New Technologies and Health
Behavior Change
Iowa State University
Exercise Psychology Class
April 18, 2011
Steven N. Blair
Arnold School of Public Health
University of South Carolina
2008 Physical Activity
Guidelines for Americans
At-A-Glance
www.health.gov/PAGuidelines/
U.S. Department of Health and
Human Services
WHO PA Recommendation
• Released by WHO in December 2010
• PA recommendations
– 5-17 yr—60 min MVPA/day, vigorous
intensity, including muscle and bone
strengthening 3 X week
– 18-64 yr—each week accumulate in bouts
of at least 10 min, 150 min moderate
intensity, 75 min vigorous intensity, or
combination of both; and resistance
training 2 X week
– 65 yr & older—same as 18-64 yr, those
with poor mobility should also do
balance exercises, and take health
conditions into account
Improving Physical
Activity for All Americans
The US National Physical
Activity Plan
A Call to Action
Released May 3, 2010
Background
• Release of the 2008 PA Guidelines for
Americans necessitates action to
ensure greater ability to comply with
those guidelines.
• National Plans in other domains
(e.g. smoking cessation, diabetes,
arthritis) have
proven successful
in the U.S.
Background
• Other nations (e.g. Finland, Australia,
U.K.) have developed National PA
Plans.
• Until May 3, 2010 there was no U.S.
National PA Plan.
What is a Physical Activity Plan?
• A comprehensive set of strategies
including policies, practices, and
initiatives aimed at increasing physical
activity in all segments of the
population.
* CDC/WHO Collaborating Center Workshop On Global Advocacy For National Physical Activity Plans
Workshop report. January, 2007
•Public Health
•Education
•Healthcare
•Volunteer and Non-Profit Organizations
•Transportation, Urban Design, Community
Planning
•Business and Industry
•Parks, Recreation, Fitness, and Sports
•Mass Media
National Physical Activity Plan
White Papers
• Published in a November 2009
supplement to the Journal of Physical
Activity and Health
– Published by Human Kinetics
(www.hkusa.com)
– Go to journal page, then to the Journal of
Physical Activity and Health, then to the
November 2009 supplement
– http://journals.humankinetics.com/jpah-back-issues/jpah-volume6-supplement-november
Public Health Sector
Sample Strategy:
• Disseminate tools and
resources important to
promoting physical activity:
– Burden of disease due to
inactivity
– Evidence-based
interventions
Public Health Sector
Sample Tactic:
• Support and expand the National
Society of Physical Activity
Practitioners in Public Health resource.
Healthcare Sector
Sample Strategy:
• Make physical activity a
patient “vital sign” that all
healthcare providers
assess and discuss with
their patients.
Healthcare Sector
Sample Tactic:
• Track patients’ level of physical activity
in electronic medical records/health
records (EMRs/EHRs).
Get Involved
www.physicalactivityplan.org
e-mail: info@physicalactivityplan.org
Overview
• Medical care costs in the U.S are ~17%
of GNP, by far the highest in the world
• By traditional public health markers
such as longevity, chronic disease
rates, infant mortality, etc; the U.S.
ranks far behind many other countries
• Most health problems are the result of
unhealthy lifestyles
• We must be more aggressive in
integrating lifestyle interventions into
medical practice and public health
programs
How to Promote Healthful
Lifestyles
• Relatively new area of research
• Application of theories, models, &
methods from behavioral science
• Social Cognitive Theory, Transtheoretical
Model (Motivational Readiness), etc
– Helping individuals use cognitive and
behavioral strategies to implement behavioral
change
Lessons Learned from Physical
Activity Intervention Studies
• Individuals who use cognitive and
behavioral strategies are more likely
to be active at 24 months than
individuals who do not use these
strategies
• Approximately 25-30% of initially
sedentary persons who participate in
Active Living will be meeting
consensus public health guidelines
for physical activity at 24 months
Behavioral Approaches to
Physical Activity Interventions
• Theoretical foundations
– Social Learning Theory
– Stages of Change Model
– Environmental/Ecological Model
• Methods
–
–
–
–
–
–
–
Problem solving
Self-monitoring
Goal setting
Social support
Cognitive restructuring
Incremental changes
Manipulating the environment
How Do People Change? Cognitive Strategies
Increasing Knowledge
Encourage person to read and
think about physical activity
Warning of Risks
Provide person with message that
being inactive is very unhealthy
Caring about
Consequences to Others
Encourage person to recognize
how his/her inactivity affects
his/her family and friends
Comprehending Benefits
Help person to think about the
personal benefits of being active
Increasing Healthy
Opportunities
Help person to become aware of
societal changes in regard to
physical activity
Marcus. Motivating People to Be Physically Active. Human Kinetics, 2003
How Do People Change? Behavioral Strategies
Substituting Alternatives
Encourage person to engage in
physical activity when it might be most
beneficial, yet is rarely done
Enlisting Social Support
Encourage person to find a friend or
family member who will provide
support for being active
Rewarding Yourself
Encourage person to reward and
praise self for being active
Committing Yourself
Encourage person to make
commitment to be active
Reminding Yourself
Help person to set up reminders to be
active
Marcus. Motivating People to Be Physically Active. Human Kinetics, 2003
Mean Energy Expenditure
kcal.kg-1 .day-1
Lifestyle
Structured
35
34
33
32
0
6
12
18
24
time in months
Project Active
Dunn et al. JAMA 1999; 281:327
24-Month Change Predicting Maintenance
Odds Ratio
10.00
p=.003
p=.03
p=.03
p=.42
p=.03
2.27
1.84
1.30
1.66
1.21
Total
Behavioral
Strategies
Total
Cognitive
Strategies
Confidence
Pros
Cons
1.00
Adjusted for Age, Gender, BMI, Intervention Group, and Cohort
Change in Behavioral Strategies Over 24Months Predicts Maintenance
Odds Ratios
10
p=.001
p=.02
p=.03
p=.06
p=.14
1.68
1.31
1.88
1.44
1.57
Committing
Yourself
Enlisting
Support
Reminding
Yourself
Substituting
Alternatives
Rewarding
Yourself
1
Adjusted for Age, Gender, BMI, Intervention Group, and Cohort
Odds Ratios for Maintenance of Physical
Activity at 24 Months
10
p < .001
p = .02
4.75
p =.003
2.61
Referent
Family High
Peer Low
Family Low Peer
Low
1.72
1
Family High
Peer High
0.1
Family Low Peer
High
The Active Living Every Day
(ALED) Program
Active Living Every Day
S Blair takes no personal royalties from the ALED book
ALED Program
Participant Resources
• Active Living Every Day book
• Online study guide
– Tracks the ALED book
– Stage-based “buddy”
– Interactive (quizzes, links, forms)
Active Living Every Day
program philosophy
• Moderate physical activity = significant
health benefits
• Lifestyle physical activity: an important
alternative
• People are more likely to become and
stay active when they learn lifestyle
skills based on their readiness to
change
Flexible delivery options
• Weekly in-person group or
individual sessions
• Online or Web-based, with
facilitator support
Hybrid: online participation
with periodic group sessions
(either in-person,
teleconference, or Web
conference)
о
Changes in Physical Functioning in the
Active Living Every Day Program (ALED)
• The 4-year Active for Life Initiative
– Goal: help participants accumulate at least 30 min MVPA most days
of the week
• 877 adults from Southwestern Ohio age ≥50 years,
sedentary or underactive (≤2 days/wk and <120 min/wk)
• Measurements at baseline and at 20 weeks
– survey assessing BMI, PA, health-related practices, and
psychosocial variables
– 4 performance-based physical functioning tests
• Results: Participants significantly increased performance
on all four tests regardless of BMI, race/ethnicity, or
baseline impairment status
Baruth M et al Int J Behav Med 2010
Improvements in Physical Functioning
Impairment Status Among Adults in
ALED Program
p<0.0001
Pre Post
p<0.0001
Pre Post
p=0.0019
Pre Post
Impaired:
≤25th percentile*
Not impaired:
>25th percentile*
*based on Rikli and
Jones’ Senior
Fitness Test Manual
normative data
30-sec
Eight Foot
Chair
Chair Stand
Up & Go
Sit-and-Reach
Percentages adjusted
for race, age, BMI, and gender
Baruth M et al Int J Behav Med 2010
How to Achieve Lifestyle Change
• Counseling by a PhD level behavioral
psychologist
• Counseling by B.A. level health
educators
• Counseling by mail and telephone
• Counseling by electronic
communications
CoEE for Technology Center to
Enhance Healthful Lifestyles
University of South Carolina
Dr. Steven Blair
Dr. Saundra Glover
Medical University of South Carolina
Dr. Carolyn Jenkins
Dr. Lisa Vandemark
Lifestyle Interventions
Integrated with Electronic
Health Records—
Kaiser Permanente
Exercise as a Vital Sign
Kaiser Permanente
Within the Visit Navigator, you will now see the “Exercise Vitals”
section immediately following the “Vitals” section.
Exercise as a Vital Sign
Kaiser Permanente
When you click on the “Exercise Vitals” the section opens up to display the
two exercise intake questions that can be completed in a quick manner.
The date and time this data was captured will also be noted/stored.
Telehealth and Weight Change
•87 participants (73 women
& 14 men)
•Mean age 50 years
•Treatment groups (Quasiexperimental design)
Kg change at 6 mo
p <0.05
•Traditional class
•Telehealth—interaction
with RD via web and email
•Control
•No difference in
satisfaction between
traditional and telehealth
•Telehealth more convenient
than traditional (p<0.0001)
Traditional Telehealth
Control
Haugen HA et al. Obes 2007;
15:3067-77
Promoting PA via PDA
• 37 healthy, inactive adults, ≥50 years of
age
• 8-week RCT
• PDA intervention (93% had not used
PDAs)
– Questions about amount and type of PA
– Alerted at 2 PM and 9 PM to complete PA
assessment
– Gave motivational and behavioral tips
• Controls—standard written materials
King AC et al. Am J Prev Med 2007; 34:138-42
Promoting PA via PDA
• Intervention participants completed 68%
of the 112 PDA entries available
• After adjusting for baseline differences
– PDA group reported 310.6 minutes of
moderate to vigorous PA/week
– Control group reported 125.5 minutes/week
– p=0.048 for group comparison
• 78.6% of PDA group reported enjoying
using the device
King AC et al. Am J Prev Med 2007; 34:138-42
Internet-plus-email Intervention
for Increasing Physical Activity
• 3-month RCT156 ethnically-diverse adult
women (mean age=42.8 y, 65% White)
• Study groups
– Tailored website + email messages
– Wait-list control
• Intervention group significantly
increased walking and total moderatevigorous physical activity compared with
controls
Dunton GF & Robertson TP. Prev Med 2008; 47:605-11
Review of Electronic Computer
Interventions to Increase Activity
• Search of PubMed or Web of Science
yields <25 studies on electronic
interventions for physical activity and <15
of these focus exclusively on activity
• Conclusions
– Using the internet can reach large populations
– Research is still in infancy but
• Results are promising with beneficial changes in
physiological and psychological factors reported
• Appears that response is similar to established
interventions
Marcus BH et al. Br J Sports Med Feb 2009
Internet-Based Learning in the
Health Professions
• Meta-analysis of 201 studies of interventions
for health professionals
– 201 studies identified
– Internet-based intervention, no interventions, or
non-internet interventions
• Conclusions
– Internet-based interventions produced consistent
and large positive effects compared with no
intervention
– Differences between internet and non-internet
(traditional) interventions were heterogeneous
and generally small, suggesting comparable
effects
Cook DA et al. JAMA 2008; 300:1181-96
Web- and Computer-Based
Smoking Cessation
• 22 RCTs of Web- and
computer-based
smoking cessation
programs
– 16,050 enrolled in
smoking cessation
groups
– 13,499 enrolled in
control groups
Myung SK et al. Arch Int Med
2009; 169:929
• Those in smoking
cessation groups were
significantly more
likely to quit
smoking—RR 1.44
(95% CI, 1.27-1.64)
• Conclusion—there is
sufficient evidence to
recommend Web- and
computer-based
smoking cessation
programs for adults
Basic Internet vs Internet plus behavioral
e-counseling
• 92 overweight adults ~BMI 33.1(3.8), 12 month RCT,
Providence RI, age = 48.5yrs(9.4)
• Randomized to basic internet or internet plus
behavioral e-counseling.
• Initial body weight loss was doubled in the ecounseling group
• Intent-to-treat analysis showed the behavioral ecounseling group lost more at 12 months than basic
Internet group
– Weight: -4.4[6.2] vs -2.0[5.7]kg; P=.04
– Waist circumference: -7.2[7.5] vs -4.4[5.7]cm; P=.05
• Internet e-counseling may be a alternative to more
burdensome clinic programs
Tate DF. JAMA, 2003; 289(14);1833-1836
Basic Internet vs Internet plus behavioral
e-counseling
Tate DF. JAMA, 2003; 289(14);1833-1836
HEALTH Project
• Physical activity and diet intervention for
TRICARE enrollees in Indiana, Ohio,
Michigan, and Illinois
• Interventions
– bookHEALTH
– teleHEALTH
– eHEALTH
• Weight loss ~5% of baseline weight at 18
months
• Increases in fruit and vegetable intake,
physical activity, and quality of life
• Cost recovery 3-6 years
LEAN Study Design
• RCT with 4 arms:
1.) Standard Care group included self-help
with a diet and PA manual
2.) GWL health counselor and 14 sessions
3.) GWL + SenseWear™ Armband group
4.) SWA alone
• Follow-up data collection visits occur at
month 4 and month 9
104
102
Weight (Kg)
100
GWL
98
GWL+SWA
SWA alone
Standard care
96
94
92
Baseline
Month 4
Month 9
Effects across time for weight. Estimates adjust for age, gender,
race, education, and wave.
Summary
• Unhealthful lifestyles are the major cause
of chronic disease morbidity and
mortality
• Lifestyle interventions have demonstrated
efficacy and effectiveness in a variety of
populations
• Our challenge now is to develop
translational interventions, using modern
technology, to reach large numbers of
individuals at a low cost.
Questions?
Behavior change topics
•
•
•
•
•
•
•
Identifying and overcoming barriers
Enlisting social support
Setting realistic goals
Coping with lapses
Rewarding yourself
Positive self-talk
Self-monitoring
Active Grandmothering
Attributable Fractions (%) for
All-Cause Deaths
40,842 Men & 12,943 Women, ACLS
18
16
14
12
10
8
6
4
2
0
Men
Women
Lo
w
CR
Ob
F
es
e
Sm
ok
er
Hy
pe
Hi
gh
rt
en
si
on
Di
ab
et
Ch
es
ol
Blair SN. Br J Sports Med 2009;43;1-2
WEBBASED
COMPUTERBASED
Theoretical Patterns of Physical Activity
Over 24 Hours
Energy Expenditure (METS)
Noon-time jog
10
8
Sedentary
Lifestyle Exercise
Leisure-Time Exercise
6
After-dinner
walk
Walk to bus
stop
4
2
0
0
2
4
6
8
10
12
Time (hours)
14
16
18
20
22
24
Center Vision
Create, evaluate, and disseminate
electronic interventions to help
individuals make and sustain lifestyle
changes for disease prevention and
management
Work with the private sector to develop
these interventions into patentable and
marketable products
Produce high-paying jobs in SC and
contribute to economic development
How to Change Unhealthful
Lifestyle Behaviors?
Behavioral science theories, models,
and interventions have been shown
to produce changes in smoking, diet,
and physical activity.
• Individuals who learn to apply
cognitive and behavioral strategies
are successful in changing health
behaviors.
• Lifestyle interventions have
demonstrated efficacy.
• Will people do it?
Solutions for the US Health
Care Crisis
Electronic health records are mentioned every day in
news reports as a solution to health care problems.
Every week major peer-reviewed medical/scientific
journals have articles and commentaries about
electronic health records.
In April 2009 the Institute of Medicine released a
book on eHealth.
To solve the health crisis we must become more
effective in helping people adopt and maintain
healthful lifestyles.
President Obama—Speech at the National
Academy of Science, April 27, 2009
• "The Recovery Act will support the long
overdue step of computerizing America's
medical records, to reduce the duplication,
waste, and errors that cost billions of dollars
and thousands of lives.
But it's important to note: these records also
hold the potential of offering patients the
chance to be more active participants in
prevention and treatment. …we have the
opportunity to offer billions and billions of
anonymous data points to medical researchers
who may find in this information evidence that
can help us better understand disease."
Steps to Success
• Begins with current behaviors, and how
they compare to public health guidelines
• Encourages small steps
• Builds confidence
• Cognitive
behavioral strategies
• Scientifically-tested methods
Computer Tailored Lifestyle Intervention
for Diet and Physical Activity
• 310 participants, BMI ≥25.0
• % reaching 150 MET-min of
• Treatment groups
PA/week at 12 months
• Computer-based
– Experimental group increased
assessment of
from 26% to 53% (p <0.001)
motivational readiness for
– Controls—30% at baseline, 37%
change
(p=0.27)
• Computer-generated 4-5
page individualized report
• Discussed report with
physician
• Control group received
packet of health
education materials
• Outcomes—12-month
change in
• Physical activity
• Body weight
• No difference in weight at 12months between groups
– 21% of experimental group lost
≥5% of baseline weight compared
with 10.6% of controls (p <0.01)
– 32% of experimental group lost
≥2.7 kg at 12-months compared
with 19% of controls losing ≥2.7
kg (OR=2.2, p <0.01)
Christian JG et al. Arch Int Med 2008; 168:141-6
Telephone Counseling for
Increasing Physical Activity
• 6-month RCT with 298 sedentary adults
(mean age=45.9 y), 72% women, 45%
white & 45% African-American
• Study groups
– Fully automated telephone-linked counseling
(TLC-PA) based on Stages of Motivational
Readiness
– TLC-Eat counseling for healthy eating
• Results
– 3-mo TLC-PA more likely to meet PA
recommendations
– 6-mo, no differences between groups
Pinto BM et al. Am J Prev Med 2002; 23:113-20