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New Technologies and Health Behavior Change Iowa State University Exercise Psychology Class April 18, 2011


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Title: New Technologies and Health Behavior Change Iowa State University Exercise Psychology Class April 18, 2011

New Technologies and Health Behavior ChangeIowa
State UniversityExercise Psychology ClassApril
18, 2011
  • Steven N. Blair
  • Arnold School of Public Health
  • University of South Carolina

2008 Physical Activity Guidelines for Americans
  • U.S. Department of Health and Human Services

WHO PA Recommendation
  • Released by WHO in December 2010
  • PA recommendations
  • 5-17 yr60 min MVPA/day, vigorous intensity,
    including muscle and bone strengthening 3 X week
  • 18-64 yreach 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 oldersame 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

  • 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)
  • proven successful
  • in the U.S.

  • Other nations (e.g. Finland, Australia, U.K.)
    have developed National PA Plans.
  • Until May 3, 2010 there was no U.S. National PA

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
  • 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 (
  • Go to journal page, then to the Journal of
    Physical Activity and Health, then to the
    November 2009 supplement
  • http//

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

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

Get Involved

  • 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
  • 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
  • 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
  • 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
Encourage person to recognize Consequences
to Others 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 Help person to become aware of
Opportunities 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
Marcus. Motivating People to Be Physically
Active. Human Kinetics, 2003
Mean Energy Expenditure .day-1
time in months
Project Active
Dunn et al. JAMA 1999 281327
Adjusted for Age, Gender, BMI, Intervention
Group, and Cohort
Adjusted for Age, Gender, BMI, Intervention
Group, and Cohort
Odds Ratios for Maintenance of Physical Activity
at 24 Months
p lt .001
p .02
p .003
Odds Ratio
The Active Living Every Day (ALED) Program
Active Living Every Day
S Blair takes no personal royalties from the ALED
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
  • Lifestyle physical activity an important
  • 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)

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 lt120
  • 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
Pre Post
Pre Post
Pre Post
Impaired 25th percentile Not impaired
gt25th percentile based on Rikli and
Jones Senior Fitness Test Manual normative data
30-sec Chair Stand
Eight Foot Up Go
Chair Sit-and-Reach
Percentages adjusted for race, age, BMI, and
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
  • 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 RecordsKaiser 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 (Quasi-experimental design)
  • Traditional class
  • Telehealthinteraction with RD via web and email
  • Control
  • No difference in satisfaction between traditional
    and telehealth
  • Telehealth more convenient than traditional

Kg change at 6 mo
p lt0.05
Traditional Telehealth Control
Haugen HA et al. Obes 2007 153067-77
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
  • Gave motivational and behavioral tips
  • Controlsstandard written materials

King AC et al. Am J Prev Med 2007 34138-42
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
  • p0.048 for group comparison
  • 78.6 of PDA group reported enjoying using the

King AC et al. Am J Prev Med 2007 34138-42
Internet-plus-email Intervention for Increasing
Physical Activity
  • 3-month RCT156 ethnically-diverse adult women
    (mean age42.8 y, 65 White)
  • Study groups
  • Tailored website email messages
  • Wait-list control
  • Intervention group significantly increased
    walking and total moderate-vigorous physical
    activity compared with controls

Dunton GF Robertson TP. Prev Med 2008
Review of Electronic Computer Interventions to
Increase Activity
  • Search of PubMed or Web of Science yields lt25
    studies on electronic interventions for physical
    activity and lt15 of these focus exclusively on
  • 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

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
  • Differences between internet and non-internet
    (traditional) interventions were heterogeneous
    and generally small, suggesting comparable

Cook DA et al. JAMA 2008 3001181-96
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
  • Those in smoking cessation groups were
    significantly more likely to quit smokingRR 1.44
    (95 CI, 1.27-1.64)
  • Conclusionthere is sufficient evidence to
    recommend Web- and computer-based smoking
    cessation programs for adults

Myung SK et al. Arch Int Med 2009 169929
Basic Internet vs Internet plus behavioral
  • 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
    e-counseling group
  • Intent-to-treat analysis showed the behavioral
    e-counseling group lost more at 12 months than
    basic Internet group
  • Weight -4.46.2 vs -2.05.7kg P.04
  • Waist circumference -7.27.5 vs -4.45.7cm
  • 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
Tate DF. JAMA, 2003 289(14)1833-1836
HEALTH Project
  • Physical activity and diet intervention for
    TRICARE enrollees in Indiana, Ohio, Michigan, and
  • Interventions
  • bookHEALTH
  • teleHEALTH
  • 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

Effects across time for weight. Estimates adjust
for age, gender, race, education, and wave.
  • Unhealthful lifestyles are the major cause of
    chronic disease morbidity and mortality
  • Lifestyle interventions have demonstrated
    efficacy and effectiveness in a variety of
  • Our challenge now is to develop translational
    interventions, using modern technology, to reach
    large numbers of individuals at a low cost.

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 () forAll-Cause
Deaths40,842 Men 12,943 Women, ACLS
Blair SN. Br J Sports Med 2009431-2
(No Transcript)
Center Vision
How to Change Unhealthful Lifestyle Behaviors?
Solutions for the US Health Care Crisis
President ObamaSpeech 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
  • Treatment groups
  • Computer-based assessment of motivational
    readiness for change
  • Computer-generated 4-5 page individualized report
  • Discussed report with physician
  • Control group received packet of health education
  • Outcomes12-month change in
  • Physical activity
  • Body weight
  • reaching 150 MET-min of PA/week at 12 months
  • Experimental group increased from 26 to 53 (p
  • Controls30 at baseline, 37 (p0.27)
  • No difference in weight at 12-months between
  • 21 of experimental group lost 5 of baseline
    weight compared with 10.6 of controls (p lt0.01)
  • 32 of experimental group lost 2.7 kg at
    12-months compared with 19 of controls losing
    2.7 kg (OR2.2, p lt0.01)

Christian JG et al. Arch Int Med 2008 168141-6
Telephone Counseling for Increasing Physical
  • 6-month RCT with 298 sedentary adults (mean
    age45.9 y), 72 women, 45 white 45
  • Study groups
  • Fully automated telephone-linked counseling
    (TLC-PA) based on Stages of Motivational
  • TLC-Eat counseling for healthy eating
  • Results
  • 3-mo TLC-PA more likely to meet PA
  • 6-mo, no differences between groups

Pinto BM et al. Am J Prev Med 2002 23113-20