W. Jack Rejeski, PhD Departments of Health/Exercise Science and Gerontology/Geriatric Medicine

1. W. Jack Rejeski, PhD Departments of Health/Exercise Science and Gerontology/Geriatric Medicine Wake Forest University Models & Theories of Health Behavior Change: Integrating Multiple Levels of Influence Grant Support: R01 AG051624-01; 5R01AG050725-03; 5R01HL122846-04; P30 AG021332; No Other Potential Conflicts of Interest to Disclose Jack Rejeski, "Achieving and Sustaining Behavior Change to Benefit Older Adults" Dec 6-7, 2018

2. Goals • To examine how models/theories have evolved across time; identifying key concepts/gaps • To argue that the way we traditionally think about the mind is restrictive and to offer an alternative • To summarizing key points/questions to ponder as we discuss various topics in this workshop Jack Rejeski, "Achieving and Sustaining Behavior Change to Benefit Older Adults" Dec 6-7, 2018

3. Health Belief Model Perceived Benefits Minus Perceived Barriers Demographic and Psychosocial Input Perceived Susceptibility Likelihood of Taking Preventive Health Action Perceived Severity Perceived Threat of Disease or Health Event Cues to Action Outcome Expectation + Value of the Outcome Expectancy-Value Figure 1. Health Belief Model (adapted from Janz & Becker, 1984) Jack Rejeski, "Achieving and Sustaining Behavior Change to Benefit Older Adults" Dec 6-7, 2018

4. Social Cognitive Theory Outcome Expectation • Sources • Mastery • Modeling • Verbal Persuasion • Physical States Self- Regulation Self-Efficacy Behavior Sociocultural Facilitators & Impediments Physical States & Personal Agency Figure 2. Social Cognitive Theory (adapted from Bandura, 2004) Jack Rejeski, "Achieving and Sustaining Behavior Change to Benefit Older Adults" Dec 6-7, 2018

5. Relapse Prevention Model • An outgrowth of SCT; deals specifically with sustaining behavior change • Central Concept: identify and address high risk situations • There is an important temporal dimension in the concept of high risk: • Immediate determinants (Phasic) • External: in-the-moment toxic social & physical environments • Internal: negative affect & physiological cues • Ineffective coping • Competing, short-term expected outcomes • Abstinence violation effect • Covert antecedents: Moderators of Immediate determinants (Tonic) • Internal: Allostatic load (aging & chronic disease) • Family history/genetic influence • Backdrop of social & physical environments Jack Rejeski, "Achieving and Sustaining Behavior Change to Benefit Older Adults" Dec 6-7, 2018

6. Incentives & Affect • Incentives (wanting & liking): Early models and theories assumed people valued health-related outcomes • Affect: The early focus was on reflective affect (“subjective liking”): both anticipated and experienced • More recent work has emphasize reflexive (implicit) affect (“core liking”: automatic, visceral) • A distinction is made between affect that is directly due to the behavior versus incidentalaffect Jack Rejeski, "Achieving and Sustaining Behavior Change to Benefit Older Adults" Dec 6-7, 2018

7. Socio-ecological Models • Multiplelevels of influence; focusing solely on the individual is unlikely to sustain behavior change • Environments: objective vs. subjective • Environments: facilitate and/or impedehealth behavior change • Environments and the people within them are in a constant state of flux (amplified in aging) Jack Rejeski, "Achieving and Sustaining Behavior Change to Benefit Older Adults" Dec 6-7, 2018

8. Traditional View of the Mind • Enables people to have an awarenessof the world and of their experience • Responsible for consciousness & gives humans the capacity to think and to feel • This promotes research on the reflective mode of processing Jack Rejeski, "Achieving and Sustaining Behavior Change to Benefit Older Adults" Dec 6-7, 2018

9. The “Mind” as a Process: Siegel, 2010 Embodied and Relational Figure 3. The Mind as a Embodied and Relational Process that Regulates Energy and Information Flow; Rejeski & Gauvin, CIA, 2013;8:657-665 Jack Rejeski, "Achieving and Sustaining Behavior Change to Benefit Older Adults" Dec 6-7, 2018

10. The Mind as Embodied • Biological processes influence how older adults think, feel, and behave • Biological inputs may be either relatively stable (tonic) or fluctuate (phasic) across time Jack Rejeski, "Achieving and Sustaining Behavior Change to Benefit Older Adults" Dec 6-7, 2018

11. Embodied Mind: State Dependent Nature of Behavior Change • 14 overweight/obese adults in a weight loss trial • Fed a controlled breakfast on two different occasions after which they played games and watched TV for 2.5 h. • On one day, after the 2.5h of relaxing activity, they consumed a glass of water, whereas on the second day they consumed BOOST (a meal replacement) • Following the consumption of either the water or the BOOST, they underwent a fMRI scan. • Dramatic decreases in self-efficacy (a 20% drop) from breakfast to the fMRI with corresponding increases in hunger and food craving Jack Rejeski, "Achieving and Sustaining Behavior Change to Benefit Older Adults" Dec 6-7, 2018 Paolini, Laurienti, Norris, Rejeski. Frontiers in Psychology, 2014;5:1-13

12. Resting State Brain Scans Axial slice: Red = STP, Amy; White = hippocampus Sagittal slice: Yellow = Insula; Green = ACC Jack Rejeski, "Achieving and Sustaining Behavior Change to Benefit Older Adults" Dec 6-7, 2018 Paolini, Laurienti, Norris, Rejeski. Frontiers in Psychology, 2014;5:1-13

13. Biological Regulatory Systems: Phenotypes for Behavior Change • Older, Obese Adults; 65-79y; 18-Month Intentional Weight Loss • 6-Months Intensive; 12-months of Maintenance Rejeski, Ambrosius, Burdette, Walkup, Marsh. JGMS, 2017; 72(11): 1547-1553 Jack Rejeski, "Achieving and Sustaining Behavior Change to Benefit Older Adults" Dec 6-7, 2018

14. Biological Regulatory Systems: Phenotypes for Behavior Change • Older, Obese Adults; 65-79y; 18-Month Intention Weight Loss • 6-Months Intensive; 12-months of Maintenance • Subset of 52 Participants with Baseline fMRI scans • At 18-Months Conducted Median Split on %Weight Loss (WL) Failure %WL = 2.87% (CI = 1.41, 4.33) Success %WL = 13.96% (CI = 11.86, 16.05) Jack Rejeski, "Achieving and Sustaining Behavior Change to Benefit Older Adults" Dec 6-7, 2018

15. Prediction Accuracy: Dynamic Network Data • Combined machine learning and functional brain networks to create multivariate prediction models: Dynamic, static & random Jack Rejeski, "Achieving and Sustaining Behavior Change to Benefit Older Adults" Dec 6-7, 2018 Percent Correctly Predicted on Y Axis: Accuracy = Overall; Sensitivity = high WL Group; Specificity = Low WL Group Mokhtari, Rejeski, Zhu et al. Neuroimage, 2018, 173, 421-473.

16. The Mind as Relational • Just as there as neural synapses, people connect through social synapses (Cozolino, 2012) • As a result of experience, our social and physical environments become embodied; risk regulators (Glass & McAtee, 2006) that shape the activity of the mind • The relational mind as antecedents of habits via nonconscious neural networks Jack Rejeski, "Achieving and Sustaining Behavior Change to Benefit Older Adults" Dec 6-7, 2018

17. Close Interpersonal Relations • Early Life Adversity (ELA): • Duffy (2018): Alters brain development leading to impaired network connectivity (impaired self-regulation) & higher rates of health-risk behaviors—smoking, alcohol, eating high fat foods and foods high in sugar • Polyvagal Theory (Porges, 2007): Ventral root of the vagus—SAFETY though social connection • Benefits of Group-Mediated Interventions • Relatedness as a core human need (incidental affect); review on loneliness by Hawkley & Cacioppo, 2010 • Data illustrate that social networks decline with aging; technology may be useful to counter this effect Jack Rejeski, "Achieving and Sustaining Behavior Change to Benefit Older Adults" Dec 6-7, 2018

18. Broader Social & Physical Environment • Lynch and colleagues (1997, NEJM): • Classified as experiencing extreme poverty in 1965, 1974 and 1985: risk 0,1,2 or 3. • Strong graded association between # of times in poverty and poor physical, cognitive, and psychological health • Glass & McAtee (2006) concluded that late life is a period of increasing vulnerability for the cumulative effects of disadvantaged social & economic environments Jack Rejeski, "Achieving and Sustaining Behavior Change to Benefit Older Adults" Dec 6-7, 2018

19. Embodied Mind Genetic & Biological Substrates of the Biological Regulatory Systems Energy and Information Flow • Biological Regulatory Systems: Body • Endocrine System • Cardiorespiratory System • Immune System • Metabolic System • Peripheral Nervous System • Biological Regulatory Systems: Brain • Origin of Subjective Experience Network connectivity that controls nonconscious processing Network connectivity that controls conscious processing Health Behavior Figure 4. The Mind as an Embodied and Relational Process Jack Rejeski, "Achieving and Sustaining Behavior Change to Benefit Older Adults" Dec 6-7, 2018

20. Relational Mind Embodied Mind Close interpersonal relations (attachment behavior) Genetic & Biological Substrates of the Biological Regulatory Systems Micro Marco • Small social groups • Communities • Schools and workplace • Health Care • National & state • Geopolitical & economic • Natural environment • Biological Regulatory Systems: Body • Endocrine System • Cardiorespiratory System • Immune System • Metabolic System • Peripheral Nervous System • Biological Regulatory Systems: Brain • Origin of Subjective Experience Network connectivity that controls nonconscious processing Network connectivity that controls conscious processing Health Behavior Figure 4. The Mind as an Embodied and Relational Process Jack Rejeski, "Achieving and Sustaining Behavior Change to Benefit Older Adults" Dec 6-7, 2018

21. Concluding Comments with Challenges to Consider • The dynamic nature of behavior change • How do we address identifying and increasing awareness of phasic influences on health behavior change? • Will new technologies enable us to intervene in real time? • The central role of incentives and affect • How do we capitalize on incentives and affect in the realm of changing the health behavior of older adults? • What role do core human needs play in behavior change? • Both conscious and nonconscious processes are operative • Should awareness be a central concept in behavior change? • Can technology be employed to intervene on implicit cognitive, affective, and motivational processes? • The importance of a developmental perspective • Greater consideration of relational influences: for example, small groups, health care (Epstein, 2017), and community initiatives (social capital) Jack Rejeski, "Achieving and Sustaining Behavior Change to Benefit Older Adults" Dec 6-7, 2018