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Behavior Analytic Approach to Increase Exercise Behavior in

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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?
• Behavioral medicine involves the application
of behavior analytic principles to the
prevention, treatment, and rehabilitation of
medical and health disorders.
• 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:
• 2 out of 3 Americans are overweight (BMI ≥ 25)
• 1 out of 3 Americans are obese (BMI ≥ 30)
• Obesity prevalence is accelerating in the U.S. (Ogden, &
Carroll, 2010)
• Prevalence of extreme morbid obesity has increased
by 75% (Sturm, 2007)
• The epidemic is not limited to America, but is also
spreading across the world (Malnick, & Knobler, 2006)
Normal-weight obesity syndrome
• Normal weight (BMI of 18.5 - 24.9)
• Body fat mass similar to obese
– Women ≥ 30%
– Men ≥ 20 – 25%
• More than 50% of normal weight Americans are
normal-weight obese (Mayo Clinic)
• 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:
• Physiological complications:
– 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)
• Psychological complications:
– depression (Malnick, & Knobler, 2006)
• Health care costs :
– $147 billion per year (Finkelstein, Trogdon, Cohen, & Dietz, 2009)
Treatments:
• Pharmacological
• Dietary or nutritional changes, naturopathic
treatment
• Surgical
– Lap Band, gastric bypass surgery, gastric reduction
duodenal switch (GRDS), cervical vagus nerve stimulation
(VNS), jaw fixation, etc.
• Exercise
• Behavioral
• Many treatments result in immediate reinforcement
with minimal response effort
Behavior analysis and weight loss
• There is a direct relationship between the
environment and healthy or unhealthy behavior
– Eating
– Exercising
• These behaviors are amenable to a behavior analytic
approach to treatment
–
–
–
–
Quantifiable
Measurable
Can be analyzed
Are susceptible to conditioning
Effective behavior analytic interventions include:
•
•
•
•
•
•
•
•
Self-monitoring
Goal setting
Caloric restrictions
Stimulus control
Behavior substitution
Relapse prevention
Social support systems
Exercise
Exercise
• Exercise facilitates weight loss through caloric
expenditure
• However, studies that incorporated exercise also
noticed ancillary improvements in:
– Adherence to reduced calorie diet (Jakicic, Wing, & Winters-Hart, 2002)
– Feelings of well being (Hansen, Stevens, & Coast, 2001)
• From a behavioral perspective, these findings may be
explained by way of stimulus-stimulus pairing
– Changes in neurotransmitter levels and rate of transfer
during and immediately following exercise
– Exercise becomes conditioned reinforcer
– Behaviors associated with accessing reinforcement
increase
• Exercise has been demonstrated to improve overall
health in normal weight, overweight, and obese
individuals, and these changes can occur without
weight loss
• In addition, research suggests that exercise plays an
important role in weight loss maintenance
– 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, & Rössner, 2005; Miller, Koceja, & Hamilton, 1997; Ryan,
& Kushner, 2010; and Annesi, & Whitaker, 2010)
Recommendations for exercise
• Cardiorespiratory
– 150 min per week (moderate-intensity)
– 75 min per week (vigorous-intensity)
– Combination of both
• Strength training
– At least 2 days per week
• Few Americans meet exercise targets
• Exercising frequency is declining
• Behavior analytic programs can increase exercise
behavior
Purpose
• To evaluate the efficacy of a behavior analytic
treatment package on exercise behavior in
overweight or obese adults.
Method
• Participants:
–
–
–
–
–
–
4 Adults: 3 female, 1 male
Age range: 26 - 48 years old
3 met criteria for overweight or obese status (BMI ≥ 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
• Materials:
– Caloric burn calculator (http://www.healthstatus.com/calculator/cbc)
– Wi-Fi Scale
– Video Conference equipment (headset, webcam, ooVoo®)
• Setting:
– Weekly video group meetings occurred online via ooVoo®,
within the participants’ homes
– All exercise activities occurred in locations determined by
participants (e.g., gym, home, park, etc.)
• Data collection:
– Exercise data were calculated via the caloric burn
calculator
– Weight and body fat composition were transmitted
electronically daily via the Wi-Fi scale
– Goal and self-monitoring logs were emailed weekly
– Baseline and current data were collected to determine
changes in fitness and health measures (endurance, heart
rates, specific medical conditions)
• Additional data collected:
– Functional movement screen
– Maximal strength
– Blood pressure
• Unique to this research:
– The current research analyzed a rich array of dependent
variables to determine changes in overall health.
– Multiple independent variables were introduced
simultaneously.
• Experimental design:
– Multiple baseline across participants
Procedure
• Baseline
– Anthropometric, cardiovascular, strength, FMS, and
exercise (variety, duration, frequency) data were collected
prior to treatment
– Preference assessment for movement and exercise
behavior
– Stimulus control evaluation
• Previous exercise activities
• Antecedents to exercise or sedentary behavior
• Goals
• General guidelines
–
–
–
–
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®
• Correspondence training
– Self-monitoring
• Participants self monitor exercise behavior daily
– Public reporting
• progress was reported daily via Twitter® to all members
• Exercise easing (shaping)
– Target successful activities
– Begin with short durations of low intensity exercise
– Goal was to establish exercise behaviors in daily routines
• Exercise diversification
– Increase the variety of activities in the weekly exercise
routine to include:
• Cardiorespiratory workouts
• Flexibility
• Strength training
• Exercise intensity shaping
– Increase the intensity, duration, and frequency of exercise
– Focus on exercising within cardio zones
• Medium
• Moderate
• Cardiovascular max
• Establishment of kedge goals
– Publicly posted (via Twitter ® within behavior health community) goals
with deadlines
– These goals encourage maintenance of exercising behavior
Interobserver Agreement (IOA)
• Second independent observer:
– Endurance
– Blood pressure
– Recovery heart rate
• Professionals:
– FMS, strength
– Blood work
• Equipment:
– Weight
– % 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
• The treatment package was effective in improving
exercise behavior, in terms of:
– Increased frequency and duration of exercise per week
– Increased variety in exercise activities
– Increased caloric burn
• Participants experienced changes in their overall
health, as measured by:
– Decreased resting HR, increased recovery HR, decreased
body fat composition, improved medical conditions
• Participants demonstrated:
– Increased endurance
Review
• Exercise program implemented within a 10-stage
weight loss program
• Combines stimulus control, shaping, goal setting,
self-monitoring, public posting, and social support
systems
• Evaluates changes in multiple dependent variables
• Demonstrates, rather than assumes, improved health
Discussion
• 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
• Exercise improves overall health in overweight,
obese, and normal weight individuals.
• Furthermore, exercise has been demonstrated to
reduce depression, and prevent age-related illnesses
• We currently live in an obesogenic environment
• The prevalence of obesity is accelerating and
spreading world wide, and it affects all ages.
• Behavior analytic weight loss treatments are
effective and result in overall improved health
• 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
• Results are preliminary
• Changes in weight, body fat composition, and
medical conditions are confounded by changes in
diet
• Self-monitoring of exercise behavior may not be
accurate
Future research
• Evaluate the effects of the exercise shaping program
independent of the 10 stage weight loss program
• Longitudinal research on maintenance of exercise
behavior more than 2 years post treatment
• Application of the exercise shaping program to
different populations of people (e.g., intellectual
disabilities, children, adolescents, teens, normal
weight obese, etc.)
• Use of device that automates data collection for
exercise
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Thank you!
For more information contact:
Gretchen A. Dittrich, M.S., BCBA (PhD
candidate)
[email protected]
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