, but is also spreading across the world (Malnick, & Knobler, 2006) Normal-weight obesity syndrome вЂў Normal weight (BMI of 18.5 - 24.9) вЂў Body fat mass similar to obese вЂ“ Women в‰Ґ 30% вЂ“ Men в‰Ґ 20 вЂ“ 25% вЂў More than 50% of normal weight Americans are normal-weight obese (Mayo Clinic) вЂў People with normal weight obesity are at risk for developing the same health problems as those who are overweight or obese Collateral effects of obesity: вЂў Physiological complications: вЂ“ Hypertension, dyslipidemia, cardiovascular disease, stroke, sleep disorders, gallbladder disease, gastroesophageal reflux disease, liver and kidney disease, cancer, metabolic syndrome, Type II diabetes, osteoarthritis, etc. (Malnick, & Knobler, 2006; Mokdad, et al., 2003) вЂў Psychological complications: вЂ“ depression (Malnick, & Knobler, 2006) вЂў Health care costs : вЂ“ $147 billion per year (Finkelstein, Trogdon, Cohen, & Dietz, 2009) Treatments: вЂў Pharmacological вЂў Dietary or nutritional changes, naturopathic treatment вЂў Surgical вЂ“ Lap Band, gastric bypass surgery, gastric reduction duodenal switch (GRDS), cervical vagus nerve stimulation (VNS), jaw fixation, etc. вЂў Exercise вЂў Behavioral вЂў Many treatments result in immediate reinforcement with minimal response effort Behavior analysis and weight loss вЂў There is a direct relationship between the environment and healthy or unhealthy behavior вЂ“ Eating вЂ“ Exercising вЂў These behaviors are amenable to a behavior analytic approach to treatment вЂ“ вЂ“ вЂ“ вЂ“ Quantifiable Measurable Can be analyzed Are susceptible to conditioning Effective behavior analytic interventions include: вЂў вЂў вЂў вЂў вЂў вЂў вЂў вЂў Self-monitoring Goal setting Caloric restrictions Stimulus control Behavior substitution Relapse prevention Social support systems Exercise Exercise вЂў Exercise facilitates weight loss through caloric expenditure вЂў However, studies that incorporated exercise also noticed ancillary improvements in: вЂ“ Adherence to reduced calorie diet (Jakicic, Wing, & Winters-Hart, 2002) вЂ“ Feelings of well being (Hansen, Stevens, & Coast, 2001) вЂў From a behavioral perspective, these findings may be explained by way of stimulus-stimulus pairing вЂ“ Changes in neurotransmitter levels and rate of transfer during and immediately following exercise вЂ“ Exercise becomes conditioned reinforcer вЂ“ Behaviors associated with accessing reinforcement increase вЂў Exercise has been demonstrated to improve overall health in normal weight, overweight, and obese individuals, and these changes can occur without weight loss вЂў In addition, research suggests that exercise plays an important role in weight loss maintenance вЂ“ People who continue to exercise post treatment at levels similar to those during treatment were more successful at maintaining weight loss for at least 1 year (Gorin, Phelan, Wing, & Hill, 2004; Elfhag, & RГ¶ssner, 2005; Miller, Koceja, & Hamilton, 1997; Ryan, & Kushner, 2010; and Annesi, & Whitaker, 2010) Recommendations for exercise вЂў Cardiorespiratory вЂ“ 150 min per week (moderate-intensity) вЂ“ 75 min per week (vigorous-intensity) вЂ“ Combination of both вЂў Strength training вЂ“ At least 2 days per week вЂў Few Americans meet exercise targets вЂў Exercising frequency is declining вЂў Behavior analytic programs can increase exercise behavior Purpose вЂў To evaluate the efficacy of a behavior analytic treatment package on exercise behavior in overweight or obese adults. Method вЂў Participants: вЂ“ вЂ“ вЂ“ вЂ“ вЂ“ вЂ“ 4 Adults: 3 female, 1 male Age range: 26 - 48 years old 3 met criteria for overweight or obese status (BMI в‰Ґ 25) 1 was struggling to lose weight after pregnancy All participants in a 10-stage weight loss program All participants had a release from PCP вЂў Materials: вЂ“ Caloric burn calculator (http://www.healthstatus.com/calculator/cbc) вЂ“ Wi-Fi Scale вЂ“ Video Conference equipment (headset, webcam, ooVooВ®) вЂў Setting: вЂ“ Weekly video group meetings occurred online via ooVooВ®, within the participantsвЂ™ homes вЂ“ All exercise activities occurred in locations determined by participants (e.g., gym, home, park, etc.) вЂў Data collection: вЂ“ Exercise data were calculated via the caloric burn calculator вЂ“ Weight and body fat composition were transmitted electronically daily via the Wi-Fi scale вЂ“ Goal and self-monitoring logs were emailed weekly вЂ“ Baseline and current data were collected to determine changes in fitness and health measures (endurance, heart rates, specific medical conditions) вЂў Additional data collected: вЂ“ Functional movement screen вЂ“ Maximal strength вЂ“ Blood pressure вЂў Unique to this research: вЂ“ The current research analyzed a rich array of dependent variables to determine changes in overall health. вЂ“ Multiple independent variables were introduced simultaneously. вЂў Experimental design: вЂ“ Multiple baseline across participants Procedure вЂў Baseline вЂ“ Anthropometric, cardiovascular, strength, FMS, and exercise (variety, duration, frequency) data were collected prior to treatment вЂ“ Preference assessment for movement and exercise behavior вЂ“ Stimulus control evaluation вЂў Previous exercise activities вЂў Antecedents to exercise or sedentary behavior вЂў Goals вЂў General guidelines вЂ“ вЂ“ вЂ“ вЂ“ Record physical activity and calories burned daily Weigh in daily on Wi-Fi scale Submit self-monitoring reports weekly Weekly online group meetings via ooVooВ® вЂў Correspondence training вЂ“ Self-monitoring вЂў Participants self monitor exercise behavior daily вЂ“ Public reporting вЂў progress was reported daily via TwitterВ® to all members вЂў Exercise easing (shaping) вЂ“ Target successful activities вЂ“ Begin with short durations of low intensity exercise вЂ“ Goal was to establish exercise behaviors in daily routines вЂў Exercise diversification вЂ“ Increase the variety of activities in the weekly exercise routine to include: вЂў Cardiorespiratory workouts вЂў Flexibility вЂў Strength training вЂў Exercise intensity shaping вЂ“ Increase the intensity, duration, and frequency of exercise вЂ“ Focus on exercising within cardio zones вЂў Medium вЂў Moderate вЂў Cardiovascular max вЂў Establishment of kedge goals вЂ“ Publicly posted (via Twitter В® within behavior health community) goals with deadlines вЂ“ These goals encourage maintenance of exercising behavior Interobserver Agreement (IOA) вЂў Second independent observer: вЂ“ Endurance вЂ“ Blood pressure вЂ“ Recovery heart rate вЂў Professionals: вЂ“ FMS, strength вЂ“ Blood work вЂў Equipment: вЂ“ Weight вЂ“ % body fat 400 BL 300 Shaping 200 100 0 1 5 9 13 17 21 25 29 33 1 5 9 13 17 21 25 29 33 1 5 9 13 17 21 25 29 33 1 5 9 13 17 21 25 29 33 800 Weekly Duration (min) 600 400 200 0 800 600 400 200 0 300 250 200 150 100 50 0 Weeks Change in Fitness Measures Endurance Participant Phase 1 B 0 60 0 0 0 94 33 C 5 66 34 4.3 1216 79 36 B 2 25 10 2.7 303 66 35 C 7 33 28 6.3 2825 60 44 B 3 --- --- 3 773 --- --- C 7 25 21 5 3500 70 50 B 1 49 40 3 351 50 50 C 5 58 41 5.3 2380 48 70 3 4 Pushups Heart rate Different activities 2 Situps Weekly exercise Days Calories burned Resting Recovery Change in Categories of Exercise Cardiorespiratory Strength training Flexibility Participant Phase Frequency Duration Frequency Duration Frequency Duration 1 B 0 0 0 0 0 0 C 3.7 136 1 2 0 0 B 2.7 101 0 0 0 0 C 4.7 328 1 60 1 75 B 3 90 1 30 1 60 C 2.7 205 1 20 3 233 B 0 0 3 45 0 0 C 3 155 5 50 0 0 2 3 4 Change in Anthropometric Measures and Medical Conditions Participant Phase Age Weight BMI % Fat 1 B 26 171 31.3 36 C --- 152 27.9 34.7 --- B 48 206 37 45.4 Fatty liver: alk phos 122, sgot 155, sgpt 322 C --- 167 29.6 40 Healthy liver: alk phos 84, sgot 26, sgpt 45 B 35 143 23.2 26.7 Daily lower back and hip pain C --- 128 20.6 23.9 Reduced pain B 38 230 28.8 23.7 High blood pressure (on medication) C --- 208 25.8 19 Will be tested to go off of medication 2 3 4 Medical conditions No weight-related conditions Preliminary Results вЂў The treatment package was effective in improving exercise behavior, in terms of: вЂ“ Increased frequency and duration of exercise per week вЂ“ Increased variety in exercise activities вЂ“ Increased caloric burn вЂў Participants experienced changes in their overall health, as measured by: вЂ“ Decreased resting HR, increased recovery HR, decreased body fat composition, improved medical conditions вЂў Participants demonstrated: вЂ“ Increased endurance Review вЂў Exercise program implemented within a 10-stage weight loss program вЂў Combines stimulus control, shaping, goal setting, self-monitoring, public posting, and social support systems вЂў Evaluates changes in multiple dependent variables вЂў Demonstrates, rather than assumes, improved health Discussion вЂў Research suggests that incorporating exercise into a weight loss program will result in improved health benefits and weight loss that maintains more than 2 years post treatment вЂў Exercise improves overall health in overweight, obese, and normal weight individuals. вЂў Furthermore, exercise has been demonstrated to reduce depression, and prevent age-related illnesses вЂў We currently live in an obesogenic environment вЂў The prevalence of obesity is accelerating and spreading world wide, and it affects all ages. вЂў Behavior analytic weight loss treatments are effective and result in overall improved health вЂў We need to utilize our knowledge of behavior, the mechanisms that change behavior, and the strategies to maintain such changes and apply it to this global problem Limitations вЂў Results are preliminary вЂў Changes in weight, body fat composition, and medical conditions are confounded by changes in diet вЂў Self-monitoring of exercise behavior may not be accurate Future research вЂў Evaluate the effects of the exercise shaping program independent of the 10 stage weight loss program вЂў Longitudinal research on maintenance of exercise behavior more than 2 years post treatment вЂў Application of the exercise shaping program to different populations of people (e.g., intellectual disabilities, children, adolescents, teens, normal weight obese, etc.) вЂў Use of device that automates data collection for exercise References Anderson, D. 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Associations of television content type and obesity in children. American Journal of Public Health, 100, 2, 334-340. Thank you! For more information contact: Gretchen A. Dittrich, M.S., BCBA (PhD candidate) gretchen.dittrich@simmons.edu