Behavior Analytic Approach to Increase Exercise Behavior in Overweight and Obese Adults

1. 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

2. 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.

3. 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)

4. 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

5. 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)

6. 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

7. 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

8. Effective behavior analytic interventions include: • Self-monitoring • Goal setting • Caloric restrictions • Stimulus control • Behavior substitution • Relapse prevention • Social support systems • Exercise

9. 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

10. 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)

11. 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

12. Purpose • To evaluate the efficacy of a behavior analytic treatment package on exercise behavior in overweight or obese adults.

13. 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®)

14. 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)

15. 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

16. 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

17. 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 ooVoo® • Correspondence training • Self-monitoring • Participants self monitor exercise behavior daily • Public reporting • progress was reported daily via Twitter® to all members

18. 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

19. 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

20. Interobserver Agreement (IOA) • Second independent observer: • Endurance • Blood pressure • Recovery heart rate • Professionals: • FMS, strength • Blood work • Equipment: • Weight • % body fat

25. 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

26. 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

27. 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

28. 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

29. 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

30. 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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40. Thank you! For more information contact: Gretchen A. Dittrich, M.S., BCBA (PhD candidate) gretchen.dittrich@simmons.edu