Behavior Analytic Approach to Increase Exercise Behavior in

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]