Patricia Dubbert, Ph.D. University of Arkansas for Medical Sciences South Central VA Mental Illness Research Education & Clinical Center VISN 16

Transcription

1 Patricia Dubbert, Ph.D. University of Arkansas for Medical Sciences South Central VA Mental Illness Research Education & Clinical Center VISN 16 Geriatric Research Education Clinical Center

2 Objectives Review methods and results for behavioral treatment of obesity Review individual and environmental factors influencing exercise and physical activity in adults Discuss appropriate uses and intervention strategies to promote exercise for weight management

3 Behavioral Therapy and Change Strategies in Treatment of Obesity

4 Behavioral Methods for Weight Management Considered the first line of intervention for overweight and obese individuals Have been used and evaluated since the 1970 s Based on behavioral science theories and research on animal and human behavior Typically provided in groups of about participants meeting weekly for about 90 minutes for at least 4 to 6 months No medications, dietary prescriptions, or meal replacements Butryn et al., Psychiatr Clin North Am, 2011

5 Behavioral Methods for Weight Management Group approach may have advantages: More efficient for providers Leaders must be trained to protocol but have varied backgrounds from psychology, nutrition, nursing, health education Provides empathy, social support, and healthy competition Weights measured in private at beginning of session Group sessions include sharing progress and challenges and teaching a new weight management skill Butryn et al., Psychiatr Clin North Am, 2011

6 Behavioral Methods for Weight Management: Key Elements Goal-Setting Objective goals that can be easily measured Typically include Daily calorie intake Weekly minutes of physical activity Number of days for which food records will be completed May set other individual goals that will help with weight loss efforts Butryn et al., Psychiatr Clin North Am, 2011

7 Behavioral Methods for Weight Management: Effective Goal-Setting Goal Component Generally Not Effective More Effective Specific I will exercise more I will exercise at least 20 minutes every day Measurable I will not eat when I am stressed I will record in my food record everything I eat and my stress level rating How, When, Where I will walk at work I will walk around the block 10 minutes before lunch and 10 minutes after dinner Realistic I will lose 50 pounds this year I will lose 10 pounds and then re-evaluate my goals

8 Behavioral Methods for Weight Management: Key Elements Self-Monitoring Considered a key element of behavioral treatment Provides feedback about how behavior compares to the goal or ideal Accountability Motivation Can be tailored to individual and environmental variables and behaviors important to individuals Electronic devices make self-monitoring easy and accurate Butryn et al., Psychiatr Clin North Am, 2011

9 Self-Monitoring More frequent monitoring related to greater success Typically includes foods, beverages, portions, calories, time of day May include fat grams, hunger, stress/mood, location, other variables Apps and electronic devices can be used instead of paper/pencil forms

10 Behavioral Methods for Weight Management: Key Elements Stimulus Control Used to change internal and external cues associated with eating, exercise, and other behaviors targeted for change Arrange cues to facilitate rather than hinder behavior change Reduce exposure to temptations for eating unhealthy foods or portion sizes Increase exposure to opportunities and cues for healthy foods and activity Butryn et al., Psychiatr Clin North Am, 2011

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12 Stimulus Control: Two Plates

13 Behavior Changes Associated with Weight Loss after 6 and 24 months of Behavioral Treatment Data from study of 390 patients in primary care Randomized to usual care, 15 min monthly counseling, or monthly counseling + medication or meal replacement After 6 months, usual care lost 2.0 kg, monthly counseling lost 3.5 kg, and enhanced counseling lost 6.6 kg Baseline diet, physical activity, and eating behavior did not predict weight loss success Volger et al., International Journal of Obesity, 2013

14 Behavior Changes Associated with Weight Loss after 6 and 24 months of Behavioral Treatment The 3 treatment groups were not different in their reported eating behavior at any time in the study All started with high intake of fruits and vegetables Percent fat decreased slightly in all 3 groups Energy expenditure in physical activity decreased across time in usual care (-50 kcal/wk) and increased in the 2 counseling groups Brief counseling (+114 kcal/wk) increased activity more than usual care, and Enhanced counseling increased the most (+624 kcal/wk) Volger et al., International Journal of Obesity, 2013

15 Behavior Changes Associated with Weight Loss after 6 and 24 months of Behavioral Treatment Best predictor of weight loss at 6 months, and at 24 months, was completing food diaries during the first 6 months The more diaries were completed, the better the weight loss This finding is consistent with several previous studies Researchers recommend that participants in behavioral treatment who only marginally or who do not complete any diaries during the first 2 weeks of treatment received additional counseling on selfmonitoring Volger et al., International Journal of Obesity, 2013

16 Behavior change interventions using Stages of Change and Social Media Conclusions from analysis of evidence from 3 trials with almost 3000 participants: Evidence was inconclusive that SoC in combination with diet and physical activity led to sustained weight loss Evidence was of low quality Conclusions from analysis of evidence from 10 studies using online social networks: Only very modest evidence that these interventions are effective Further research is needed Maher et al., J Med Internet Res, 2014; Mastellos Cochrane Database Syst Rev, 2014

17 Stages of Change and Motivational Readiness for Weight Management Helpful constructs that can guide providers and policy makers in thinking about what strategies may be most effective for people at different stages of change or readiness One size does not work for all Interventions designed for people who are in the choir may not work for those who are sitting in the back pew or in the parking lot Transtheoretical Model s Stages of Change can help guide when to use different behavior change strategies

18 Physical Activity and Exercise in Weight Management

19 Physical activity is... any bodily movement produced by skeletal muscles that results in energy expenditure Caspersen, Powell, & Christenson, 1985, Public Health Reports

20 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

21 Exercise is a subset of physical activity defined as planned, structured, and repetitive bodily movement done to improve or maintain one or more components of physical fitness Caspersen, Powell, & Christenson, 1985, Public Health Reports

22 Exercise includes Training for athletics and sports Structured bouts of physical activity for increasing fitness and health risk factor management Rehabilitative training following illness and injury

23 Physical fitness is... a set of attributes that people have or achieve that relates to the ability to perform physical activity Caspersen, Powell, & Christenson, 1985, Public Health Reports

24 Well Known 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.) Bouchard et al., 1994

25 And Brain Fitness! Bouchard et al., Physical Activity and Health,2012

26 Physical Activity and Public Health: Updated Recommendation for Adults from the ACSM and the AHA(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:

27 Health Benefits of Physical Activity in Treatment of Obesity

28 Importance of Exercise in Weight Management Healthy levels of physical activity and exercise are associated with numerous benefits Benefits seen in obese as well as non-obese Activity may attenuate some of obesity risks High levels of cardiorespiratory fitness associated with greater survival in all BMI categories

29 Exercise in Weight Management: How much Exercise is needed to lose weight? ACSM, Med Sci Sports Exerc, 2009

30 Exercise in Weight Management: How much Exercise is needed to lose weight? Moderate physical activity of 150 to 250 minutes/week effective to help prevent weight gain Moderate physical activity of 150 to 250 minutes/week produces only modest weight loss (about 2 kg or 5 pounds) Physical activity greater than 250 minutes/week may produce greater weight loss Physical activity of minutes/day may improve weight loss with moderate but not severe diet restriction ACSM, Med Sci Sports Exerc, 2009

31 Appropriate Exercise Intervention Strategies for Weight Management Type of intervention Weight Loss Clinically significant weight loss Activity tracker step goal 0 to 1 kg loss Unlikely Aerobic training only 0 to 2 kg loss Possible but only with extremely high volume Resistance training only None Unlikely Aerobic and resistance training only Caloric restriction combined with aerobic training 0 to 2 kg loss Possible but only with extremely high volume Can achieve 10 kg loss or greater Possible ACSM, Med Sci Sports Exerc, 2009; Swift, Prog Cardiovasc Dis, 2014

32 Physical Activity Recommendation for Weight Loss and Prevention of Weight Regain in Adults Adults should participate in at least 150 minutes per week of moderate intensity physical activity to prevent significant weight gain and reduce associated chronic disease risk factors Overweight and obese adults should participate in 150 minutes per week of moderate intensity physical activity to elicit modest reductions in body weight Greater weight loss and enhanced prevention of weight gain are likely with doses of physical activity that approximate 250 to 300 minutes per week (approximately 2000 kcal/week) of moderate intensity exercise ACSM, Medicine & Science in Sports & Exercise, 2009

33 How much exercise is necessary for health benefits in weight management? Any amount is better than none! Activity at less than recommended levels has significant benefits for both physical and mental health Try to reduce sedentary time as well as increase physical activity

34 Encouraging Healthy Physical Activity in Clinical Practice Weight Management

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36 Recognize Barriers to Exercise External Time family, work, other demands Unsafe neighborhoods Lack of social support & discrimination Weather Lack of health care provider advice & support Internal Motivation Low fitness & energy Depressed mood Dislike sensations of exercise arousal & sweating Beliefs embarrassment, fear of injury

37 Cognitive-Behavioral Strategies Used In Effective Exercise Promotion Programs Match counseling to patient s readiness to change Culturally tailor instructions/promotion material Individualize recommendations (activity type, intensity, duration) Minimize burden for patient (sessions/week, parking, home-based options) Encourage self-monitoring (exercise/activity diaries) Feedback Review of diaries, wearing pedometers, measures of fitness improvement Ongoing contacts/follow-up for support and problemsolving

38 Resources to Help You, Your Patients, and Families with Weight Management and Exercise

39 Lots of GOOD stuff for free on federal government websites

40 National Institute on Aging website a treasure chest of intervention materials

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42 Tip Sheets for Using Exercise to Enhance Emotional Wellness

43 What you think about when you exercise may be important Coming soon

44 Thank You Be Active, Be Healthy!