Pilot Test of an Acceptance-Based Behavioral Intervention to Promote Physical Activity During Weight Loss Maintenance

Testing the Feasibility and Acceptability of an Acceptance and Commitment Therapy Intervention to Increase Physical Activity among Individuals with Depression: A Protocol Paper

Background

Engaging in regular physical activity (PA) is particularly important among individuals with depression, who are at heightened risk for a host of negative health outcomes. However, people with depression are 50% less likely to meet national guidelines for PA and face unique barriers to PA adherence, including lower distress tolerance and motivation for exercise. Acceptance and Commitment Therapy (ACT) may offer promise for increasing PA among adults with depressive symptoms due to its effects on distress tolerance and motivation. Therefore, we developed ACTivity, an ACT-based intervention designed to promote PA among low-active adults with elevated depressive symptoms. Prior to testing the efficacy of ACTivity in an RCT, an important first step is to conduct a preliminary trial to establish feasibility of study procedures for the ACTivity and comparison intervention programs, as well as to establish the credibility/acceptability of the intervention. The purpose of this paper is to describe the ACTivity intervention and the design of this feasibility trial.

Method/Design

We will conduct a feasibility RCT with two parallel groups and a 1:1 allocation ratio comparing ACTivity to a comparison intervention (relaxation training + PA promotion) among 60 low-active adults with elevated depressive symptoms. All study procedures will be conducted remotely.

Discussion

Results of this feasibility study will inform a subsequent RCT designed to test the efficacy of ACTivity. If shown to be efficacious, ACTivity will provide a treatment that can be widely disseminated to increase PA among adults with depressive symptoms and thereby decrease their risk for chronic disease.

A scoping review of behavior change techniques used to promote physical activity among women in midlife

Women in midlife experience health risks that could be mitigated by regular physical activity and reduced sedentary time, but this population rarely achieves physical activity levels that would protect their health. As a result, many behavioral interventions are designed to promote physical activity in this population, which are purportedly guided by theoretical models of health behavior (change) and activate an associated set of behavior change techniques (BCTs). The efficacy and effectiveness of these interventions appear to be limited, however, raising questions about their design and adaptation for women in midlife. Several aspects of these interventions are currently unclear. Specifically, which women they target (i.e., how “midlife” and “sedentary” or “inactive” are defined), which theoretical models or behavior BCTs are used, and how BCTs are activated in such interventions. A synthesis of this information would be useful as an initial step toward improving physical activity interventions for this at-risk group, and thus, represented the goal of the present scoping review. Eligibility required publication in a peer-reviewed journal in English between 2000 and 2021, inclusion of only women in midlife who did not have any medical or other restrictions on their physical activity (e.g., cancer diagnosis), and free-living physical activity or sedentary behavior as the target outcome (with associated assessment). Of the 4,410 initial results, 51 articles met inclusion criteria, and these described 36 unique interventions. More than half of the articles (59%) named an underlying theoretical model and interventions included an average of 3.76 identifiable BCTs (range 1–11). However, descriptions of many interventions were limited and did not provide enough detail to determine whether or how specific BCTs were activated. Interventions also used a wide range of inclusion criteria for age range and starting activity level, which has implications for targeting/tailoring and effectiveness, and many interventions focused on marginalized populations (e.g., women from racial/ethnic minority backgrounds, those un- or under-insured). The present review identifies some strengths and highlights important limitations of existing literature, as well as key opportunities for advancing the design and potential utility of physical activity interventions for women in midlife.

Subjective experiences of physical activity and forecasting bias during behavioral weight loss

Introduction

Engagement in physical activity (PA) is a critical component of behavioral weight loss (BWL) treatment. Subjective experiences surrounding PA may shape exercise decisions and need to be further understood within a BWL sample.

Methods

Participants in this study were adults with overweight/obesity enrolled in an 18-month BWL program. At baseline, six, and 18 months, participants (N = 320) predicted how they would feel during a lab-based walking task and rated their experiences mid-walk and post-walk. They also completed self-report questionnaires assessing depressive symptoms and discomfort intolerance.

Results and Discussion

Results indicated that exercise experience and expectations were more positive at later treatment points than at baseline. At each assessment point, post-walk ratings were more positive than mid-walk ratings, but pre-walk ratings did not differ from mid-walk ratings, suggesting BWL participants were relatively accurate in predicting their PA experience. These results suggest treatment-seeking adults with overweight/obesity feel most positive upon completion of PA, may not experience a forecasting bias as hypothesized and seem to have increasingly positive PA expectations and experiences as they proceed through treatment and lose weight. Lower discomfort intolerance and depressive symptoms were associated with more positive PA expectations and experiences. Understanding these individual differences in PA experience can inform intervention strategies.

Why We Are Not Acting to Save Ourselves: ACT, Health, and Culture

Chronic health conditions are increasing at an alarming rate worldwide, and many could be prevented if people were to engage in specific lifestyle behaviors. Intervening on lifestyle behaviors is challenging due to the fact that the consequences associated with unhealthy behaviors are temporally distant and probabilistic, and the aversive functions of covert stimuli may interfere with people's engagement in healthy, preventative behaviors. This article explores the role of relational framing in the promotion of healthy lifestyle behaviors and summarizes research supporting the use of acceptance and commitment training (ACT) as a framework for prevention and intervention. We explore how ACT alters the context in which rigid patterns of rule following occur. ACT loosens the literal functions of stimuli so that experiential-avoidance behaviors are weakened, and healthy, values-consistent behaviors are strengthened. We propose culture-wide interventions inspired by contextual behavior science so that healthier societies can be cultivated.

Preliminary Evaluation of a 1-Day Acceptance and Commitment Therapy Workshop for Increasing Moderate-to-Vigorous Physical Activity in Adults with Overweight or Obesity

BACKGROUND

Novel strategies to help adults with overweight/obesity increase motivation for becoming active are needed. This single-arm trial aimed to test the feasibility, acceptability, and preliminary efficacy of a 4-h acceptance and commitment therapy (ACT)-based workshop intervention for increasing moderate-to-vigorous physical activity (MVPA) among insufficiently active adults with overweight/obesity.

METHODS

Participants (N = 41) received a 1-day 4-h ACT workshop followed by weekly e-mails and monthly phone calls for 3 months. The primary outcome was change in accelerometer-measured MVPA minutes/day at 3 and 6 months. Process variables (i.e., autonomous motivation, PA acceptance) through which the ACT intervention was hypothesized to increase MVPA were assessed via questionnaires.

RESULTS

Participants completed 91% of phone calls and 75% of e-mail surveys. Acceptability ratings were > 4.5 out of 5 for "understandable," "useful," and "intent-to-use" on all intervention components. Participants on average achieved significant increases in bouted and total MVPA at 3 months that were maintained at 6 months. Participants also reported significant increases in physical activity acceptance and autonomous motivation, the latter of which related to MVPA changes.

CONCLUSION

Results support the feasibility and acceptability of the ACT workshop intervention for promoting MVPA changes among insufficiently active adults with overweight/obesity. Rigorous testing of this approach as a low-intensity standalone or add-on intervention to increase MVPA is warranted.

Feasibility, Acceptability, and Preliminary Target Engagement of a Healthy Physical Activity Promotion Intervention for Bulimia Nervosa: Development and Evaluation via Case Series Design

Bulimia nervosa (BN) is characterized by a pattern of binge eating and compensatory behaviors as well as an overemphasis on body weight and shape in self-evaluation. Although cognitive behavioral therapy (CBT) is efficacious, recent reviews suggest that only 30% of patients reach abstinence at posttreatment. One potential reason for these poor outcomes is that CBT fails to adequately reduce elevated negative affect (NA) and shape and weight concern, which have been shown to be correlated with poorer treatment outcomes in BN. Therefore, novel treatment components that focus on improving NA and shape and weight concern are needed in order to enhance outcomes. Promoting physical activity (PA) is a promising avenue through which to reduce NA and improve body image in healthy individuals, other clinical populations (e.g., individuals with depression or anxiety), and individuals with eating disorders. While prescribing PA for individuals with BN has been controversial (due to concerns that exercise maybe be used to compensate for binge episodes or become driven or compulsive), this approach may have many benefits, including promoting healthy lifetime exercise habits that reduce likelihood of relapse through the improvement of emotion regulation skills and weight regulation. Given the promise of PA for targeting key maintenance factors of BN, we developed a 12-session healthy PA promotion intervention for BN and tested initial feasibility, acceptability, and preliminary target engagement in an iterative case series design (n = 3). The treatment provided cognitive-behavioral skills designed to identify, practice, and achieve behavioral goals while asking patients to engage in up to 150 minutes of moderate-to-vigorous PA per week, which was preplanned during each session with the client's therapist. Results suggested that the healthy PA promotion intervention was both feasible and acceptable to deliver. In addition, the intervention resulted in a clinically significant decrease in BN symptom frequency in each participant. Further, participants showed clinically significant decreases in NA and shape and weight concern. The current study demonstrates that healthy PA interventions can have beneficial effects on BN symptoms, NA, and shape and weight concern. However, due to the small sample size, conclusions must be treated with caution. Future research should investigate additional approaches for promoting healthy PA and include a larger sample in order to further test initial efficacy of this treatment approach.

Psychometric Properties of the Persian Version of the Weight Control Strategies Scale (WCSS)

Objective: The purpose of the present study was to examine the validity and reliability of the Persian version of the Weight Control Strategies Scale among individuals engaged in weight loss or weight maintenance.

Method: This descriptive study conducted from October 2019 to February 2020 on social media networks. A total of 420 men and women were selected using consecutive sampling. They completed the Persian version of the Weight Control Strategies Scale and the Self-Compassion Scale. Data were analyzed using descriptive statistics, Cronbach’s α, confirmatory factor analysis, and Pearson product-moment correlations.

Results: Internal consistency for the total score of the Persian version of Weight Control Strategies Scale was excellent and acceptable to good for all 4 subscales (in all cases over α = 0.70). Confirmatory factor analysis supported the factor structure of the original model of the scale, but, it was different from the model at the item level. Moreover, the Persian version of Weight Control Strategies Scale had good convergent validity.

Conclusion: Psychometrically speaking, the Persian version of the Weight Control Strategies Scale is a valid and reliable tool to assess the psychological and behavioral profile of individuals engaging in losing or maintaining weight, both for clinical and research purposes.

Affective Determinants of Physical Activity: A Conceptual Framework and Narrative Review

The literature on affective determinants of physical activity (PA) is growing rapidly. The present paper aims to provide greater clarity regarding the definition and distinctions among the various affect-related constructs that have been examined in relation to PA. Affective constructs are organized according to the Affect and Health Behavior Framework (AHBF), including: (1) affective response (e.g., how one feels in response to PA behavior) to PA; (2) incidental affect (e.g., how one feels throughout the day, unrelated to the target behavior); (3) affect processing (e.g., affective associations, implicit attitudes, remembered affect, anticipated affective response, and affective judgments); and (4) affectively charged motivational states (e.g., intrinsic motivation, fear, and hedonic motivation). After defining each category of affective construct, we provide examples of relevant research showing how each construct may relate to PA behavior. We conclude each section with a discussion of future directions for research.

Physical discomfort intolerance as a predictor of weight loss and physical activity in a lifestyle modification program

This study examined physical discomfort intolerance (DI) as a baseline predictor of weight loss and physical activity outcomes, and assessed whether changes in DI during the initial phase of weight loss prospectively predicted long-term treatment outcomes among adults enrolled in a group-based lifestyle modification program for obesity. DI was measured at baseline and 6 months, and weight and accelerometer-measured physical activity were assessed at baseline, 6 months, and 12 months. Baseline DI was not related to weight loss or physical activity at either timepoint. Change in DI during the first 6 months of treatment was not related to concurrent (i.e., 6-month) weight loss and physical activity, but was significantly predictive of weight loss and physical activity at 12 months. Assessing early changes in DI may help to identify individuals at risk for suboptimal outcomes. Future research should evaluate behavioral weight loss interventions designed to target DI.

Intrinsic Motivation Mediates the Association Between Exercise-Associated Affect and Physical Activity Among Adolescents

American adolescents overwhelmingly engage in insufficient physical activity (PA). Attention has turned to the role of affect in shaping PA, raising questions as to whether the impact of affect on PA is direct/automatic or cognitively mediated ("Type 1" or "Type 2" in the dual-process model). This study examines whether intrinsic motivation (IM) mediates the association between affect and PA. Adolescents (N = 142, 48% Male, 20% non-Latino White, mean age = 11.04 years, mean VO2 = 37.19 ml/kg/min, mean BMI = 63.19) completed assessments of cardiorespiratory fitness, affective response to exercise on a stationary cycle, IM, preferred exercise intensity, and moderate-to-vigorous PA (MVPA; ActiGraph). Fitness, exercise intensity and MVPA assessments were repeated 5 months later. Tests for mediation showed that affect predicted PA at baseline and 5 months, and IM mediated the relationship between affect and PA both cross-sectionally (CI = 0.03, 0.17) and longitudinally (CI = 0.04, 0.18). Results suggest a cognitively mediated pathway from affect to behavior. Adolescent PA may be increased either by enhancing IM or by tailoring interventions to accommodate individuals with a predisposition to respond to exercise with negative affect. This study is registered with Clinicaltrials.gov (ID # NCT01876602).