Brooks C. Wingo

Self-efficacy as a Predictor of Weight Change and Behavior Change in the PREMIER Trial

OBJECTIVES Determine whether self-efficacy independently predicted weight loss in a behavioral intervention and explore factors that influence the path between self-efficacy and weight change. DESIGN Secondary analysis of the PREMIER trial, a randomized controlled trial testing effects of lifestyle interventions on blood pressure. SETTING Four academic medical centers. PARTICIPANTS PREMIER recruited adults (n = 810) with pre-hypertension/stage 1 hypertension, not currently receiving medication. This analysis excluded participants in the control arm, resulting in n = 537. INTERVENTIONS Participants were randomly assigned to 1 of 3 groups: advice only, established lifestyle recommendations, or established lifestyle recommendations plus Dietary Approaches to Stop Hypertension dietary pattern. MAIN OUTCOME MEASURES Self-efficacy (dietary self-efficacy [DSE], exercise self-efficacy [ESE]), dietary intake, fitness. ANALYSIS Pearson correlations, 1-way analysis of variance, mediation analyses. RESULTS Despite an overall decrease in DSE/ESE, change in DSE/ESE significantly predicted weight change at 6 (β = -.21, P < .01; β = -.19, P < .01, respectively) and 18 months (β = -.19, P < .01; β = -.35, P < .01). Change in percent calories from fat partially mediated the DSE/weight change relationship at 6 months. Change in fitness partially mediated the ESE/weight change relationship at 18 months. CONCLUSIONS AND IMPLICATIONS Changes in DSE/ESE were not associated with behavior change as hypothesized. Additional research is needed to identify mediators between self-efficacy and adoption of behaviors that influence weight loss.

Using Formative Research to Develop a Worksite Health Promotion Program for African American Women

ABSTRACT Objectives: To describe the development of a culturally appropriate worksite health promotion program (WHPP) designed to promote increased physical activity and improved nutrition in a high risk group of African American women. Methods: The program was based on EatRight, which is a lifestyle-oriented weight control program that focuses on food volume, rather than calories. Formative research included four nominal group technique (NGT) sessions conducted with 14 African American women from the selected worksite to gather input on job factors that affected their weight and daily life factors that affected their amount of physical activity. Their responses were used to adapt existing EatRight materials to target areas of special need for this unique group. Results: Themes emerged from the NGT sessions that indicated stress at work and an environment of unhealthy eating, in addition to social eating and lack of social support for healthy eating added to unhealthy eating patterns at work. In response to physical activity, the primary themes included lack of time to exercise, stress of multiple family roles and responsibilities, and perceived physical barriers to physical activity. Discussion: Based on the NGT themes, EatRight materials were adapted and additional topics (e.g., increasing social support, overcoming limitations, and time management) were included to develop a WHPP that addressed issues that the participants identified as relevant for their work and home lives. Conducting the NGT sessions and EatRight classes in the work environment, we were able to provide a convenient, familiar environment which fostered social support among participants. We believe that a culturally appropriate modification of EatRight holds great promise in addressing health disparities seen among African American women by offering education on lifestyle changes that will decrease weight through nutrition and physical activity.

Exercise Recommendations and Considerations for Persons With Spinal Cord Injury

Increasing activity and exercise is essential for health and quality of life for people living with spinal cord injury (SCI). Obesity, cardiovascular disease, and diabetes are 2 to 4 times higher for people with SCI compared to the general population. This is due, in part, to low levels of activity, limited access and opportunities to participate in exercise, as well as changes in muscle and heart function that are common after injury. Exercise is necessary to improve fitness and reduce long-term health complications after SCI. Below are exercise recommendations for improving cardiovascular health, muscular strength and endurance, and flexibility for people with SCI.

A study of a culturally enhanced EatRight dietary intervention in a predominately African American workplace.

CONTEXT The workplace may be an ideal venue for engaging African American women in behavioral interventions for weight reduction. OBJECTIVE To examine the effectiveness of a culturally enhanced EatRight dietary intervention among a group of predominately African American women in a workplace setting. DESIGN Crossover design study. SETTING Workplace. PARTICIPANTS A total of 39 women volunteered for this study, of whom 27 completed it. INTERVENTION The control period involved observation of participants for 22 weeks after receiving standard counseling on lifestyle methods to achieve a healthy weight; following the control period, participants crossed over to the 22-week intervention period. The intervention was culturally enhanced using feedback derived from formative assessment and delivered as 15 group sessions. MAIN OUTCOME MEASURES The primary outcome measure was the difference in weight change between the control and intervention periods; changes in waist circumference and quality of life were secondary outcomes. RESULTS Most participants were obese, with a mean baseline body mass index of 36 kg/m², weight of 97.9 kg, and waist circumference of 111 cm. Weight increased during the control period by 0.7 kg but decreased by 2.6 kg during the intervention (net difference = -3.4 kg, P <.001), with 30% of participants losing 5% or more of body weight. Compared to the control period, there was a significant decrease in waist circumference (-3.6 cm, P =.006) and improvement in weight-related quality of life (5.7, P =.03). CONCLUSIONS This pilot study demonstrated the feasibility of a culturally enhanced behavioral weight loss intervention in a predominately African American workplace setting. The workplace may be conducive for targeting African American women who are disproportionately affected by obesity.

Cultural Perceptions of Weight in African American and Caucasian Women

OBJECTIVE To determine if African American (AA) and Caucasian women grouped variables related to race and weight into discrete clusters and if there were discernable response patterns with unique subgroup characteristics. METHODS Women (N=277, 48% AA) completed a card sorting task, ranking 28 variables. We used multidimensional scaling to determine perceived similarities and differences between variables, and latent class analysis to identify subgroups responding similarly. RESULTS We identified 5 clusters of variables and 4 response patterns, which were demographically and anthropometrically distinct. CONCLUSIONS These results can be used for empirical cultural tailoring of behavioral weight loss interventions.

Fear of physical response to exercise among overweight and obese adults

Regular physical activity has been shown to have significant impact on both physical and mental health; however, over half of adults in the US do not meet current recommendations for physical activity. Pain is one of the most commonly cited barriers to physical activity among adults. Fear of pain has been shown to have a significant correlation with pain-related disorders including back pain and arthritis, but no studies have examined the role that weight plays on these fears. We conducted three focus groups (n = 21) to explore the role of fear-avoidance beliefs related to exercise among a group of overweight and obese adults. Focus group members discussed their beliefs that overweight and obese adults have more exaggerated physical responses to exercises than normal weight adults. They also endorsed a belief that overweight and obese individuals interpret similar physical responses differently than normal weight individuals, and that these interpretations lead to fear that may result in exercise avoidance. Further exploration of the role of fear in exercise avoidance will be useful in designing tailored exercise prescriptions and physical activity interventions that may increase adherence among overweight and obese adults.

Effects of Calorie Restriction in Obese Older Adults: The CROSSROADS Randomized Controlled Trial.

Background We lack a comprehensive assessment of the risks and benefits of calorie restriction in older adults at high risk for cardiometabolic disease. Calorie restriction may reduce visceral adipose tissue (VAT) but also have negative effects on lean mass and quality of life. Methods We conducted a 52-week, randomized controlled trial involving 164 older adults with obesity taking at least one medication for hyperlipidemia, hypertension, or diabetes. Interventions included an exercise intervention alone (Exercise), or with diet modification and body weight maintenance (Maintenance), or with diet modification and energy restriction (Weight Loss). The primary outcome was change in VAT at 12 months. Secondary outcomes included cardiometabolic risk factors, functional status, and quality of life. Results A total of 148 participants had measured weight at 12 months. Despite loss of -1.6% ± 0.3% body fat and 4.1% ± 0.7% initial body weight, Weight Loss did not have statistically greater loss of VAT (-192.6 ± 185.2 cm3) or lean mass (-0.4 ± 0.3 kg) compared with Exercise (VAT = -21.9 ± 173.7 cm3; lean mass = 0.3 ± 0.3 kg). Quality of life improved in all groups with no differences between groups. No significant changes in physical function were observed. Weight Loss had significantly greater improvements in blood glucose (-8.3 ± 3.6 mg/dL, p < .05) and HDL-cholesterol (5.3 ± 1.9, p < .01) compared with Exercise. There were no group differences in the frequency of adverse events. Conclusions While moderate calorie restriction did not significantly decrease VAT in older adults at high risk for cardiometabolic disease, it did reduce total body fat and cardiometabolic risk factors without significantly more adverse events and lean mass loss.

Exploratory Study Examining Clinical Measures of Adiposity Risk for Predicting Obesity in Adolescents with Physical Disabilities.

ObjectiveThe purposes of this study were to assess the accuracy of clinical measures for predicting adiposity when compared with a criterion standard of body fat percentage measured by dual-energy X-ray absorptiometry and to determine the most appropriate cut points for classifying obesity for each measure in adolescents with physical disability. DesignBody mass index, triceps skinfolds, and waist, arm, and leg circumferences were collected on 29 adolescents aged 14–17 yrs with spinal cord injury, cerebral palsy, or spina bifida. Percentage of body fat was measured using dual-energy X-ray absorptiometry. Multiple linear regression models were used to assess the ability of measures to predict percentage of body fat. Receiver operating characteristic curves were used to identify optimal cut points for each measure. ResultsAlthough all clinical measures correlated with body fat as measured by dual-energy X-ray absorptiometry, current cut points are not adequate in this group. Using a body mass index of 20 kg/m2 (boys) and 19 kg/m2 (girls) was optimal but still misclassified a significant number of participants as nonobese in this group. Using the optimal cut points for waist circumference, which were 83 cm (boys) and 78 cm (girls), was the best predictor. ConclusionsBody mass index, triceps skinfolds, and waist, leg, and arm circumferences are valid measures for estimating obesity in adolescents with physical disability, but further research is needed to validate disability-specific cut points. To Claim CME Credits:Complete the self-assessment activity and evaluation online at http://www.physiatry.org/JournalCME CME Objectives:Upon completion of this article, the reader should be able to: (1) Understand disparities in obesity rates among adolescents with mobility disabilities; (2) Describe limitations of current clinical screening methods of obesity in children with mobility disabilities; and (3) Identify potential alternatives for obesity screening in children with mobility disabilities. Level:Advanced Accreditation:The Association of Academic Physiatrists is accredited by the Accreditation Council for Continuing Medical Education to provide continuing medical education for physicians. The Association of Academic Physiatrists designates this activity for amaximumof 1.5 AMA PRA Category 1 Credit(s)™. Physicians should only claim credit commensurate with the extent of their participation in the activity.

Calorie Restriction in Overweight Seniors: Response of Older Adults to a Dieting Study: The CROSSROADS Randomized Controlled Clinical Trial

We conducted a study designed to evaluate whether the benefits of intentional weight loss exceed the potential risks in a group of community-dwelling obese older adults who were at increased risk for cardiometabolic disease. The CROSSROADS trial used a prospective randomized controlled design to compare the effects of changes in diet composition alone or combined with weight loss with an exercise only control intervention on body composition and adipose tissue deposition (Specific Aim #1: To compare the effects of changes in diet composition alone or combined with weight loss with an exercise only control intervention on body composition, namely visceral adipose tissue), cardiometabolic disease risk (Specific Aim #2: To compare the effects of a change in diet composition alone or combined with weight loss with an exercise only control intervention on cardiometabolic disease risk), and functional status and quality of life (Specific Aim #3: To compare the effects of a change in diet composition alone or combined with weight loss with an exercise only control intervention on functional status and quality of life). Participants were randomly assigned to one of three groups: Exercise Only (Control) Intervention, Exercise + Diet Quality + Weight Maintenance Intervention, or Exercise + Diet Quality + Weight Loss Intervention. CROSSROADS utilized a lifestyle intervention approach consisting of exercise, dietary, and behavioral components. The development and implementation of the CROSSROADS protocol, including a description of the methodology, detailing specific elements of the lifestyle intervention, assurances of treatment fidelity, and participant retention; outcome measures and adverse event monitoring; as well as unique data management features of the trial results, are presented in this article.

Body Mass Index and Chronic Health Conditions as Predictors of Exercise Fear-Avoidance Beliefs

Obese adults often experience heightened physical responses to exercise, and some may interpret this response as a sign that they are in danger of harm or injury. This fear of harm, or fearavoidance beliefs (FAB), leads some individuals to avoid exercise, leading to increased sedentary behavior and further difficulty maintaining weight. Evidence indicates that body mass index (BMI) is predictive of FAB, but no research has considered the impact of medical conditions on FAB in obese adults. The purpose of this study was to assess the impact of cardiorespiratory and musculoskeletal conditions on FAB. Participants (n=155) completed the Exercise Fear Avoidance Scale (EFAS), a checklist of medical conditions, and the Pain Disability Index. We calculated differences in EFAS scores between groups with and without each condition using t-tests. We used linear regression to calculate the amount of variance in EFAS scores accounted for by BMI, age, pain and condition. Individuals reporting a cardiorespiratory or musculoskeletal condition had significantly higher EFAS scores than those who did not (7.4 points, P<.001; 4.4 points, P=.001, respectively). BMI, pain and age explained significant portions of the variance in EFAS scores (P=.003; P<.001; P=.001, respectively). When added to the regression equations, no condition significantly added to the variance in EFAS scores. While those with cardiorespiratory and musculoskeletal conditions may have higher FAB than those without, BMI appears to contribute to this fear even in individuals without these conditions. Practitioners should consider FAB when discussing exercise recommendations with obese individuals regardless of cardiorespiratory or musculoskeletal history.