Exploring refinements in targeted behavioral medicine intervention to advance public health

Serving up FLAN. a food literacy and nutrition intervention to fend off food insecurity

BACKGROUND

Food insecurity, an ongoing and accelerating problem in the U.S., is an economic and social condition involving limited or uncertain access to adequate food. Some of the highest rates of food insecurity in 2022 were found among individuals who were Hispanic/Latinx (20.8%), a population that already faces disproportionate health and socioeconomic disadvantages. There remains an urgent health-related need to identify sustainable strategies to prevent food insecurity in the Latinx population.

METHODS

A first-generation pilot investigation was conducted using data derived from a sub-study connected to the Computerized Physical Activity Support for Seniors (COMPASS) Trial, a 12-month cluster-randomized controlled trial among older Latinx adults. The sub-study focused on two nutrition interventions that included (1) the Food Literacy and Nutrition (FLAN) curriculum, and (2) a nutrition information-only control. Research hypotheses aimed to determine whether the FLAN intervention reduced food insecurity and increased daily fruit and vegetable servings.

RESULTS

On average, participants (n = 39) were 61.5 years of age (SD = 6.7), mostly female (69%), and reported Spanish as their primary language (69%). The FLAN intervention was associated with decreased odds of food insecurity at 12 months (AOR = 0.71, 95% CI = 0.54, 0.95; p = 0.03) when compared to the nutrition-information only control intervention. Although no between-group differences in daily fruit and vegetable servings were found, there was a significant correlation between changes in daily fruit and vegetable servings from baseline to six months and changes in food insecurity from baseline to 12 months (r = -0.51, p = 0.01).

CONCLUSIONS

The FLAN intervention, a bilingual and culturally tailored educational curriculum, yielded 12-month improvements in food security among a small sample of older Latinx adults. Evidence from this investigation highlights the potential utility of implementing the FLAN curriculum among individuals who are at an increased risk of food insecurity. Further investigation in a larger sample is merited to determine whether the 12-month decreases in food insecurity that were produced by the FLAN intervention can be replicated.

TRIAL REGISTRATION

ClinicalTrials gov Identifier: NCT02111213. Registered on 04/02/2014.

Engagement With Remote Delivery Channels in a Physical Activity Intervention for Senior Women in the US

PURPOSE

Identify the effects of engagement with different intervention delivery channels on physical activity (PA), and the participant subgroups engaging with the different channels, among Women's Health Initiative Strong and Healthy (WHISH) PA trial participants.

DESIGN

Secondary analysis of data from WHISH, a pragmatic trial that used passive randomized consent.

SETTING

United States (remote intervention in all 50 states).

SAMPLE

18,080 U.S. women, aged 68-99 years, assigned to the WHISH PA intervention arm.

MEASURES

6 dichotomous variables operationalized engagement: Engagement with Targeted Inserts, Email (opened), Email (clicked links), Website (logging in), Website (tracking), Interactive Voice Response (IVR). PA was measured using the CHAMPS PA questionnaire.

ANALYSIS

Linear regressions evaluated effects of engagement on PA. Conditional Inference Trees identified subgroups of participants engaging with different channels based on demographic and psychosocial variables.

RESULTS

Engagement with each channel, except IVR, was associated with significantly more hours/week of PA (square root coefficients .29 - .13, P values <.001). Consistently across channels, features that identified subgroups of participants with higher engagement included younger age, and higher levels of PA and physical function. Subgroups with the highest engagement differed from those with the lowest in most participant characteristics.

CONCLUSIONS

For equitable population-level impact via large-scale remotely-delivered PA programs, it may be necessary to identify strategies to engage and target harder to reach subgroups more precisely.

CLINICAL TRIAL REGISTRATION

The WHISH trial is registered at ClinicalTrials.gov (No. NCT02425345).

Serving Up FLAN. A Food Literacy and Nutrition Intervention to Fend Off Food Insecurity

Background

Food insecurity, an ongoing and accelerating problem in the U.S., is an economic and social condition involving limited or uncertain access to adequate food. Some of the highest rates of food insecurity in 2022 were found among individuals who were Hispanic-Latinx (20.8%), a population that already faces disproportionate health and socioeconomic disadvantages. There remains an urgent health-related need to identify sustainable strategies to prevent food insecurity in the Latinx population.

Methods

A first-generation pilot investigation was conducted using data derived from a sub-study connected to the Computerized Physical Activity Support for Seniors (COMPASS) Trial, a 12-month cluster-randomized controlled trial among older Latinx adults. The sub-study focused on two nutrition interventions that included 1) the Food Literacy and Nutrition (FLAN) curriculum, and 2) a nutrition information-only control. Research hypotheses aimed to determine whether the FLAN intervention reduced food insecurity and increased daily fruit and vegetable servings.

Results

On average, participants (n = 39) were 61.5 years of age (SD = 6.7), mostly female (69%), and reported Spanish as their primary language (69%). The FLAN intervention was associated with decreased odds of food insecurity at 12 months (AOR = 0.71, 95% CI = 0.54, 0.95; p = 0.03) when compared to the nutrition-information only control intervention. Although no between-group differences in daily fruit and vegetable servings were found, there was a significant correlation between changes in daily fruit and vegetable servings from baseline to six months and changes in food insecurity from baseline to 12 months (r = -0.51, p = 0.01).

Conclusions

The FLAN intervention, a bilingual and culturally tailored educational curriculum, yielded 12-month improvements in food security among a small sample of older Latinx adults. Evidence from this investigation suggests the potential utility of implementing the FLAN curriculum among individuals who are at an increased risk of food insecurity. Further investigation in a larger sample is merited to determine whether the 12-month decreases in food insecurity that were produced by the FLAN intervention can be replicated.

Trial Registration

ClinicalTrials.gov Identifier: NCT02111213.

Moderators of a Diet and Physical Activity Intervention: who Responds Best to Sequential vs. Simultaneous Approaches

BACKGROUND

Given that low physical activity levels and poor dietary intake are co-occurring risk factors for chronic disease, there is a need for interventions that target both health behaviors, either sequentially or simultaneously. Little is known about participant characteristics that are associated with better or worse response to sequential and simultaneous interventions.

METHOD

The 12-month Counseling Advice for Lifestyle Management (CALM) randomized trial (N = 150; Mage = 55.3 years) targeted these two behaviors either via a sequential approach - dietary advice first then exercise advice added ("Diet-First") or exercise advice first then dietary advice added ("Exercise-First") - or via a simultaneous approach. The objective was to examine demographic, clinical, and psychosocial moderators of intervention effects on 12-month change in (1) moderate-to-vigorous physical activity (MVPA), (2) fruit/vegetable intake, (3) caloric intake from saturated fat, and (4) weight. Hierarchical regressions first compared Diet-First to Exercise-First, followed by comparisons of these arms combined ("sequential") to the simultaneous arm.

RESULTS

Older age, higher baseline BMI, and lower social support were associated with higher MVPA in Exercise-First vs. Diet-First, while lower tangible support was associated with higher fruit/vegetable intake in Exercise-First but not in Diet-First. Poor sleep was associated with higher levels of MVPA in the sequential arm than in the simultaneous arm. Lower vitality was associated with greater weight loss in the sequential arm than in the simultaneous arm, while the opposite was true for those who were not married.

CONCLUSION

Identifying moderators of treatment response can allow the behavioral medicine field to enhance intervention efficacy by matching participant subgroups to their best-fitting interventions.

TRIAL REGISTRATION

NCT00131105.

Estimating the Effects of a Complex, Multidimensional Moderator: An Example of Latent Class Moderation to Examine Differential Intervention Effects of Substance Use Services

Improvements in substance use disorder recovery may be achieved by recognizing that effective interventions do not work equally well for all individuals. Heterogeneity of intervention effects is traditionally examined as a function of a single variable, such as gender or baseline severity. However, responsiveness to an intervention is likely a result of multiple, intersecting factors. Latent class moderation enables the examination of heterogeneity in intervention effects across subgroups characterized by profiles of characteristics. This study analyzed data from adolescents (aged 13 to 18 years old) who needed treatment for cannabis use (n = 14,854) and participated in the Global Appraisal of Individual Needs to evaluate differential effects of substance use services on cannabis use outcomes. We demonstrate an adjusted three-step approach using weights that account for measurement error; sample codes in Mplus and Latent Gold are provided and data are publicly available. Indicators of the latent class moderator comprised six contextual (e.g., recovery environment risk) and individual (e.g., internal mental distress) risk factors. The latent class moderator comprised four subgroups: low risk (21.1%), social risk (21.1%), environmental risk (12.5%), and mixed risk (45.2%). Limited moderation of associations between level of care and any past 90-day cannabis use were observed. In predicting number of cannabis use-days, compared to individuals with low risk, those with environmental risk showed improved outcomes from intensive outpatient care whereas individuals with social risk and mixed risk showed improved outcomes from residential care (all compared to early intervention/outpatient care). Latent class moderation holds potential to elucidate heterogeneity in intervention effectiveness that otherwise may go undetected.

Effects of Desk Pedaling Work Rate on Concurrent Work Performance among Physically Inactive Adults: A Randomized Experiment

PURPOSE

Under-desk pedaling devices could help reduce health risks associated with the global decline in work-related energy expenditure. However, the optimal pedaling work rate to facilitate concurrent work performance among physically inactive adults is unclear. We examined the effects of two light-intensity pedaling work rates on physically inactive adults' work performance.

METHODS

We recruited equal numbers of older (45-65 yr) versus younger (20-44 yr), male versus female, and overweight/obese (body mass index [BMI], 25-35 kg·m -2 ) versus normal weight (BMI, 18.5-24.9 kg·m -2 ) participants. Using a Graeco-Latin square design, participants ( n = 96) completed a laboratory experiment to evaluate the effects of using an under-desk pedaling device at two seated light-intensity work rates (17 and 25 W), relative to a seated nonpedaling condition on objectively measured typing, reading, logical reasoning, and phone task performance. Ergonomic comfort under each pedaling work rate was also assessed. Equivalence tests were used to compare work performance under the pedaling versus nonpedaling conditions.

RESULTS

Treatment fidelity to the 17- and 25-W pedaling work rates exceeded 95%. Mean work performance scores for each pedaling and nonpedaling condition were equivalent under alpha = 0.025. Age, sex, and BMI did not significantly moderate the effect of pedaling on work performance. Participants reported greater ergonomic comfort while completing work tasks at the 17-W relative to the 25-W work rate.

CONCLUSIONS

Physically inactive adults obtained similar work performance scores under the 17- and 25-W pedaling and the nonpedaling conditions, suggesting that either pedaling work rate could help reduce health risks of sedentary work time. The 17-W work rate yielded greater ergonomic comfort and may be an appropriate starting point for introducing diverse inactive workers to under-desk pedaling.

Empowering Our People: Syndemic Moderators and Effects of a Culturally Adapted, Evidence-Based Intervention for Sexual Risk Reduction among Native Americans with Binge Substance Use

Native American (NA) communities are disproportionately affected by the intersecting, synergistic epidemics of sexually transmitted infections (STIs) and substance use. Targeted approaches to addressing these syndemics are critical given the relative scarcity of mental health and behavioral specialists in NA communities. We conducted a series of moderation analyses using data from a randomized controlled trial of the EMPWR (Educate, Motivate, Protect, Wellness, Respect) intervention for reducing sexual risk behaviors, culturally adapted for NA adults with recent binge substance use living on rural reservations. We considered several potential moderators and substance use and sexual risk outcomes at 6- and 12-months post-baseline. Three hundred and one people participated in the study. Age, marital status, educational attainment, employment, and depressive symptoms were differentially associated with intervention effects. EMPWR could be strengthened with the incorporation of additional skills-building related to condom use negotiation with casual partners. For individuals with lower educational attainment or without employment, additional supports and approaches to intervention may be needed. Importantly, this study did not identify intersecting sexual risk and substance use behaviors as moderators of EMPWR effectiveness, suggesting that NA adults with varying levels of risk behavior may be equally likely to benefit from this intervention.

Regular and App-enhanced Maintenance of Physical Activity among Latinas: A Feasibility Study

Introduction

Few studies have focused on physical activity (PA) maintenance, particularly among minority populations; smartphone apps could provide valuable tools. This study aimed to 1) assess and understand PA maintenance among Latinas who completed a PA intervention; and 2) evaluate the feasibility, acceptability and preliminary efficacy of commercial smartphone apps as tools for PA maintenance.

Methods

For this feasibility study, 27 Latinas who completed a PA intervention and increased their PA were randomly assigned to enhanced maintenance (i.e., taught to use commercial smartphone apps, N=14), or regular maintenance (i.e., no additional treatment, N=13). After 3-months, the feasibility and acceptability of using apps for PA maintenance was assessed via survey questions, analyzed using descriptive statistics. PA was reassessed via the 7-day PA Recall and analyzed using longitudinal mixed effects regression models. Qualitative data were collected via open-ended interview questions and analyzed using thematic analysis.

Results

43% of enhanced maintenance participants reported using study apps at least "a little" and 21% using them "a lot." Although not statistically significant, enhanced maintenance participants reported a smaller drop in PA from post-intervention to post-maintenance, compared to regular maintenance participants. Several participants expressed approval of the apps, while others reported on factors that kept them from using the apps for PA maintenance.

Conclusion

Incorporating lessons learned from this study, larger randomized trials are warranted to evaluate the efficacy of using smartphone apps to support PA maintenance. The widespread use of apps could make them ideal tools to support PA maintenance after interventions in different settings.

Sustainable Diets for Cardiovascular Disease Prevention and Management

PURPOSE OF REVIEW

Healthy dietary patterns are recommended for prevention of cardiovascular disease, which remains the leading cause of morbidity and mortality globally. In this review, we discuss dietary patterns that are not only optimal for CVD prevention and management but also sustainable in maximizing health, environmental, and economic benefits.

RECENT FINDINGS

The growing literature on sustainable diets in the context of environmental sustainability includes subtopics of climate change, land use, biodiversity loss, freshwater use, and reactive nitrogen emissions. Similarly, economic sustainability, beyond the retail cost of food, extends to healthcare costs and the economic costs of environmental destruction related to current agricultural practices and food choices. Dietary patterns that are high in plant foods and low in animal foods could maximize health, environmental, and economic benefits; however, questions remain about how to best promote these patterns to achieve wider adoption in an environmentally and economically sustainable way.

Preferences for mHealth physical activity interventions during chemotherapy for breast cancer: a qualitative evaluation

PURPOSE

Physical activity has been shown to decline over the course of chemotherapy in breast cancer survivors; yet it may reduce treatment-related side effects and emerging evidence indicates it may improve disease outcomes. Mobile health (mHealth) interventions may be an effective, scalable strategy to increase physical activity during treatment. However, little is known about breast cancer patients' interests and preferences for these interventions. It is important to understand patients' interests and preferences prior to development of mHealth physical activity interventions to increase their relevance and efficacy.

METHODS

Breast cancer survivors (n = 30) participated in a semi-structured phone interview and were asked about barriers and facilitators to physical activity during chemotherapy as well as their preferences on a range of potential mHealth intervention features. Transcribed interviews were coded and key themes were analyzed using an iterative, inductive approach.

RESULTS

Five key themes were extracted from the interviews: (1) need for education about physical activity during chemotherapy; (2) treatment side effects inhibit physical activity; (3) a structured, home-based, tech-supported program with in-person elements is most feasible; (4) need for a personalized, highly tailored intervention; and (5) importance of social support from other breast cancer survivors, friends, and family.

CONCLUSIONS

Breast cancer survivors are interested in mHealth physical activity interventions during chemotherapy, but preferences for intervention content and delivery varied. Future work should engage patients and survivors in intervention development and testing.

Breast cancer survivors' preferences for mHealth physical activity interventions: findings from a mixed methods study

PURPOSE

Despite the benefits of physical activity for breast cancer survivors, the majority remain insufficiently active. Mobile health (mHealth) physical activity interventions may be a more scalable strategy to increase activity among survivors. However, little is known about their preferences for mHealth intervention features. This study explored survivors' preferences for these features.

METHODS

Survivors (N = 96; Mage = 55.8 (SD = 10.2)) self-reported demographic and disease characteristics, physical activity. A subset (n = 28) completed a semi-structured phone interview. Transcribed interviews were evaluated using a thematic content analysis approach and consensus review. Following interviews, the full sample self-reported interests and preferences for intervention features via online questionnaires. Quantitative data were analyzed using descriptive statistics.

RESULTS

Five themes emerged from interview data: (1) importance of relevance to breast cancer survivors; (2) easy to use; (3) integration with wearable activity trackers; (4) provide sense of accomplishment; and (5) variability in desired level of structure and personalization. The highest ranked intervention features were: daily and weekly progress feedback (87.5%), newsfeed (86.6%), activity challenges (81.3%), and scheduling tool (79.2%). Survivors were interested in receiving progress feedback (80.2%) and motivational (78.1%) and reminder (75.0%) messages.

CONCLUSIONS

Breast cancer survivors are interested in mHealth physical activity promotion interventions, but preferences varied around themes of relevance, ease of use, and enhancing personal motivation.

IMPLICATIONS FOR CANCER SURVIVORS

Engaging survivors in developing and implementing remotely delivered mHealth activity promotion interventions may enhance their effectiveness.

Adherence to Hunger Training over 6 Months and the Effect on Weight and Eating Behaviour: Secondary Analysis of a Randomised Controlled Trial

Monitoring blood glucose prior to eating can teach individuals to eat only when truly hungry, but how adherence to 'hunger training' influences weight loss and eating behaviour is uncertain. This exploratory, secondary analysis from a larger randomized controlled trial examined five indices of adherence to 'hunger training', chosen a priori, to examine which adherence measure best predicted weight loss over 6 months. We subsequently explored how the best measure of adherence influenced eating behavior in terms of intuitive and emotional eating. Retention was 72% (n = 36/50) at 6 months. Frequency of hunger training booklet entry most strongly predicted weight loss, followed by frequency of blood glucose measurements. Participants who completed at least 60 days of booklet entry (of recommended 63 days) lost 6.8 kg (95% CI: 2.6, 11.0; p < 0.001) more weight than those who completed fewer days. They also had significantly higher intuitive eating scores than those who completed 30 days or less of booklet entry; a difference (95% CI) of 0.73 (0.12, 1.35) in body-food choice congruence and 0.79 (0.06, 1.51) for eating for physical rather than emotional reasons. Adherent participants also reported significantly lower scores for emotional eating of -0.70 (-1.13, -0.27). Following hunger training and focusing on simply recording ratings of hunger on a regular basis can produce clinically significant weight loss and clinically relevant improvements in eating behaviour.

Testing the comparative effects of physical activity advice by humans vs. computers in underserved populations: The COMPASS trial design, methods, and baseline characteristics

While physical inactivity is a key risk factor for a range of chronic diseases and conditions associated with aging, a significant proportion of midlife and older adults remain insufficiently active. This is particularly true for ethnic minority populations such as Latino adults for whom few culturally adapted programs have been developed and tested. The major objective of this 12-month cluster-randomized controlled trial is to test the comparative effectiveness of two linguistically and culturally adapted, community-based physical activity interventions with the potential for broad reach and translation. Ten local community centers serving a sizable number of Latino residents were randomized to receive one of two physical activity interventions. The Virtual Advisor program employs a computer-based embodied conversational agent named "Carmen" to deliver interactive, individually tailored physical activity advice and support. A similar intervention program is delivered by trained Peer Advisors. The target population consists of generally healthy, insufficiently active Latino adults ages 50years and older living within proximity to a designated community center. The major outcomes are changes in walking and other forms of physical activity measured via self-report and accelerometry. Secondary outcomes include physical function and well-being variables. In addition to these outcome analyses, comparative cost analysis of the two programs, potential mediators of intervention success, and baseline moderators of intervention effects will be explored to better determine which subgroups do best with which type of intervention. Here we present the study design and methods, including recruitment strategies and yield as well as study baseline characteristics.

TRIAL REGISTRATION

clinicaltrial.gov Identifier=NCT02111213.

Advancing Cancer Prevention and Behavior Theory in the Era of Big Data

The era of “Big Data” presents opportunities to substantively address cancer prevention and control issues by improving health behaviors and refining theoretical models designed to understand and intervene in those behaviors. Yet, the terms “model” and “Big Data” have been used rather loosely, and clarification of these terms is required to advance the science in this area. The objectives of this paper are to discuss conceptual definitions of the terms “model” and “Big Data”, as well as examine the promises and challenges of Big Data to advance cancer prevention and control research using behavioral theories. Specific recommendations for harnessing Big Data for cancer prevention and control are offered.

Effects of Three Motivationally Targeted Mobile Device Applications on Initial Physical Activity and Sedentary Behavior Change in Midlife and Older Adults: A Randomized Trial

BACKGROUND

While there has been an explosion of mobile device applications (apps) promoting healthful behaviors, including physical activity and sedentary patterns, surprisingly few have been based explicitly on strategies drawn from behavioral theory and evidence.

OBJECTIVE

This study provided an initial 8-week evaluation of three different customized physical activity-sedentary behavior apps drawn from conceptually distinct motivational frames in comparison with a commercially available control app.

STUDY DESIGN AND METHODS

Ninety-five underactive adults ages 45 years and older with no prior smartphone experience were randomized to use an analytically framed app, a socially framed app, an affectively framed app, or a diet-tracker control app. Daily physical activity and sedentary behavior were measured using the smartphone's built-in accelerometer and daily self-report measures.

RESULTS

Mixed-effects models indicated that, over the 8-week period, the social app users showed significantly greater overall increases in weekly accelerometry-derived moderate to vigorous physical activity relative to the other three arms (P values for between-arm differences = .04-.005; Social vs. Control app: d = 1.05, CI = 0.44,1.67; Social vs. Affect app: d = 0.89, CI = 0.27,1.51; Social vs. Analytic app: d = 0.89, CI = 0.27,1.51), while more variable responses were observed among users of the other two motivationally framed apps. Social app users also had significantly lower overall amounts of accelerometry-derived sedentary behavior relative to the other three arms (P values for between-arm differences = .02-.001; Social vs. Control app: d = 1.10,CI = 0.48,1.72; Social vs. Affect app: d = 0.94, CI = 0.32,1.56; Social vs. Analytic app: d = 1.24, CI = 0.59,1.89). Additionally, Social and Affect app users reported lower overall sitting time compared to the other two arms (P values for between-arm differences < .001; Social vs. Control app: d = 1.59,CI = 0.92, 2.25; Social vs. Analytic app: d = 1.89,CI = 1.17, 2.61; Affect vs. Control app: d = 1.19,CI = 0.56, 1.81; Affect vs. Analytic app: d = 1.41,CI = 0.74, 2.07).

CONCLUSION

The results provide initial support for the use of a smartphone-delivered social frame in the early induction of both physical activity and sedentary behavior changes. The information obtained also sets the stage for further investigation of subgroups that might particularly benefit from different motivationally framed apps in these two key health promotion areas.

TRIAL REGISTRATION

ClinicalTrials.gov NCT01516411.

Interest in Using Workplace Energy Expenditure Devices Among Primary Care Patients

BACKGROUND

Workplace energy expenditure devices (WEEDs), such as bicycle desks and treadmill desks, can contribute to weight gain prevention and disease risk-reduction. Little is known about the extent to which adults with diverse health risk factors are interested in using WEEDs.

METHODS

Primary care patients aged 18 to 65 years at 2 outpatient clinics in Central Pennsylvania completed a cross-sectional survey in April, 2014 to assess interest in using "a small pedaling device under the desk" and "walking on a treadmill with a desk attached" if these options were provided at no cost. Demographic and health risk factors were also assessed. Multiple logistic regression analyses were used to examine the associations of demographic and health risk factors with interest in using WEEDs.

RESULTS

Among 240 patients, 106 (44.2%) reported interest in using WEEDs. Of these 106 patients, interest in using a bicycle desk (91.5%) was higher than interest in using a treadmill desk (65.1%), P < .001. Females were more likely than males to be interested in using a bicycle desk, and patients aged 18 to 44 years were more likely than those aged 45 to 65 years to be interested in using a treadmill desk.

CONCLUSIONS

Results suggest that diverse patient populations may have interest in using WEEDs. Promoting use of WEEDs in primary care practices could help meet national standards for providing comprehensive, patient-centered care.

An observational study identifying obese subgroups among older adults at increased risk of mobility disability: do perceptions of the neighborhood environment matter?

BACKGROUND

Obesity is an increasingly prevalent condition among older adults, yet relatively little is known about how built environment variables may be associated with obesity in older age groups. This is particularly the case for more vulnerable older adults already showing functional limitations associated with subsequent disability.

METHODS

The Lifestyle Interventions and Independence for Elders (LIFE) trial dataset (n = 1600) was used to explore the associations between perceived built environment variables and baseline obesity levels. Age-stratified recursive partitioning methods were applied to identify distinct subgroups with varying obesity prevalence.

RESULTS

Among participants aged 70-78 years, four distinct subgroups, defined by combinations of perceived environment and race-ethnicity variables, were identified. The subgroups with the lowest obesity prevalence (45.5-59.4%) consisted of participants who reported living in neighborhoods with higher residential density. Among participants aged 79-89 years, the subgroup (of three distinct subgroups identified) with the lowest obesity prevalence (19.4%) consisted of non-African American/Black participants who reported living in neighborhoods with friends or acquaintances similar in demographic characteristics to themselves. Overall support for the partitioned subgroupings was obtained using mixed model regression analysis.

CONCLUSIONS

The results suggest that, in combination with race/ethnicity, features of the perceived neighborhood built and social environments differentiated distinct groups of vulnerable older adults from different age strata that differed in obesity prevalence. Pending further verification, the results may help to inform subsequent targeting of such subgroups for further investigation.

TRIAL REGISTRATION

Clinicaltrials.gov Identifier =  NCT01072500.

Putting evidence into practice: an update of evidence-based interventions for cancer-related fatigue during and following treatment

Cancer-related fatigue (CRF) has deleterious effects on physical, social, cognitive, and vocational functioning, and causes emotional and spiritual distress for patients and their families; however, it remains under-recognized and undertreated. This article critically reviews and integrates the available empirical evidence supporting the efficacy of pharmacologic and nonpharmacologic treatment approaches to CRF, highlighting new evidence since 2007 and 2009 Putting Evidence Into Practice publications. Interventions that are recommended for practice or likely to be effective in improving fatigue outcomes include exercise; screening for treatable risk factors; management of concurrent symptoms; yoga; structured rehabilitation; Wisconsin ginseng; cognitive-behavioral therapies for insomnia, pain, and depression; mindfulness-based stress reduction; and psychoeducational interventions such as anticipatory guidance, psychosocial support, and energy conservation and activity management. This information can be applied to improve the management of CRF, inform health policy and program development, shape the design of clinical trials of new therapies for CRF, and drive basic and translational research.

Depression moderates treatment efficacy of an HIV secondary-prevention intervention for HIV-positive late middle-age and older adults

An estimated one-third of HIV-positive older adults continues to engage in sexual behaviors that risk HIV transmission or the acquisition of other sexually transmitted infections. A recently completed pilot randomized controlled trial of telephone-administered motivational interviewing (Tele-MI) targeting sexual risk behavior in 100 HIV-positive late middle-age and older adults found that a four-session Tele-MI intervention reduced episodes of non-condom-protected anal and vaginal intercourse. This secondary analysis examined the moderating effect of baseline depressive symptoms on intervention efficacy. When compared to one session of Tele-MI or standard of care, four sessions of Tele-MI produced greater reductions in sexual risk behavior in participants with subsyndromal depression at baseline but was no more efficacious than the other two conditions for participants with no or elevated baseline depressive symptoms. Large-scale studies that further elucidate the role of depression in sexual risk reduction interventions for HIV-positive persons are needed.

A mediator effect size in randomized clinical trials

To understand the process by which a treatment (T) achieves an effect on outcome (O) and thus to improve the effect of T on O, it is vital to detect mediators, to compare the impact of different mediators, and to develop hypotheses about the causal factors (all mediators) linking T and O. An index is needed to facilitate interpretation of the potential clinical importance of a mediator (M) of choice of T on treatment O in randomized clinical trials (RCTs). Ideally such a mediator effect size should (1) be invariant under any rescaling of M and O consistent with the model used, and (2) reflect the difference between the overall observed effect of T on O and what the maximal effect of T on O could be were the association between T and M broken. A mediator effect size is derived first for the traditional linear model, and then more generally for any categorical (ordered or non-ordered) potential mediator. Issues such as the problem of multiple treatments, outcomes and mediators, and of causal inferences, and the correspondence between this approach and earlier ones, are discussed. Illustrations are given of the application of the approach.

Behavioral medicine in the 21st century: transforming "the Road Less Traveled" into the "American Way of Life"

INTRODUCTION

A key objective of this paper is to describe some major challenges and opportunities facing the behavioral medicine field in the current decade. Amidst current US statistics that present a sobering image of the nation's health, there have been a number of notable achievements in the behavioral medicine field that span the scientific/health continuum. However, many of these achievements have received little notice by the public and decision makers.

METHODS

A case is presented for the potential of scientific narrative for presenting behavioral medicine evidence in ways that engage attention and compel action. Additional areas for behavioral medicine engagement include expanding interdisciplinary connections into new arenas, continuing the growth of activities involving emerging technologies, building international connections, and engaging with policy.

CONCLUSION

Finally, the fundamental importance of an integrated behavioral medicine field that plays an active role in supporting and advancing its members and the field as a whole is discussed.

Reallocating time to sleep, sedentary behaviors, or active behaviors: associations with cardiovascular disease risk biomarkers, NHANES 2005-2006

Sleep and sedentary and active behaviors are linked to cardiovascular disease risk biomarkers, and across a 24-hour day, increasing time in 1 behavior requires decreasing time in another. We explored associations of reallocating time to sleep, sedentary behavior, or active behaviors with biomarkers. Data (n = 2,185 full sample; n = 923 fasting subanalyses) from the cross-sectional 2005-2006 US National Health and Nutrition Examination Survey were analyzed. The amounts of time spent in sedentary behavior, light-intensity activity, and moderate-to-vigorous physical activity (MVPA) were derived from ActiGraph accelerometry (ActiGraph LLC, Pensacola, Florida), and respondents reported their sleep duration. Isotemporal substitution modeling indicated that, independent of potential confounders and time spent in other activities, beneficial associations (P < 0.05) with cardiovascular disease risk biomarkers were associated with the reallocation of 30 minutes/day of sedentary time with equal time of either sleep (2.2% lower insulin and 2.0% lower homeostasis model assessment of β-cell function), light-intensity activity (1.9% lower triglycerides, 2.4% lower insulin, and 2.2% lower homeostasis model assessment of β-cell function), or MVPA (2.4% smaller waist circumference, 4.4% higher high-density lipoprotein cholesterol, 8.5% lower triglycerides, 1.7% lower glucose, 10.7% lower insulin, and 9.7% higher homeostasis model assessment of insulin sensitivity. These findings provide evidence that MVPA may be the most potent health-enhancing, time-dependent behavior, with additional benefit conferred from light-intensity activities and sleep duration when reallocated from sedentary time.

Television viewing time in Hong Kong adult population: associations with body mass index and obesity

Background

Obesity is increasing dramatically in the Asia-Pacific region particularly China. The population of Hong Kong was exposed to modernization far earlier than the rest of China, reflecting conditions that are likely to be replicated as other Chinese cities undergo rapid change. This study examined the relationship between television viewing and obesity in a Hong Kong sample. Information about the relationship between a key sedentary behavior, TV viewing, and obesity, and its moderation by demographic characteristics may identify sectors of the population at highest risk for excess weight.

Methods

Data were from Hong Kong Family and Health Information Trends Survey (2009–2010), a population-based survey on the public's use of media for health information and family communication by telephone interviews with 3,016 Hong Kong adults (age≥18 years). TV viewing time, body mass index (BMI), physical activity and other lifestyle variables were analyzed.

Results

Viewing time was longer in women, increased with age but decreased with education level and vigorous physical activity (all P<0.01). Longer TV viewing time was significantly associated with higher BMI (Coefficients B = 0.17, 95% CI: 0.11, 0.24) after adjusting for age, gender, employment status, marital status, education level, smoking activity and vigorous physical activity. This association was stronger in women than men (Coefficients B: 0.19 versus 0.15) and strongest in those aged 18 to 34 years (Coefficients B = 0.35). Furthermore, an hour increase in daily TV viewing was associated with 10% greater odds of being obese.

Conclusions

A significant socioeconomic gradient in television viewing time was observed. TV viewing time positively associated with BMI and obesity. The TV viewing – BMI associations were strongest in women and young adults, suggesting vulnerable groups to target for obesity prevention by decreasing TV viewing.

Exploring behavioral markers of long-term physical activity maintenance: a case study of system identification modeling within a behavioral intervention

Efficacious interventions to promote long-term maintenance of physical activity are not well understood. Engineers have developed methods to create dynamical system models for modeling idiographic (i.e., within-person) relationships within systems. In behavioral research, dynamical systems modeling may assist in decomposing intervention effects and identifying key behavioral patterns that may foster behavioral maintenance. The Active Adult Mentoring Program was a 16-week randomized controlled trial of a group-based, peer-delivered physical activity intervention targeting older adults. Time-intensive (i.e., daily) physical activity reports were collected throughout the intervention. We explored differential patterns of behavior among participants who received the active intervention (N = 34; 88% women, 64.1 ± 8.3 years of age) and either maintained 150 minutes/week of moderate to vigorous intensity physical activity (MVPA; n = 10) or did not (n = 24) at 18 months following the intervention period. We used dynamical systems modeling to explore whether key intervention components (i.e., self-monitoring, access to an exercise facility, behavioral initiation training, behavioral maintenance training) and theoretically plausible behavioral covariates (i.e., indoor vs. outdoor activity) predicted differential patterns of behavior among maintainers and nonmaintainers. We found that maintainers took longer to reach a steady-state of MVPA. At week 10 of the intervention, nonmaintainers began to drop whereas maintainers increased MVPA. Self-monitoring, behavioral initiation training, percentage of outdoor activity, and behavioral maintenance training, but not access to an exercise facility, were key variables that explained patterns of change among maintainers. Future studies should be conducted to systematically explore these concepts within a priori idiographic (i.e., N-of-1) experimental designs.

Exploring connections between moderators and mediators: commentary on subgroup analyses in intervention research

Although subgroup analyses, and moderator analyses more generally, in intervention research are fraught with analytic and conceptual challenges, they provide invaluable insights into the effectiveness of intervention strategies and the theoretical models upon which they rest. The papers in this Special Issue engage these challenges and offer investigators a set of strategies that will enhance how they think about, measure, test, and report evidence of moderated intervention effects. In this commentary, I echo the call for more thoughtful work on moderated intervention effects and, in particular, urge investigators to pursue opportunities to integrate questions regarding mediation as they work to specify how intervention strategies operate across populations, settings, and behavioral domains.

Determining who responds better to a computer- vs. human-delivered physical activity intervention: results from the community health advice by telephone (CHAT) trial

BACKGROUND

Little research has explored who responds better to an automated vs. human advisor for health behaviors in general, and for physical activity (PA) promotion in particular. The purpose of this study was to explore baseline factors (i.e., demographics, motivation, interpersonal style, and external resources) that moderate intervention efficacy delivered by either a human or automated advisor.

METHODS

Data were from the CHAT Trial, a 12-month randomized controlled trial to increase PA among underactive older adults (full trial N = 218) via a human advisor or automated interactive voice response advisor. Trial results indicated significant increases in PA in both interventions by 12 months that were maintained at 18-months. Regression was used to explore moderation of the two interventions.

RESULTS

Results indicated amotivation (i.e., lack of intent in PA) moderated 12-month PA (d = 0.55, p < 0.01) and private self-consciousness (i.e., tendency to attune to one's own inner thoughts and emotions) moderated 18-month PA (d = 0.34, p < 0.05) but a variety of other factors (e.g., demographics) did not (p > 0.12).

CONCLUSIONS

Results provide preliminary evidence for generating hypotheses about pathways for supporting later clinical decision-making with regard to the use of either human- vs. computer-delivered interventions for PA promotion.

Pre-college matriculation risk profiles and alcohol consumption patterns during the first semesters of college

Excessive alcohol consumption represents a significant concern on U.S. college campuses, and there is a need to identify students who may be at risk for engaging in risky alcohol use. The current study examined how variables measured prior to college matriculation, specifically alcohol-related decision-making variables drawn from the Theory of Reasoned Action (i.e., alcohol expectancies, attitudes, and normative beliefs), were associated with patterns of alcohol use prior to and throughout the first semesters of college. Participants were 392 undergraduate students (56% female) from a large Northeastern U.S. university. Decision-making variables were assessed prior to college matriculation, and alcohol use was measured with five assessments before and throughout freshman and sophomore semesters. Latent profile analysis was used to identify types of students with distinct patterns of decision-making variables. These decision-making profiles were subsequently linked to distinct patterns of alcohol use using latent transition analysis. Four distinct decision-making profiles were found and were labeled "Anti-Drinking," "Unfavorable," "Mixed," and "Risky." Five drinking patterns were observed and included participants who reported consistently low, moderate, or high rates of alcohol use. Two patterns described low or non-drinking at the pre-college baseline with drinking escalation during the measurement period. Students' likelihood of following the various drinking patterns varied according to their decision-making. Findings suggest the early identification of at-risk students may be improved by assessing decision-making variables in addition to alcohol use. The findings also have implications for the design of early identification assessments to identify at-risk college students and for the targeting of alcohol prevention efforts to students based on their alcohol-related attitudes and beliefs.

Translating the Diabetes Prevention Program lifestyle intervention for weight loss into primary care: a randomized trial

BACKGROUND

The Diabetes Prevention Program (DPP) lifestyle intervention reduced the incidence of type 2 diabetes mellitus (DM) among high-risk adults by 58%, with weight loss as the dominant predictor. However, it has not been adequately translated into primary care.

METHODS

We evaluated 2 adapted DPP lifestyle interventions among overweight or obese adults who were recruited from 1 primary care clinic and had pre-DM and/or metabolic syndrome. Participants were randomized to (1) a coach-led group intervention (n = 79), (2) a self-directed DVD intervention (n = 81), or (3) usual care (n = 81). During a 3-month intensive intervention phase, the DPP-based behavioral weight-loss curriculum was delivered by lifestyle coach-led small groups or home-based DVD. During the maintenance phase, participants in both interventions received lifestyle change coaching and support remotely-through secure email within an electronic health record system and the American Heart Association Heart360 website for weight and physical activity goal setting and self-monitoring. The primary outcome was change in body mass index (BMI) (calculated as weight in kilograms divided by height in meters squared) from baseline to 15 months.

RESULTS

At baseline, participants had a mean (SD) age of 52.9 (10.6) years and a mean BMI of 32.0 (5.4); 47% were female; 78%, non-Hispanic white; and 17%, Asian/Pacific Islander. At month 15, the mean ± SE change in BMI from baseline was -2.2 ± 0.3 in the coach-led group vs -0.9 ± 0.3 in the usual care group (P < .001) and -1.6 ± 0.3 in the self-directed group vs usual care (P = .02). The percentages of participants who achieved the 7% DPP-based weight-loss goal were 37.0% (P = .003) and 35.9% (P = .004) in the coach-led and self-directed groups, respectively, vs 14.4% in the usual care group. Both interventions also achieved greater net improvements in waist circumference and fasting plasma glucose level.

CONCLUSION

Proven effective in a primary care setting, the 2 DPP-based lifestyle interventions are readily scalable and exportable with potential for substantial clinical and public health impact.

TRIAL REGISTRATION

clinicaltrials.gov Identifier: NCT00842426.

Translating the Diabetes Prevention Program lifestyle intervention for weight loss into primary care: a randomized trial

BACKGROUND

The Diabetes Prevention Program (DPP) lifestyle intervention reduced the incidence of type 2 diabetes mellitus (DM) among high-risk adults by 58%, with weight loss as the dominant predictor. However, it has not been adequately translated into primary care.

METHODS

We evaluated 2 adapted DPP lifestyle interventions among overweight or obese adults who were recruited from 1 primary care clinic and had pre-DM and/or metabolic syndrome. Participants were randomized to (1) a coach-led group intervention (n = 79), (2) a self-directed DVD intervention (n = 81), or (3) usual care (n = 81). During a 3-month intensive intervention phase, the DPP-based behavioral weight-loss curriculum was delivered by lifestyle coach-led small groups or home-based DVD. During the maintenance phase, participants in both interventions received lifestyle change coaching and support remotely-through secure email within an electronic health record system and the American Heart Association Heart360 website for weight and physical activity goal setting and self-monitoring. The primary outcome was change in body mass index (BMI) (calculated as weight in kilograms divided by height in meters squared) from baseline to 15 months.

RESULTS

At baseline, participants had a mean (SD) age of 52.9 (10.6) years and a mean BMI of 32.0 (5.4); 47% were female; 78%, non-Hispanic white; and 17%, Asian/Pacific Islander. At month 15, the mean ± SE change in BMI from baseline was -2.2 ± 0.3 in the coach-led group vs -0.9 ± 0.3 in the usual care group (P < .001) and -1.6 ± 0.3 in the self-directed group vs usual care (P = .02). The percentages of participants who achieved the 7% DPP-based weight-loss goal were 37.0% (P = .003) and 35.9% (P = .004) in the coach-led and self-directed groups, respectively, vs 14.4% in the usual care group. Both interventions also achieved greater net improvements in waist circumference and fasting plasma glucose level.

CONCLUSION

Proven effective in a primary care setting, the 2 DPP-based lifestyle interventions are readily scalable and exportable with potential for substantial clinical and public health impact.

TRIAL REGISTRATION

clinicaltrials.gov Identifier: NCT00842426.

Incorporating prototyping and iteration into intervention development: a case study of a dining hall-based intervention

BACKGROUND

Previous research from the fields of computer science and engineering highlight the importance of an iterative design process (IDP) to create more creative and effective solutions.

OBJECTIVE

This study describes IDP as a new method for developing health behavior interventions and evaluates the effectiveness of a dining hall-based intervention developed using IDP on college students' eating behavior and values.

PARTICIPANTS

participants were 458 students (52.6% female, age = 19.6 ± 1.5 years [M ± SD]).

METHODS

The intervention was developed via an IDP parallel process. A cluster-randomized controlled study compared differences in eating behavior among students in 4 university dining halls (2 intervention, 2 control).

RESULTS

The final intervention was a multicomponent, point-of-selection marketing campaign. Students in the intervention dining halls consumed significantly less junk food and high-fat meat and increased their perceived importance of eating a healthful diet relative to the control group.

CONCLUSION

IDP may be valuable for the development of behavior change interventions.

Treatment matching for obesity: identifying mediators of psychosocial and behavioral intervention components

In light of the limited long-term success of obesity treatments, it is tempting to consider the elusive goal of ‘treatment matching', in which characteristics of individuals are optimally matched to targeted treatments to improve success. Previous frameworks for treatment matching in obesity have primarily focused on basic physiological characteristics, such as initial degree of overweight, and on treatment intensity, such as stepped-care alternatives (self-help manuals, group support, medication and surgery). Few studies have empirically evaluated the success of these frameworks. Given recent advances in genomics, neuroscience and other fields, both the breadth of domains and combinations of individuals' characteristics that could be used for treatment matching have increased markedly. Although the obesity field seems poised to build on these advances, a crucial challenge remains regarding the treatments themselves. Ultimately, the success of treatment matching will rely on identifying treatment intervention components with well-differentiated and empirically supported mediators, that is, clear insights into how intervention components work. Here we examine the scope of this challenge specifically for the design of efficacious psychosocial and behavioral intervention components, and identify areas for future research.

Skin cancer concerns and genetic risk information-seeking in primary care

BACKGROUND

Genomic testing for common genetic variants associated with skin cancer risk could enable personalized risk feedback to motivate skin cancer screening and sun protection.

METHODS

In a cross-sectional study, we investigated whether skin cancer cognitions and behavioral factors, sociodemographics, family factors, and health information-seeking were related to perceived importance of learning about how (a) genes and (b) health habits affect personal health risks using classification and regression trees (CART).

RESULTS

The sample (n = 1,772) was collected in a large health maintenance organization as part of the Multiplex Initiative, ranged in age from 25-40, was 53% female, 41% Caucasian, and 59% African-American. Most reported that they placed somewhat to very high importance on learning about how genes (79%) and health habits (88%) affect their health risks. Social influence actors were associated with information-seeking about genes and health habits. Awareness of family history was associated with importance of health habit, but not genetic, information-seeking.

CONCLUSIONS

The investment of family and friends in health promotion may be a primary motivator for prioritizing information-seeking about how genes and health habits affect personal health risks and may contribute to the personal value, or personal utility, of risk information. Individuals who seek such risk information may be receptive to interventions aimed to maximize the social implications of healthy lifestyle change to reduce their health risks.

Women's cognitive and affective reactions to breast cancer survivor stories: a structural equation analysis

OBJECTIVE

Compare the immediate affective and cognitive reactions to cancer survivor stories about mammography and breast cancer vs. a didactic, informational approach.

METHODS

Participants (N=489) were African American women age 40 years and older (mean=61). Most had ≤high school education (67%), annual household income ≤$20,000 (77%), and a prior mammogram (89%). Participants completed surveys before and after watching the narrative or informational video. We used structural equation modeling to examine the large number of inter-related latent constructs.

RESULTS

Women who watched the narrative video experienced more positive and negative emotions, found it easier to understand the video, had more positive evaluations of the video, reported stronger identification with the message source (i.e., perceived similarity, trust, liking), and were more engaged with the video.

CONCLUSION

Narratives elicited immediate reactions consistent with theorized pathways of how communication affects behavior. Future studies should examine whether and how these immediate outcomes act as mediators of the longer term effects of narratives on affect, cognitions, and behavior.

PRACTICE IMPLICATIONS

Stories of other women's experiences may be more powerful than a didactic presentation when encouraging African American women to get a mammogram.

Pre-intervention distress moderates the efficacy of psychosocial treatment for cancer patients: a meta-analysis

This meta-analysis examined whether effects of psychosocial interventions on psychological distress in cancer patients are conditional upon pre-intervention distress levels. Published articles and unpublished dissertations between 1980 and 2005 were searched for interventions reporting the Hospital Anxiety and Depression Scale (HADS) or the Spielberger State-Trait Anxiety Inventory (STAI). Multilevel mixed-effects modeling was used to meta-analyze effect-sizes separately for the HADS (27 trials, 2,424 patients) and STAI (34 trials, 2,029 patients). Pre-intervention distress significantly moderated intervention effects, explaining up to 50% of the between-study effect-size variance: effects on anxiety and depression were generally negligible when pre-intervention distress was low and pronounced when it was high. These results could not be explained by differences in intervention type, setting, dose, and whether intervention was targeted at distressed patients. Psychosocial interventions may be most beneficial for cancer patients with elevated distress. Future research should identify which treatment components are most effective for these patients to facilitate optimal treatment tailoring and cost-effective health care.

A comparison of the efficacy of an appearance-focused skin cancer intervention within indoor tanner subgroups identified by latent profile analysis

The reduction of intentional exposure to ultraviolet (UV) radiation is an important area of skin cancer prevention. Hillhouse et al. (Cancer 113:3257-3266, 2008) have developed an appearance-focused intervention with evidence of efficacy in lowering indoor tanning UV exposure in young women. In the current study, a subgroup approach was used to determine moderators of intervention efficacy. Undergraduate females in two regions of the United States (n = 362) were randomized into an intervention or control condition. Latent profile analysis was used to identify subgroups of indoor tanners based on patterns of indoor tanning motives. Intervention efficacy was examined within each subgroup. We found evidence for 4 subgroups of tanners: knowledgeable-appearance tanners, low-knowledge tanners, low-knowledge, relaxation tanners, and knowledgeable, low-appearance and low-relaxation tanners. The intervention significantly reduced indoor tanning for the low-knowledge subgroup (34% of the sample). The utility of the subgroup approach in developing targeted behavioral skin cancer interventions is discussed.

Identifying subgroups of U.S. adults at risk for prolonged television viewing to inform program development

BACKGROUND

Although adverse health effects of prolonged TV viewing have been increasingly recognized, little population-wide information is available concerning subgroups at greatest risk for this behavior.

PURPOSE

This study sought to identify, in a U.S. population-derived sample, combinations of variables that defined subgroups with higher versus lower levels of usual TV-viewing time.

METHODS

A total of 5556 adults from a national consumer panel participated in the mail survey in 2001 (55% women, 71% white, 13% black, and 11% Hispanic). Nonparametric risk classification analyses were conducted in 2008.

RESULTS

Subgroups with the highest proportions of people watching >14 hours/week of TV were identified and described using a combination of demographic (i.e., lower household incomes, divorced/separated); health and mental health (i.e., poorer rated overall health, higher BMI, more depression); and behavioral (i.e., eating dinner in front of the TV, smoking, less physical activity) variables. The subgroup with the highest rates of TV viewing routinely ate dinner while watching TV and had lower income and poorer health. Prolonged TV viewing also was associated with perceived aspects of the neighborhood environment (i.e., heavy traffic and crime, lack of neighborhood lighting, and poor scenery).

CONCLUSIONS

The results can help inform intervention development in this increasingly important behavioral health area.

Why and how to improve physical activity promotion: lessons from behavioral science and related fields

This commentary highlights the importance of regular physical activity to the nation's health and discusses some of the major challenges and opportunities currently facing the field.

The Effectiveness of Lifestyle Physical Activity Interventions to Reduce Cardiovascular Disease

Lifestyle interventions have evolved from proof of concept pilot studies to efficacy and effectiveness studies and have now moved toward translation and dissemination studies because of their demonstrated ability to improve cardiovascular diseases (CVD) outcomes including blood pressure. When combined with diet, they also have demonstrated the ability to normalize blood glucose and help to regulate weight. This review highlights the converging lines of evidence that led to lifestyle physical activity interventions beginning with early epidemiology studies and provides evidence for the efficacy and effectiveness of lifestyle interventions. However, if lifestyle interventions are to play a role in preventing CVD and improving CVD outcomes, their use must be more widespread. This will require translational and dissemination research in order to understand how to move into real world settings. Successful examples of translational studies will be highlighted and issues related to theoretical and practical issues as well as capacity building will be discussed. Building bridges between research and practice must be done if lifestyle interventions are to deliver on their public health promise.