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1.  Relationship of Initial Self-Regulatory Ability with Changes in Self-Regulation and Associated Fruit and Vegetable Consumption in Severely Obese Women Initiating an Exercise and Nutrition Treatment: Moderation of Mood and Self-Efficacy 
An emphasis on increasing self-regulation is an alternate to nutrition education, which has had poor results in the behavioral treatment of obesity. Although appropriately designed weight-loss treatments may enhance one’s self-regulatory ability to control eating, whether improvements are moderated by psychosocial factors such as initial self-regulatory skills use, self-efficacy to control eating, and mood is unknown. Severely obese women (BMI 35-50 kg·m-2) were randomized into 26-week treatments of exercise supported by cognitive-behavioral methods paired with either nutrition education (n = 114) or cognitive-behavioral methods applied to controlled eating (n = 121). Improvement in self-regulation for controlled eating was 36.9% greater (p < 0.01) for the group incorporating cognitive-behavioral methods for controlled eating. Change in self-regulation was significantly associated with self-regulation at baseline (β = -0.33). Both mood and self-efficacy for controlled eating significantly moderated this relationship. Increased self-regulation was associated with both increases in fruit and vegetable consumption and fruit and vegetable intake at treatment end. The present findings increase our understanding of psychosocial variables associated with increased self-regulatory skills usage and improvements in eating that, after replication, may be used to improve the effects of behavioral weight-loss treatments.
Key pointsInitial self-regulatory abilities do not appear to affect improvements in self-regulation for eating, however direct training in behavioral skills are predictors of change.The relationship of self-regulation improvements and improved eating is significant, and affected by mood and self-efficacy in women with obesity.Instruction in behavioral skills such as cognitive restructuring and relapse prevention is associated with better improvements in eating than typical methods of nutrition education.Cognitive-behavioral methods for exercise may be paired with cognitive-behavioral methods for eating to maximize longer-term effects on eating behaviors.
PMCID: PMC3761514  PMID: 24149553
Behavioral treatment; cognitive-behavioral; health psychology; obesity treatment; self-regulation
2.  Relationship of Exercise Volume with Change in Depression and Its Association with Self-Efficacy to Control Emotional Eating in Severely Obese Women 
Introduction. Exercise may improve one's perceived ability to control overeating related to negative emotions through psychological pathways such as reduced depression; however, the volume required is unclear. Methods. Severely obese women (N = 88) participated in a 24-week exercise and nutrition treatment incorporating self-regulatory skills training, and were assessed on depression, self-efficacy, self-regulatory skills usage, weight, and waist circumference, at baseline and treatment end. Results. Subjects completing low-moderate (40–149.9 minutes/week) and public health (≥150 minutes/week) volumes of exercise had significant and similar reductions in depression scores. No significant changes were found for those completing <40 minutes/week. For all subjects aggregated, depression change was significantly related to change in self-efficacy to control emotional eating; however, this relationship was completely mediated by changes in self-regulatory skill usage. When changes in depression, self-efficacy, and self-regulatory skills usage were entered into multiple regression equations as predictors, only self-regulatory skill changes explained significant unique portions of the overall variance in weight and weight circumference change. Discussion. Exercise of less than half the public health recommendation was associated with depression improvement, with no dose-response effect. Changes in depression, self-efficacy, and self-regulation may be salient variables to account for in behavioral weight-loss treatment research.
PMCID: PMC3226245  PMID: 22135751
3.  Behaviorally Supported Exercise Predicts Weight Loss in Obese Adults Through Improvements in Mood, Self-Efficacy, and Self-Regulation, Rather Than by Caloric Expenditure 
The Permanente Journal  2011;15(1):23-27.
Background: The relationship of exercise to weight loss, beyond minimal caloric expenditures possible in obese and deconditioned individuals, requires clarification.
Objective: We assessed whether changes in theory-based psychological variables associated with participation in an exercise treatment extended to psychologically based predictors of controlled eating and weight and waist-circumference reductions.
Methods: A group of 137 adults with severe obesity (mean body mass index, 42.2 kg/m2) volunteered for an exercise-support and nutrition-education treatment of 26 weeks' duration that was based on social cognitive theory. Exercise- and eating-related measures of mood, self-regulation, and self-efficacy were obtained at baseline and at treatment end, along with weight, waist circumference, and exercise volume. Analyses were also conducted separately for women participants only (n = 102).
Results: Treatment-induced changes in total mood disturbance, self-regulatory skill usage for exercise, and exercise self-efficacy were significantly related to changes in self-efficacy to control emotional eating, self-regulatory skill usage for controlled eating, and overall self-efficacy for controlled eating, respectively (p < 0.001). Changes in the eating-related measures significantly predicted changes in weight and waist circumference with adjusted R2 values from 0.15 to 0.21 and 0.28 to 0.30, respectively (p < 0.001). Post-hoc testing indicated a strong negative correlation between exercise completed and weight change (r = −0.62); however, only 12.4% of the observed weight change was accounted for through associated caloric expenditures.
Conclusion: Exercise may support weight loss primarily through psychological rather than physiological pathways. Although the models tested were viable, additional modifiable variables may further strengthen the prediction of weight and waist-circumference change and benefit weight-loss theory and treatment outcomes.
PMCID: PMC3048629  PMID: 21505614
4.  From Morbid Obesity to a Healthy Weight Using Cognitive-Behavioral Methods: A Woman's Three-Year Process With One and One-Half Years of Weight Maintenance 
The Permanente Journal  2012;16(4):54-59.
Background: Obesity is a national health problem regularly confronting medical professionals. Although reduced-energy (kilocalorie [kcal]) eating and increased exercise will reliably reduce weight, these behaviors have been highly resistant to sustained change.
Objective: To control eating using theory-based cognitive-behavioral methods that leverage the positive psychosocial effects of newly initiated exercise as an alternate to typical approaches of education about appropriate nutrition.
Method: A woman, age 48 years, with morbid obesity initiated exercise through a 6-month exercise support protocol based on social cognitive and self-efficacy theory (The Coach Approach). This program was followed by periodic individual meetings with a wellness professional intended to transfer behavioral skills learned to adapt to regular exercise, to then control eating. There was consistent recording of exercises completed, foods consumed, various psychosocial and lifestyle factors, and weight.
Results: Over the 4.4 years reported, weight decreased from 117.6 kg to 59.0 kg, and body mass index (BMI) decreased from 43.1 kg/m2 to 21.6 kg/m2. Mean energy intake initially decreased to 1792 kcal/day and further dropped to 1453 kcal/day by the end of the weight-loss phase. Consistent with theory, use of self-regulatory skills, self-efficacy, and overall mood significantly predicted both increased exercise and decreased energy intake. Morbid obesity was reduced to a healthy weight within 3.1 years, and weight was maintained in the healthy range through the present (1.3 years later).
Conclusion: This case supports theory-based propositions that exercise-induced changes in self-regulation, self-efficacy, and mood transfer to and reinforce improvements in corresponding psychosocial factors related to controlled eating.
PMCID: PMC3523938  PMID: 23251120
5.  The family partners for health study: a cluster randomized controlled trial for child and parent weight management 
Nutrition & Diabetes  2014;4(1):e101-.
The purpose of this study was to test a two-phased nutrition and exercise education, coping skills training, and exercise intervention program for overweight or obese low-income ethnic minority 2nd to 4th grade children and their parents in rural North Carolina, USA.
A cluster randomized controlled trial was carried out with 358 children (7–10 years) and a parent for each child (n=358). General linear mixed models were used to determine the effects of the intervention on weight, adiposity, health behaviors, and eating and exercise self-efficacy by examining changes in children and parents from baseline to completion of the study (18 months).
At 18 months, children in the experimental group did not have a significantly decreased body mass index (BMI) percentile (P=0.470); however, they showed a reduction in the growth rate of their triceps (P=0.001) and subscapular skinfolds (P<0.001) and an improvement in dietary knowledge (P=0.018) and drank less than one glass of soda per day (P=0.052) compared with the control group. Parents in the experimental group had decreased BMI (P=0.001), triceps (P<0.001) and subscapular skinfolds (P<0.001) and increased nutrition (P=0.003) and exercise (P<0.001) knowledge and more often drank water or unsweetened drinks (P=0.029). At 18 months, children in the experimental group did not show significant improvement in eating (P=0.956) or exercise self-efficacy (P=0.976). Experimental parents demonstrated improved socially acceptable eating self-efficacy (P=0.013); however, they did not show significant improvement in self-efficacy pertaining to emotional eating (P=0.155) and exercise (P=0.680).
The results suggest that inclusion of children and parents in the same intervention program is an effective way to decrease adiposity and improve nutrition behaviors in both children and parents and improve weight and eating self-efficacy in parents.
PMCID: PMC3904082  PMID: 24418827
overweight; obesity; children; parents; intervention
6.  Changes in Theory-Based Psychological Factors Predict Weight Loss in Women with Class III Obesity Initiating Supported Exercise 
Journal of Obesity  2010;2010:171957.
Background. Psychological factors' effect on weight loss is poorly understood, in general, and specifically in the severely obese. Objective. To examine whether a behavioral model based on tenets of social cognitive and self-efficacy theory will increase understanding of the relationship between exercise and weight loss. Methods. Fifty-one women with severe obesity participated in a 24-week exercise and nutrition information treatment and were measured on changes in psychological factors and exercise attendance. Results. A significant portion of the variance in BMI change (adjusted for number of predictors) was accounted for by the behavioral model (R2adj = 0.23). Entry of exercise session attendance only marginally improved the prediction to 0.27. Only 19% of the weight lost was directly attributable to caloric expenditure from exercise. Conclusions. Findings suggest that participation in an exercise program affects weight loss through psychological pathways and, thus, may be important in the behavioral treatment of severe obesity.
PMCID: PMC2911610  PMID: 20700411
7.  Examining the Psychological Pathways to Behavior Change in a Group-Based Lifestyle Program to Prevent Type 2 Diabetes 
Diabetes Care  2012;35(4):699-705.
To examine the psychological process of lifestyle change among adults at risk for type 2 diabetes.
A randomized control trial in which 307 volunteers (intervention, n = 208; wait control, n = 99) diagnosed with prediabetes completed a six-session group-based intervention to promote healthier living. Participants’ motivation to change, diet and exercise self-efficacy, mood, knowledge about diabetes, activity levels, healthy eating, waist circumference, and weight were assessed before and after the program.
Participation in the program was associated with significant increases in healthy eating and physical activity, reductions in waist and weight, and improvements in motivation, positive mood, self-efficacy, and knowledge. Examination of the pathways to lifestyle change showed that the educational aspect of the program increased activity levels because it increased diabetes knowledge and improved mood. Eating behavior was not mediated by any of the psychological variables. Improvements in diet and physical activity were, in turn, directly associated with changes in weight and waist circumference.
Although the program significantly improved motivation, self-efficacy, and mood, its impact on knowledge uniquely explained the increase in physical activity. Group-based programs that are tailored to lifestyle behaviors may provide a cost-effective method of diabetes prevention, but more research is needed to explain why they improve healthy eating.
PMCID: PMC3308314  PMID: 22338102
8.  Predicting Weight Outcomes in Preadolescence: The Role of Toddlers’ Self-regulation Skills and the Temperament Dimension of Pleasure 
To investigate the role of toddlers’ self-regulation skills and temperament in predicting weight outcomes in preadolescence.
Participants for this study included 195 children (114 girls) obtained from three different cohorts participating in a larger ongoing longitudinal study. At 2 years of age, participants participated in several laboratory tasks designed to assess their self-regulation abilities, including emotion regulation, sustained attention, and delay of gratification, while parents filled out a temperament questionnaire to assess toddlers’ pleasure expression. Height and weight measures were collected when children were 4, 5, 7, and 10 years of age. Children also filled out a body image and eating questionnaire at the 10 year visit.
Self-regulation skills in toddlers were associated with both BMI development, pediatric obesity, and body image/eating concerns. The temperament dimension of pleasure was also associated with BMI development and pediatric obesity but not body image/eating concerns.
Self-regulation difficulties across domains as well as temperament based pleasure in toddlers represented significant individual risk factors for the development of pediatric obesity eight years later. Early self-regulation difficulties also contributed to body image and eating concerns that typically accompanied overweight children. The mechanisms by which early self-regulation skills and temperament based pleasure may contribute to the development of pediatric obesity and associated weight concerns are discussed.
PMCID: PMC3543516  PMID: 23044856
pediatric obesity; BMI; body image; self-regulation; toddlerhood; preadolescence
9.  Effects of 12-month exercise on health-related quality of life: a randomized controlled trial 
Preventive medicine  2011;52(5):344-351.
We investigated exercise effects on health-related quality of life (HRQOL) and exercise self-efficacy, and tested effect modification by baseline body mass index (BMI) and gender.
Middle-aged women (n=100) and men (n=102) were randomly assigned to either exercise (360 minutes/week of moderate-to-vigorous aerobic exercise) or control in Seattle, WA from 2001–2004. Demographics, anthropometrics, exercise self-efficacy (5-item self-efficacy questionnaire) and HRQOL (SF-36) were assessed at baseline and 12 months. Analysis of covariance adjusting for baseline scores was used to compare HRQOL and exercise self-efficacy scores between the exercise and control groups.
At 12 months, exercisers demonstrated higher exercise self-efficacy than controls (percent change from baseline: −6.5% vs. −15.0%, p<0.01), without differences in HRQOL. Baseline BMI category and gender did not modify these effects. In exploratory analyses comparing exercisers and controls within subgroups defined by gender and BMI, 12-month HRQOL scores [(role-physical (+7.0% vs. −13.1%), vitality (+15.6% vs. −4.2%), social functioning (+10.0% vs. −3.5%), and mental health (+6.8% vs. −2.9%)] were higher only among overweight male exercisers (p<0.05, vs. control).
360 minutes/week of exercise, recommended for weight maintenance, did not have negative effects on exercise self-efficacy or HRQOL. This level of exercise may increase HRQOL among overweight men.
PMCID: PMC3086667  PMID: 21371498
10.  Relations of Self-Appraisal and Mood Changes with Voluntary Physical Activity Changes in African American Preadolescents in an After-School Care Intervention 
There is an increasing prevalence of overweight in preadolescents that predicts physical problems over the lifespan. Physical inactivity has been implicated as an associated factor, with African American youth being at an increased risk. Based on social cognitive theory, and proposed correlates of physical activity in youth, changes over 12 weeks in measures of self-appraisal (general self, physical appearance, physical self-concept, exercise barriers self-efficacy) and mood (tension, vigor), and their relations with voluntary physical activity changes, were assessed within an after-school care physical activity intervention. Participants were volunteers recruited from children already registered for a 12-week segment of YMCA after-school care. The treatment group consisted of 146 African American preadolescents with the control group comprised of 123 African American preadolescents who were scheduled to receive the program during the next sequence that it was offered. Results indicated the intervention group reported significantly more positive self-appraisals, reduced tension, and enhanced vigor. Bivariate and multiple regression analyses indicated that when each of the 4 self-appraisal and 2 mood factors were simultaneously entered into a regression equation, 36% of the variance in voluntary physical activity was explained. Findings support the treatment's association with theoretically based correlates of physical activity in the present sample, and suggest directions for physical activity interventions for youth.
Key pointsSocial cognitive theory offers a framework for understanding correlates of physical activity in youth.This study suggests that it is possible for a convenient physical activity intervention, led by after-school care counselors with minimal training, to improve participants' self-perceptions, mood, and voluntary physical activity.Improvements in self-perceptions and mood appeared to be significantly associated with increased free-time physical activity in African American 8- to 12-year-olds.This study's findings may lead to a better understanding of physical activity promotion in youth, and foster improvements in physical activity curricula.
PMCID: PMC3761451  PMID: 24149459
Physical activity; exercise; body mass index; youth; health behavior
11.  Change in Goal Ratings as a Mediating Variable between Self-Efficacy and Physical Activity in Older Men 
Few studies have examined the associations between exercise self-efficacy, goals, and physical activity over time.
This study examines whether self-selected goals mediate the changes in exercise self-efficacy on physical activity over 12 months.
Data are derived from 313 older men participating in the Veterans Life Study.
Changes in exercise self-efficacy were significantly associated with changes in physical activity both directly (βs = .25 and .24, p < .05) and indirectly (βs = .24 and .30, p < .05) through changes in health-related and walking goal ratings (βs = .19 and .20, p < .05). Both types of goal setting continued to partially mediate the relationship between exercise self-efficacy and physical activity when covariates were added to the models. This study extends the application of social cognitive and goal-setting theories to physical activity by showing that goals partially mediate the relationship between exercise self-efficacy and physical activity over time.
PMCID: PMC2904848  PMID: 20387023
goal setting; physical activity; self-efficacy; randomized controlled trial; older adults
12.  An Acute Exercise Session Increases Self-Efficacy in Sedentary Endometrial Cancer Survivors and Controls 
Self-efficacy can be affected by mastery experiences and somatic sensations. A novel exercise experience and associated sensations may impact self-efficacy and subsequent behaviors. We investigated the effect of a single exercise session on self-efficacy for sedentary endometrial cancer survivors compared with sedentary women of a similar age, but with no cancer history.
Twenty survivors and 19 controls completed an exercise session performed as a submaximal cycle ergometry test. Sensations and efficacy were measured before and after exercise. Repeated measures analysis of variance (ANOVA) was performed. Regression models were used to determine predictors of self-efficacy and subsequent exercise.
Self-efficacy increased for both survivors and controls, but survivors had a higher rate of increase, and the change predicted subsequent exercise. The association between exercise-related somatic sensations and self-efficacy differed between the 2 groups.
A novel exercise experience had a larger effect on self-efficacy and subsequent exercise activity for endometrial cancer survivors than controls. Somatic sensations experienced during exercise may differ for survivors, which may be related to the experience of having cancer. Understanding factors affecting confidence in novel exercise experiences for populations with specific cancer histories is of the utmost importance in the adoption of exercise behaviors.
PMCID: PMC3024053  PMID: 21088310
special needs populations; exercise psychology; health behavior
13.  Toddler self-regulation skills predict risk for pediatric obesity 
To investigate the role of early self-regulation skills, including emotion regulation, sustained attention, and inhibitory control/reward sensitivity, in predicting pediatric obesity in early childhood.
Participants for this study included 57 children (25 girls) obtained from three different cohorts participating in a larger ongoing longitudinal study. At 2 years of age, participants participated in several laboratory tasks designed to assess their self-regulation abilities. Height and weight measures were collected when children were 2 and 5.5 years of age.
Self-regulation skills in toddlerhood were predictive of both normal variations in BMI development and pediatric obesity. Specifically, emotion regulation was the primary self-regulation skill involved in predicting normative changes in BMI as no effects were found for sustained attention or inhibitory control/reward sensitivity. However, both emotion regulation and inhibitory control/reward sensitivity predicted more extreme weight problems (i.e., pediatric obesity), even after controlling for 2yr BMI. Thus, toddlers with poorer emotion regulation skills and lower inhibitory control skills/higher reward sensitivity were more likely to be classified as overweight/at risk at 5.5 years of age.
Early self-regulation difficulties across domains (i.e., behavioral, and emotional) represent significant individual risk factors for the development of pediatric obesity. Mechanisms by which early self-regulation skills may contribute to the development of pediatric obesity are discussed.
PMCID: PMC2854309  PMID: 20065961
pediatric obesity; self-regulation; emotion regulation; sustained attention; inhibitory control; reward sensitivity; toddlerhood; early childhood
14.  Problem Solving, Treatment Adherence, and Weight-Loss Outcome Among Women Participating in Lifestyle Treatment for Obesity 
Eating behaviors  2009;10(3):146-151.
This study examined whether improvements in problem-solving abilities mediate the relation between treatment adherence and weight-loss outcome in the behavioral treatment of obesity.
272 women (mean ± SD age = 59.4 ± 6.2 years, BMI = 36.5 ± 4.8) participated in a 6-month lifestyle intervention for obesity. Body weight and problem-solving skills (as measured by the Social Problem Solving Inventory—Revised) were assessed pre- and posttreatment. The completion of self-monitoring logs during the intervention served as the marker of treatment adherence.
At posttreatment, participants lost 8.4 ± 5.8 kg, an 8.8% reduction in body weight. Changes in weight were associated with increased problem-solving skills and with higher levels of treatment adherence. Improvements in problem-solving skills partially mediated the relation between treatment adherence and weight-loss outcome. Moreover, participants with weight reductions > 10% demonstrated significantly greater improvements in problem-solving skills than those with reductions < 5%.
Improvements in problem-solving skills may enable participants to overcome barriers to adherence and thereby enhance treatment-induced weight losses.
PMCID: PMC2726832  PMID: 19665096
Obesity; Weight Loss; Problem-Solving; Adherence; Self-Monitoring
15.  The effect of exercise absence on affect and body dissatisfaction as moderated by obligatory exercise beliefs and eating disordered beliefs and behaviors 
Psychology of sport and exercise  2012;13(4):500-508.
Research suggests that exercise absence is frequently associated with greater guilt and negative affect, particularly when obligatory exercise beliefs and eating disordered psychopathology are considered. Two separate studies used ecological momentary assessment (EMA) to examine differences in mood on exercise and non-exercise days and the moderating impact of obligatory exercise beliefs and eating disordered beliefs and behaviors.
Both studies recruited female university students who endorsed frequent exercise behavior and study two also recruited based on level of eating disordered psychopathology. Participants completed the Obligatory Exercise Questionnaire at baseline and EMA measures of affect and exercise behavior for approximately one week. Study two participants also completed measures of body dissatisfaction and cognitions.
Results of study one suggest that obligation to exercise appears to have a greater impact on general level of affect than does exercise absence or the interaction of these two. In addition, in study two, eating disorder symptomatology was significantly associated with affect and cognition while exercise absence and obligatory exercise beliefs were not.
The present studies suggest that the absence of exercise is not associated with significant changes in affect or cognitions. However, obligation to exercise and eating disorder symptomatology do impact affect and cognitions.
PMCID: PMC3427598  PMID: 22930654
Physical activity; Obligatory; Body image; Ecological momentary assessment; Eating disorders; Affect
16.  Social Anxiety and Self-consciousness in Binge Eating Disorder: Associations with Eating Disorder Psychopathology 
Comprehensive Psychiatry  2011;53(6):740-745.
Research has consistently shown that anxiety disorders are common among individuals with eating disorders. Although social phobia has been found to be highly associated with eating disorders, less is known about social anxiety in individuals with binge eating disorder (BED). The present study examined associations between social anxiety and self-consciousness with BMI and eating-disorder psychopathology in BED.
Participants were 113 overweight or obese treatment seeking men and women with BED. Participants were administered semi-structural diagnostic clinical interviews and completed a battery of self-report measures.
Social anxiety was positively and significantly correlated with shape- and weight-concerns, and binge eating frequency. After accounting for depressive levels, social anxiety and self-consciousness accounted for significant variance in eating-, shape-, and weight-concerns and overall eating-disorder global severity scores (Eating Disorder Examination). Social anxiety also accounted for significant variance in binge eating frequency after co-varying for depressive levels. Social anxiety and self-consciousness were not significantly associated with BMI or dietary restraint.
Our findings suggest that greater social anxiety and heightened self-consciousness are associated with greater eating disorder psychopathology, most notably with greater shape- and weight-concerns and binge eating frequency in patients with BED. Social anxiety and self-consciousness do not appear to be merely functions of excess weight, and future research should examine whether they contribute to the maintenance of binge eating and associated eating-disorder psychopathology.
PMCID: PMC3306525  PMID: 22152497
17.  Perceived Stress, Behavior, and Body Mass Index Among Adults Participating in a Worksite Obesity Prevention Program, Seattle, 2005–2007 
Stress in numerous contexts may affect the risk for obesity through biobehavioral processes. Acute stress has been associated with diet and physical activity in some studies; the relationship between everyday stress and such behavior is not clear. The objective of this study was to examine associations between perceived stress, dietary behavior, physical activity, eating awareness, self-efficacy, and body mass index (BMI) among healthy working adults. Secondary objectives were to explore whether eating awareness modified the relationship between perceived stress and dietary behavior and perceived stress and BMI.
Promoting Activity and Changes in Eating (PACE) was a group-randomized worksite intervention to prevent weight gain in the Seattle metropolitan area from 2005 through 2007. A subset of 621 participants at 33 worksites provided complete information on perceived stress at baseline. Linear mixed models evaluated cross-sectional associations.
The mean (standard deviation [SD]) Perceived Stress Scale-10 score among all participants was 12.7 (6.4), and the mean (SD) BMI was 29.2 kg/m2 (6.3 kg/m2). Higher levels of perceived stress were associated with lower levels of eating awareness, physical activity, and walking. Among participants who had low levels of eating awareness, higher levels of perceived stress were associated with fewer servings of fruit and vegetables and greater consumption of fast food meals.
Dietary and physical activity behaviors of workers may be associated with average levels of perceived stress. Longitudinal studies are needed, however, to support inclusion of stress management or mindfulness techniques in workplace obesity prevention efforts.
PMCID: PMC3477899  PMID: 23036611
18.  Exercise adherence, cardiopulmonary fitness and anthropometric changes improve exercise self-efficacy and health-related quality of life 
Regular exercise increases exercise self-efficacy and health-related quality of life (HRQOL); however, the mechanisms are unknown. We examined the associations of exercise adherence and physiological improvements with changes in exercise self-efficacy and HRQOL.
Middle-aged adults (N=202) were randomized to 12 months aerobic exercise (360 minutes/week) or control. Weight, waist circumference, percent body fat, cardiopulmonary fitness, HRQOL (SF-36), and exercise self-efficacy were assessed at baseline and 12 months. Adherence was measured in minutes/day from activity logs.
Exercise adherence was associated with reduced bodily pain, improved general health and vitality, and reduced role-emotional scores (Ptrend≤0.05). Increased fitness was associated with improved physical functioning, bodily pain and general health scores (Ptrend≤0.04). Reduced weight and percent body fat were associated with improved physical functioning, general health, and bodily pain scores (Ptrend<0.05). Decreased waist circumference was associated with improved bodily pain and general health but with reduced role-emotional scores (Ptrend≤0.05). High exercise adherence, increased cardiopulmonary fitness and reduced weight, waist circumference and percent body fat were associated with increased exercise self-efficacy (Ptrend<0.02).
Monitoring adherence and tailoring exercise programs to induce changes in cardiopulmonary fitness and body composition may lead to greater improvements in HRQOL and self-efficacy that could promote exercise maintenance.
PMCID: PMC3923574  PMID: 23036856
physical activity; intervention study; aerobic; physical fitness
19.  Supported Exercise Improves Controlled Eating and Weight through Its Effects on Psychosocial Factors: Extending a Systematic Research Program Toward Treatment Development 
The Permanente Journal  2012;16(1):7-18.
Background: Behavioral weight-loss treatments have been overwhelmingly unsuccessful. Many inadequately address both behavioral theory and extant research—especially in regard to the lack of viability of simply educating individuals on improved eating and exercise behaviors.
Objective: The aim was to synthesize research on associations of changes in exercise behaviors, psychosocial factors, eating behaviors, and weight; and then conduct further direct testing to inform the development of an improved treatment approach.
Methods: A systematic program of health behavior-change research based on social cognitive theory, and extensions of that theory applied to exercise and weight loss, was first reviewed. Then, to extend this research toward treatment development and application, a field-based study of obese adults was conducted. Treatments incorporated a consistent component of cognitive-behaviorally supported exercise during 26 weeks that was paired with either standard nutrition education (n = 183) or cognitive-behavioral methods for controlled eating that emphasized self-regulatory methods such as goal setting and caloric tracking, cognitive restructuring, and eating cue awareness (n = 247).
Results: Both treatment conditions were associated with improved self-efficacy, self-regulation, mood, exercise, fruit and vegetable consumption, weight, and waist circumference; with improvements in self-regulation for eating, fruit and vegetable consumption, weight, and waist circumference significantly greater in the cognitive-behavioral nutrition condition. Changes in exercise- and eating-related self-efficacy and self-regulation were associated with changes in exercise and eating (R2 = 0.40 and 0.17, respectively), with mood change increasing the explanatory power to R2 = 0.43 and 0.20. Improved self-efficacy and self-regulation for exercise carried over to self-efficacy and self-regulation for controlled eating (β= 0.53 and 0.68, respectively).
Conclusions: Development and longitudinal testing of a new and different approach to behavioral treatment for sustained weight loss that emphasizes exercise program-induced psychosocial changes preceding the facilitation of improved eating and weight loss should be guided by our present research.
PMCID: PMC3327117  PMID: 22529754
20.  Assessment of dietitians' nutrition counselling self-efficacy and its positive relationship to reported skill usage 
Previous studies on nutrition counselling self-efficacy assessed small groups of dietitians in focused practice areas or evaluated the effectiveness of skills training on only a few skills. This descriptive study developed a comprehensive scale to examine self-efficacy in a large, cross-sectional sample of practising dietitians in performing various counselling skills that promote dietary behaviour changes.
A valid and reliable instrument was developed and administered through the Internet to survey dietitians in the United States from various areas of dietetics and with varying years of experience. Items included counselling self-efficacy, skill usage, and counselling-related job characteristics. Of 612 respondents, one group (n=486) conducted counselling more than 50% of their work week; the other group (n=126) less than 50%. Factor analysis was used for scale development. Independent samples t-tests and chi-square tests were performed for group comparisons. Correlations and multiple regression analyses further assessed the relationships among variables.
The resultant unidimensional scale contained 25 items. Dietitians reported high self-efficacy scores and frequent skill usage. Those who counsel more than 50% of their work week were more likely to work in outpatient settings and private practice; reported higher self-efficacy scores, and held longer and repeated sessions. Self-efficacy scores were positively correlated with counselling-related job characteristics. Years of counselling experience and skill usage significantly predicted self-efficacy scores.
Dietitians perceive themselves to be highly self-efficacious in using counselling skills which may contribute positively to their professional practice. However, the relationship between counselling self-efficacy and actual performance warrants future investigation.
PMCID: PMC2917920  PMID: 20113386
self-efficacy; nutrition counselling; counselling skills
21.  Weight Loss Following a Clinic-Based Weight Loss Program Among Adults with Attention Deficit/Hyperactivity Disorder Symptoms 
Eating and weight disorders : EWD  2010;15(3):e166-e172.
The purpose of the present study was to compare obese patients screening positive or negative for attention deficit/hyperactivity disorder (ADHD) on pre-treatment body mass index (BMI), weight loss following a 16 week clinic-based behavioral weight loss program, weight loss attempts, dietary and physical activity habits, perceived difficulty of weight control skills, and eating self-efficacy.
Patients who completed a behavioral weight loss program were approached to complete questionnaires on ADHD and eating habits. Medical charts were reviewed to obtain weight at pre- and post-treatment.
Participants (N=63) were 75% female, mean age was 49 (standard deviation = 10.3), mean body mass index (BMI) was 41.4 kg/m2(standard deviation = 6.8) and 30% screened positive for ADHD on the Adult ADHD Symptom Rating Scale. Participants screening positive for ADHD did not have a higher BMI at baseline (p =.41), but reported more previous weight loss attempts (p=.01) and lost less weight (p= .02) than participants who screened negative. Participants screening positive also reported consuming fast food meals more frequently (p=.04), higher levels of emotional eating (p=.002), greater difficulty with weight control skills (p=.01), and lower eating self-efficacy (p=.001).
Attention-related problems appear to be common among weight treatment-seeking samples and represent a significant barrier to weight control that has not yet been addressed in the literature.
PMCID: PMC3211042  PMID: 21150252
attention deficit hyperactivity disorder; obesity; weight loss; adults; weight behaviors
22.  Accuracy of Self-reported Weight and Height in Binge Eating Disorder: Misreport is Not Related to Psychological Factors 
Obesity (Silver Spring, Md.)  2009;18(6):1266-1269.
This study examined the degree of misreport in weight, height, and BMI among overweight adults (n=392) with binge eating disorder (BED) and tested whether the degree of misreport was associated with eating disorder psychopathology and psychological variables. Male (n=97) and female (n=295) participants self-reported height and weight and were subsequently measured by clinic staff. Participants also completed a series of diagnostic interviews and self-report assessments. Discrepancies between self-reported and measured values were modest. The degree of misreport for weight, height, and BMI was not related to eating disorder features, depression, and self-esteem. Overall, the errors in self-reported weight and height by overweight patients with BED were very slight. The degree of discrepancy between self-reported and measured values was not related to eating disorder or psychological features, suggesting that such data are not biased or systematically related to individual differences in overweight patients with BED.
PMCID: PMC2877172  PMID: 19834465
23.  Predictors of exercise intervention dropout in sedentary individuals with type 2 diabetes 
While the benefits of exercise in people with type 2 diabetes mellitus (T2D) is well-known, knowledge of factors associated with dropouts of exercise intervention trials is limited. Examining clinical and psychosocial factors related to dropout is a necessary first step to developing effective exercise program. We examined the predictors of a randomized trial of exercise intervention dropout among sedentary individuals with T2D.
Participants (n=140) were randomly allocated to a 6-month, 3 times per week exercise intervention, or to a control group. Psychological well-being was assessed using a 36-Item Short Form, the Profile of Mood States questionnaire and an Exercise Self-Efficacy scale. Total percent body fat, and abdominal subcutaneous and visceral fat were measured. Insulin resistance was assessed with the quantitative insulin sensitivity check index. Fitness was expressed as VO2 peak during treadmill testing.
There were significantly more dropouts in the exercise group than the control group (ρ=−0.220, P<.01). Those who dropped out of the study had less exercise self-efficacy for lifting weight (ρ =0.187, P<.05). Physiological parameters associated with dropouts included low fitness (ρ =0.255, P<.01); higher insulin resistance (ρ =0.167, P<.05); higher total percent body fat (ρ =−0.213, P<.05); and higher subcutaneous abdominal fat (ρ =−0.220, P<.05). In the multiple logistic regression model, exercise group assignment, insulin resistance, and fitness remained significant predictors of dropouts.
Special attention to the sedentary individuals with high insulin resistance and poor fitness should be incorporated into implementing exercise programs to improve diabetes treatment.
PMCID: PMC3496000  PMID: 23011489
adherence; aerobic exercise; resistance exercise; diabetes; fitness
24.  Self-reported binge eating in severe pediatric obesity: Impact on weight change in a randomized controlled trial of family-based treatment 
This study sought to document self-reported binge eating in a large sample of severely obese children and to examine the impact of binge eating on changes in percent overweight among children randomized to family-based behavioral treatment (Intervention) versus control (Usual Care).
Participants and Methods
As part of a larger randomized controlled trial, 192 children ages 8-12 years (M = 10.2, SD = 1.2) with a mean BMI percentile of 99.2 (SD = 0.7) completed assessments at baseline and 6-, 12- and 18-months post-randomization. A parent or guardian also participated. Child psychological symptoms, including binge eating, were measured prior to randomization using self-report questionnaires. Child height and weight were measured at baseline, 6-, 12- and 18-months. The primary study outcome was percent overweight (i.e., percent over median BMI for age and sex).
Twenty-two children (11.5%) endorsed binge eating at baseline (Binge Eating Group). Children in the Binge Eating Group were younger and had more depressive, anxiety and eating disorder symptoms and lower self-esteem than children in the rest of the sample (No Binge Eating Group). There also were differences between the Binge Eating and No Binge Eating groups with respect to the short-term effects of treatment group assignment on change in percent overweight during the study. Specifically, improvements in percent overweight in the Intervention condition relative to Usual Care were documented in the No Binge Eating Group only. Among children in the Binge Eating Group, those assigned to Intervention showed a 2.6% increase in percent overweight, on average, at the completion of acute treatment as compared to an 8.5% decrease among children without binge eating. However, these effects were not maintained during follow-up.
Results of this study suggest the importance of considering binge eating in the development of weight management programs for severely obese youth.
PMCID: PMC2891360  PMID: 20157322
childhood obesity; binge eating; eating disorder; treatment moderator; clinical trial
25.  Self-Regulatory Processes and Exercise Adherence in Older Adults 
Self-efficacy and the use of self-regulatory strategies are consistently associated with physical activity behavior. Similarly, behavioral inhibition and cognitive resource allocation, indices of executive control function, have also been associated with this health behavior.
The purpose of this study was to examine the hypothesis that self-efficacy mediates the relationship between self-regulatory processes, such as executive function, and sustained exercise behavior.
Older adults (N = 177, mean age = 66.44 years) completed measures of executive function, self-reported use of self-regulatory strategies and self-efficacy prior to and during the first month of a 12-month exercise intervention. Percentage of exercise classes attended over the following 11 months was used to represent adherence. Data were collected from 2007 to 2010 and analyzed in 2010–2011. Structural equation models were tested examining the effect of executive function and strategy use on adherence via efficacy.
As hypothesized, results showed significant direct effects of two elements of executive function and of strategy use on self-efficacy and of efficacy on adherence. In addition, there were significant indirect effects of strategy use and executive function on adherence via self-efficacy.
Higher levels of executive function and use of self-regulatory strategies at the start of an exercise program enhance beliefs in exercise capabilities, which in turn leads to greater adherence.
PMCID: PMC3160622  PMID: 21855742

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