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This prospective, naturalistic study examined the relationship between different exercise dimensions (i.e., frequency, intensity, duration, and omissions of planned exercise) and psychological well-being among community adults participating in self-selected exercise. For at least 2 months, participants kept daily exercise diaries and provided weekly ratings for depressed mood, anxiety, sleep quality, concentration, alertness, confidence, weight satisfaction, physical fitness, appetite, satisfaction with physical shape and appearance, and stress experienced. Linear mixed model analyses revealed positive associations between exercise frequency, intensity, and duration across a broad range of psychological and mood-related outcomes. In contrast, omissions of planned exercise were associated with a global and detrimental effect on psychological health. A main effect of age and a moderating effect of gender was observed in many of the models. This work contributes to literature on exercise dimensions and psychological constructs and informs future research that is needed to develop physical activity recommendations for improved mental health.

Accelerating diabetes rates have resulted in a global public health epidemic. Lifestyle change is a cornerstone of care, yet regimen demands may result in adherence difficulties. Distress, depression, and other psychosocial concerns are higher in those with diabetes. While interventions, such as the Diabetes Prevention Program appear to be effective, further research is needed to support the translation of interventions to prevent diabetes. Studies assessing optimal approaches to promoting effective decision making, coping and adherence are needed. More information is needed to evaluate the influence and potential of emerging technologies on intervention delivery and quality of life in children and adults with diabetes. Theoretically informed, interdisciplinary studies that consider ecological models are needed to develop a roadmap for policies and diabetes management recommendations. Reduction of diabetes-related health disparities is a critical area for future studies. Behavioral medicine scientists and practitioners are poised to address these and other proposed future research directions to advance diabetes prevention and management.

Background:This study assessed physical activity (PA) in community dwelling adults with Type 2 diabetes, using multiple instruments reflecting internationally normed PA and diabetes-specific self-care behaviors.Methods:Two hundred and fifty-three Black (44.8%) and White (55.2%) Americans [mean age = 57.93; 39.5% male] recruited at low-income clinic and community health settings. Participants completed validated PA self-report measures developed for international comparisons (International Physical Activity Questionnaire Short Form), characterization of diabetes self-care (Summary of Diabetes Self-Care Activities Measure; SDSCA) and exercise-related domains including provider recommendations and PA behaviors and barriers (Personal Diabetes Questionnaire; PDQ).Results:Self-reported PA and PA correlates differed by instrument. BMI was negatively correlated with PA level assessed by the PDQ in both genders, and assessed with SDSCA activity items in females. PA levels were low, comparable to previous research with community and diabetes samples. Pain was the most frequently reported barrier; females reported more frequent PA barriers overall.Conclusions:When using self-report PA measures for PA evaluation of adults with diabetes in clinical settings, it is critical to consider population and setting in selecting appropriate tools. PA barriers may be an important consideration when interpreting PA levels and developing interventions. Recommendations for incorporating these measures in clinical and research settings are discussed.

Introduction: Few Americans follow recommendations regarding nutrition or physical activity, and few physicians provide nutritional counseling (NC) or physical activity counseling (PAC) to patients. Clinical, systems-based, and institutional barriers to teaching and providing NC and PAC exist, but theoretical models of behavior change and principles of adult learning theory (ALT) can enable medical educators to overcome these barriers. Methods: We developed an educational intervention consisting of interactive lectures and two standardized patient experiences to provide first-year medical students with practical experience in PAC and NC. Students completed pre and post educational assessments of attitudes, knowledge, and self-efficacy with the counseling techniques. Results: Knowledge scores increased from 6.1 to 8.5 (p

The American Association of Diabetes Educators hosted a Monitoring Symposium during which 18 invited participants considered pre-set questions regarding how diabetes education can more effectively address barriers to monitoring for people with diabetes and related conditions. This report provides a summary of the moderated discussion and highlights the key points that apply to diabetes educators and other providers involved with diabetes care. The participating thought leaders reviewed findings from published literature and participated in a moderated discussion with the aim of providing practical advice for health care practitioners regarding monitoring for people with diabetes so that the overall health of this population can be enhanced. The discussants also defined monitoring for diabetes as including that done by the clinician or laboratory, as well as self-monitoring. The discussion was distilled into key points that apply to diabetes educators and other providers involved with diabetes care. Participants developed specific recommendations for a self-monitoring behavior and monitoring framework. People with diabetes benefit from instruction and guidance about self-monitoring and decision making that is based on monitored results and informed interactions with providers. Importantly, collaboration among the entire diabetes care community is needed to ensure that monitoring is performed and utilized to its fullest advantage. Going forward, it will be critical to mitigate barriers to diabetes self-management and training and to identify linkages and partnerships to address barriers to self-monitoring.

Key factors motivating persons to adopt and adhere to regular exercise are frequently examined but have not yet been clearly identified. Schema Theory and Attribution Theory have been shown to predict exercise and other health-enhancing behaviors. We examined the role of exercise schemata related to perceived success or failure in self-determined exercise goal and ACSM frequency guideline attainment in an adult sample. The findings supported previous exercise behavior results. Exerciser schematics exercised more frequently, for longer duration per exercise session/bout, and reported higher levels of subjective exercise intensity. Exerciser schematics had higher levels of self-efficacy and positive outcome expectancies for exercise, and were more than four times more likely to rate exercise goal attainment success than failure. Attribution internality, stability, and personal control over exercise were predictive of exerciser schemata and schematics were more likely (OR = 24.16) to meet exercise frequency ...

Aim To develop and evaluate the validity and reliability of The Personal Diabetes Questionnaire (PDQ), a brief, yet comprehensive measure of diabetes self-care behaviors, perceptions and barriers. To examine individual items to provide descriptive and normative information and provide data on scale reliability and associations between PDQ scales and concurrently assessed HBA1c and BMI. Method Items were written to address nutritional management, medication utilization, blood glucose monitoring, and physical activity. The initial instrument was reviewed by multidisciplinary diabetes care providers and items subsequently revised until the measure provided complete coverage of the diabetes care domains using as few items as possible. The scoring scheme was generated rationally. Subjects were 790 adults (205 with type 1 and 585 with type 2 diabetes) who completed the PDQ while waiting for clinic appointments. Results Item completion rates were high, with few items skipped by participants. Subscales demonstrated good internal consistency (Cronbach α = .650–.834) and demonstrated significant associations with BMI (p ≤ .001) and HbA1c (p ≤ .001). Conclusions The PDQ is a useful measure of diabetes self-care behaviors and related perceptions and barriers that is reliable and valid and feasible to administer in a clinic setting. This measure may be used to obtain data for assessing diabetes self-management and barriers and to guide patient care.

Purpose. Research findings can help support diabetes care providers' efforts to provide optimal education and clinical care in their practices. Much has been written about the importance of using evidence-based approaches to help ensure quality patient care. This article highlights practical strategies for helping diabetes care providers maintain an evidence-based practice. Topical content includes 1) an overview of common types of evidence available, 2) recommendations for useful resources to find the evidence, and 3) examples of strategies that diabetes care providers could use to stay informed regarding available evidence. Conclusion. By using available resources to personally examine the evidence, diabetes care providers can make informed decisions regarding ways to optimally educate and treat patients using the best practices available. Guidelines for enhancing acquisition of best evidence and integrating the evidence into daily practice include being familiar with the types of evidence available; knowing where to find the best sources of evidence to inform practice; keeping current on landmark randomized, controlled trials in the field; and using the evidence in clinical practice by applying evidence in daily clinical decision-making.

We describe one approach for recruitment and retention of minority individuals in intervention research using a systematic environmental perspective based on Bronfenbrenner’s ecological systems (BES) model and the construct of temporality. An exemplar in a physical activity intervention study with low-income and primarily African American women is presented. The exemplar illustrates application of BES and temporality to enhance recruitment and retention in research focused on understanding and accommodating environmental influences. . Using this theory based approach resulted in successful recruitment and a high level of participant retention.

Background Regular physical activity is a health promotion and disease prevention behavior. Of all demographic groups, low-income women report the lowest levels of physical activity. Research objective The purpose of this study was to test an intervention aimed at reducing community environmental barriers to physical activity in low-income women. Methods The research design was mixed methodology: (1) quantitative (quasi-experimental, pretest-posttest, cohort design in which no treatment partitioning was possible) and (2) qualitative (focus groups). The setting was a church-sponsored community center centrally located in a low-income urban neighborhood. The comparison group was recruited first followed by the intervention group to control for setting. The sample consisted of 104 women (comparison group, n = 53; intervention group, n = 51) between the ages of 18 and 63 years who were residents of neighborhoods served by the community center. Results No between-group differences were found for physical activity behavior. Significant between-group differences in cholesterol (P = .007) and perception of physical activity (P = .033) were observed. Significant intervention group increases from pretest to posttest were found related to advanced registered nurse practitioner support, friend support, and more positive physical activity environment at the community center. Qualitative data supported and enriched the quantitative data. Conclusions Physical activity levels were not significantly different between the groups. In a sample of low-income women who have multiple barriers, improving attitudes, expanding their knowledge of community resources, and providing physical activity opportunities in their neighborhoods are important intermediate steps toward initiation and maintenance of regular physical activity.

Objective To examine the association of heart disease with depression and the impact of treatment with anti-depressants on this association in older males with type 2 diabetes. Research design and methods In this cross-sectional study, data were collected from the electronic medical record system of the Veterans Affairs Medical Center (VAMC) in a large mid-western city in the United States. Subjects were 8185 males older than 40, with a history of type 2 diabetes, who had visited the VAMC within the previous 6 years. Odds ratios were used to measure bivariate associations; multivariate logistic regression was used to adjust for potential confounding factors. Results After adjustments for confounding variables, significant associations were found between depression and any adverse heart event (OR = 1.34, p = 0.001), coronary artery disease (OR = 1.23, p = 0.039), myocardial infarction (MI; OR = 1.77, p p = 0.034). Examination of the interaction between depression and anti-depressant prescription status indicated that, except for MI, these associations were no longer significant among those who had been prescribed anti-depressants, but remained significant and were increased in magnitude among those who had not been prescribed anti-depressants. Conclusions These findings support the premise that co-morbid depression in diabetics is associated with the occurrence of adverse heart events, and further suggest that treatment of depression with anti-depressants moderates this association.

Background Patient-centered perspectives on self-monitoring of blood glucose (SBMG) were assessed in adults with type 2 diabetes using a self-regulation conceptual framework. Methods Participants (N = 589; 53 % female) were adults with type 2 diabetes who were recruited during routine appointments at a diabetes outpatient clinic in the Southeastern/lower Midwestern region of the United States. Results Participant’s had varying perceptions regarding provider recommendations for SMBG (responder n = 380). Personal blood glucose testing patterns were also varied and reports frequently omitted (responder n = 296). Respondent’s most frequent personal pattern was to test “occasionally, as needed,” which did not differ by insulin use status, gender or age. In those not prescribed insulin, HbA1c reflected better control in those testing at least once per week (p = .040) or with a blood glucose goal (p = .018). 30.9 % endorsed at least monthly perceived encounters with SMBG barriers, with higher reports by women (p = .005) and younger (p = .006) participants. Poorer glycemic control was observed for participants with more frequently reported scheduling (p = .025, .041) and discouragement (p = .003) barriers. Conclusions Findings suggest that many may experience difficulty integrating SMBG into their lives and are unsure of recommendations and appropriate function. Research is needed to promote best practice recommendations for SMBG.

Diabetes has reached epidemic proportions and is widely encountered by clinicians in medical settings. National Standards for diabetes education recommend utilization of an interdisciplinary team, setting individual lifestyle goals and managing barriers. However, typical diabetes education programs lack integration of strategies for translating recommendations into behavioral actions. The present intervention was developed to assess the feasibility and efficacy of a short-term cognitive-behavioral intervention aimed at optimizing self-care behaviors in adults with diabetes in a “real world” medical setting. Participants were 20 adults who had completed medical model outpatient diabetes education. The intervention consisted of 6 weekly sessions that addressed the role of behavior in diabetes including self-care barriers, cognitions and self-regulation. Pre-post intervention data indicated greater specificity in goal-setting. Participants who kept activity records had the greatest lifestyle activity behavior change. Findings suggest that a brief intervention addressing realistic goal-setting is feasible and can promote meaningful health behavior changes. Clinical psychology can provide a bridge between current diabetes care recommendations and available medical resources by providing training in and delivery of empirically supported behavior change strategies and evaluation of diabetes care treatment approaches.

Extensive research supports the biopsychosocial model, but the current health care system generally operates according to a model of mind-body dualism. Integrated primary behavioral health care offers an alternative to this dualism. This paper describes the University of Louisville Graduate Psychology Education (GPE) program, a pre-doctoral integrated primary behavioral health care training program. This program emphasizes four shared psychosocial determinants that have been associated with physical health status: Victimization and potentially traumatic stress exposure, emotional functioning, social relationship functioning, and illness representations. It does so within the broader context of providing care for individuals who are underserved and economically disadvantaged. The initial phase of the program is evaluated and implications for graduate psychology education and patient care are discussed.

OBJECTIVE—The intensive treatment of diabetes to achieve strict glycemic control is a common clinical goal, but it is associated with an increased incidence of hypoglycemia. Becoming hypoglycemic while driving is a hazardous condition and may lead to a greater incidence of driving mishaps. This study investigated whether diabetes is associated with increased risk of driving mishaps and correlates of such a relationship. RESEARCH DESIGN AND METHODS—During routine visits to diabetes specialty clinics in seven U.S. and four European cities, consecutive adults with type 1 diabetes, type 2 diabetes, and nondiabetic spouse control subjects (n = 341, 332, and 363, respectively) completed an anonymous questionnaire concerning diabetes and driving. RESULTS—Type 1 diabetic drivers reported significantly more crashes, moving violations, episodes of hypoglycemic stupor, required assistance, and mild hypoglycemia while driving as compared with type 2 diabetic drivers or spouse control subjects (P < 0.01–0.001). Type 2 diabetic drivers had driving mishap rates similar to nondiabetic spouses, and the use of insulin or oral agents for treatment had no effect on the occurrence of driving mishaps. Crashes among type 1 diabetic drivers were associated with more frequent episodes of hypoglycemic stupor while driving, less frequent blood glucose monitoring before driving, and the use of insulin injection therapy as compared with pump therapy. One-half of the type 1 diabetic drivers and three-quarters of the type 2 diabetic drivers had never discussed hypoglycemia and driving with their physicians. CONCLUSIONS—Type 1 diabetic drivers are at increased risk for driving mishaps, but type 2 diabetic drivers, even on insulin, appear not to be at a higher risk than nondiabetic individuals. Clinical and treatment factors appear to increase risk, e.g., more frequent hypoglycemia while driving, method of insulin delivery, and infrequent self-testing before driving. Physicians are encouraged to talk to their type 1 diabetic patients about hypoglycemia and driving.

Patients desire to have information about health-related behaviors (e.g., exercise) provided to them by their health care provider. Outcomes of clinical trials in physical activity counseling are modest at best and therefore, the degree of effectiveness of physical activity counseling in the primary care setting remains unclear. We describe what may be considered a “real-world” example of behavior change counseling aimed at primary or secondary risk factor identification and modification for CHD in women. We examined rates of baseline and follow-up physical activity in our sample of midlife Caucasian and African American women (N = 227) participating in a hospital-based CHD-risk screening. Baseline physical activity levels and rates of return for follow-up appointments were quite low with only negligible achievement of behavior change recommendations. In light of these findings, the potential role of behavioral medicine in training and collaboration with health care providers in primary care behavior counseling is discussed.

Diabetes mellitus has reached unprecedented proportions worldwide. The WHO estimated that in 2012 there were 347 million individuals with diabetes mellitus worldwide affecting ~9 % of the population >18 years of age. It is projected that between 2005 and 2030 deaths due to diabetes would have doubled. Due to the rapid increase in obesity prevalence globally, the World Health Organization (WHO) has declared that there is now a global epidemic of obesity. Internationally, emergence of new cases of diabetes mellitus (diabetes) parallels the increases seen in Western countries and are increasing even more quickly in Asia. The risks of type 2 diabetes in these countries tend to increase at levels of body mass index generally classified as non-obese in Non Hispanic White Westerners. These worldwide changes are due to an accelerated prevalence of obesity, today’s predominance of sedentary lifestyle and the rapidly growing population of older adults, including an increased proportion of those belonging to ethnic groups with especially high rates of diabetes. In the USA the estimated number of individuals with diabetes was estimated at 25.8 million and 8.3 % of the population. Of these, 18.8 million were diagnosed and 7 million undiagnosed. By 2012, prevalence was 29.1 million and 9.3 % of the population with 21 million diagnosed and 8.1 million undiagnosed. Type 2 diabetes disproportionately affects minority populations, including African Americans (13.2 %), Hispanics (12.8 %), Native Americans (15.9 %), and Asian Americans (9 %). Risk factors for diabetes that are specific to these populations include genetic, behavioral, and lifestyle factors.

Dietary assessment in diabetes may be enhanced by considering patient-centered perspectives and barriers to change within IDF guidelines. Consideration of readiness to change (RTC) diet in underserved samples may guide future interventions in high risk populations. This study assesses the utility of a rapid assessment of RTC diet in a medically underserved sample.Participants were 253 Black (43.7%) and White (55.1%) American adults with type 2 diabetes [M age=57.93 (11.52); 60.5% female; 19% below the US poverty threshold]. Participants were recruited at medical clinics and completed validated self-report measures assessing diabetes knowledge, self-efficacy and dietary behaviors and barriers by RTC.Stage-based comparisons identified significant differences in diabetes and dietary domains: participants in the Action stage endorsed fewer behavioral dietary barriers (p.001), more frequent dietary problem-solving (p.001), and greater diabetes self-efficacy (p.001) than participants in the Contemplation and Preparation stages. Women were more likely to be in the Preparation stage and beyond (p.05).Findings highlight the clinical utility of a brief measure of RTC in understanding patient perspectives toward dietary behaviors in a medically underserved sample. The impact of gender on RTC diet warrants further exploration.

The usefulness of new, lowered diabetes diagnostic criterion to identify undiagnosed diabetics in a high-risk sample of women was evaluated. Participants were 228 midlife women undergoing screening for heart attack risk. Fasting plasma glucose levels of participants who were not diagnosed with diabetes were examined to assess the number of women who would meet diagnostic criteria for diabetes using old (140 mg/dL) and new 126 mg/dL) American Diabetes Association criteria. The new criterion identified more women than did the old criterion, particularly African Americans. Use of the new criterion flagged nearly 50% as many women as originally diagnosed as diabetic at the time of screening. Early identification of diabetes may afford earlier, preventive interventions that may reduce morbidity and mortality. Thus, findings from this study suggest that use of the new, lowered diabetes diagnostic criterion may have significant public health benefits for midlife women.

The goals of this study were to create a taxonomy of problem situations for diet adherence in persons with insulin-dependent diabetes mellitus (Type 1 diabetes) and a behavioral diagnosis by grouping patients together who have similar adherence problems. In study one, 29 patients with Type 1 diabetes kept food diaries for 4 weeks. Adherence was assessed using eight behavioral measures: (1) compliance with a meal plan, (2) energy intake, (3) protein, (4) carbohydrates, (5) fat, (6) self-reported overeating, (7) self-reported undereating, and (8) ratings of impulsive eating. The occurrence of each behavior was quantified in a wide range of situational contexts including meal, social context, physical location, and mood. Cluster analysis of behaviors, situations, and behaviors-in-situations was used to create a hierarchical classification model consisting of five major categories of adherence problems: (1) compliance with meal plan, (2) undereating, (3) overeating, (4) impulsive eating, and (5) lifestyle differences. Within each category, situations were associated with everyday eating habits and special circumstances such as social events, and meals in restaurants. Grouping patients based on the similarity of their adherence problems resulted in five diagnostic groups: (1) emotional binge eaters, (2) restrained eaters, (3) unrestrained eaters, (4) undereaters, and (5) cyclical diet bingers. In study two, 28 subjects kept diaries during an intervention program designed to enhance dietary adherence. Study two results were similar to study one. Situation taxonomy and behavioral diagnosis are potentially useful ways to understand the intervention needs of those attempting maintaining dietary behavior changes.

Exercise plays an important preventive and rehabilitative role in coronary heart disease. Unfortunately, cardiac rehabilitation exercise programs have high drop out rates. Several studies with noncardiac patients indicate that exercise-related strategies engaged in during exercise play an important role in exercise performance and adherence. We assessed exercise-related cognitions utilized by a group of cardiac rehabilitation patients who were adherent to a structured exercise program. Thirty-six subjects provided information on their cardiac history and exercise patterns and reported on the thoughts that they might have when exercising in situations depicted in 11 vignettes. Responses, rated using a reliable coding scheme, revealed that the majority of thoughts involved evaluating progress relative to goals and engaging in motivational self-talk. Other strategies reported included using cognitive distraction, thinking about body shape and arousal, making comparisons between self and others, and engaging in social distraction and interaction. Findings suggest that the exercise adherent subjects in this study use specific cognitive and behavioral strategies. Future studies comparing exercise thoughts of both adherent and nonadherent persons and prospective evaluation of their relationships to exercise adherence appear warranted.

Purpose The purpose of this study was to evaluate the effectiveness of diabetes self-management education or training provided by diabetes educators in reducing complications and improving quality of life. Methods Commercial and Medicare payer-derived claims data were used to assess the relationship between DSME/T and cost. Unlike the prior study that examined diabetes education provided by all professionals, the current study focused on the value of interventions performed as part of formal accredited/recognized diabetes education programs provided by diabetes educators only. Specifically, the current study focused on diabetes education delivered in diabetes self-management training programs based on 2 codes (G0108 and G0109). Results Results of the study provide insights into the differences in trends between participants and nonparticipants in DSMT. People with diabetes who had DSMT encounters provided by diabetes educators in accredited/recognized programs are likely to show lower cost patterns when compared with a control group of people with diabetes without DSMT encounters. People with diabetes who have multiple episodes of DSMT are more likely to receive care in accordance with recommended guidelines and to comply with diabetes-related prescription regimens, resulting in lower costs and utilization trends. Conclusions and Policy Implications The collaboration between diabetes educators and patients continues to demonstrate positive clinical quality outcomes and cost savings. This analysis shows that repeated DSMT encounters over time result in a dose-response effect on positive outcomes.

Lung cancer patients generally experience high levels of physical and psychological distress and decreased quality of life (QOL). Sense of coherence (SOC) has been conceptualized as a personality orientation reflecting the degree to which an individual perceives their world as comprehensible, manageable and meaningful. The present study investigated the associations of SOC with QOL in lung cancer. It also examined potential psychological mediators by which SOC may exert its influences on QOL. Fifty-six participants with non-small cell lung cancer were administered self-report assessments of SOC, QOL and psychological distress. Results revealed that SOC was positively associated with QOL and this relationship may be mediated by depressive symptoms. The current study supports the notion that SOC may be a protective factor with regard to psychological adjustment and QOL in cancer survivors.

Many health professionals lack important teaching skills, perhaps adding to patient difficulties in understanding and adopting therapeutic diets. Research suggests that teaching skills improved after dietitians took a continuing education course entitled "Effective Patient Teaching." Our study tested whether dietitians' new skills would persist in the field and whether selected patient outcomes would differ as a result. Thirty staff dietitians from six urban hospitals were videotaped teaching patients, then randomly assigned to take the Effective Patient Teaching course or not (control group). Follow-up videotapes were made after 1 week, 1 month, and 3 months. After each teaching session, patient satisfaction and recall were assessed. Two judges rated 20 teaching skills, which were divided into four subsets for analysis. Repeated measures analyses of variance showed overall gains only for the group that took the Effective Patient Teaching course, which scored higher than the control group at 1 week and 1 month, but not at baseline or 3 months. Gains occurred in presentation skills and essential teaching functions. Throughout the study, interpersonal skills were high and adherence promotion skills were low for dietitians in both groups. Groups did not differ on patient satisfaction or recall. Improvements in dietitians' teaching skills translated to the field immediately after they completed the continuing education program, but not all gains were sustained after 3 months. We recommend that dietitians assess their teaching and adherence promotion skills, obtain training where warranted, and periodically reassess the application of those skills during patient teaching sessions.

Although most U.S. adults have initiated an exercise program at some time, only a fraction are able to maintain consistent exercise. Instead, research suggests that intermittent exercise is commonplace among U.S. adults, underscoring the importance of identifying factors associated with consistent exercise at a level that promotes health and long-term maintenance of this activity. We proposed a theoretical model in which mindfulness and acceptance may promote exercise initiation and maintenance. Mindfulness, acceptance, and suppression were examined as a function of exercise status in 266 YMCA exercisers. Those who were successful at maintaining exercise tended to score higher on measures of mindfulness and acceptance, and lower on measures of suppression. Findings are discussed in light of our proposed theoretical model in which exercisers having greater mindfulness and acceptance are less reactive; responding with more balanced appraisals to threats to their exercise regimen which in turn promotes increased exercise maintenance. Future studies should utilize longitudinal design to examine causal relationships between variables.

In the USA, 44% of persons with self-reported diagnosed diabetes are aged 65 years or older and 18% are over age 75 years. The aim of diabetes intervention is to prevent or delay the development of long-term complications of high blood glucose and related metabolic abnormalities and improve the quality of life. “Metabolic syndrome” refers to a cluster of abnormalities that includes hypertension, dyslipidemia, abnormal blood glucose, and abdominal obesity. Over 40% of adults over the age of 70 have the metabolic syndrome. Hypoglycemia is a major limiting factor in the management of diabetes. Factors that may play a role in the increased risk of hypoglycemia in older adults include poor nutritional status, cognitive dysfunction, polypharmacy, and comorbid illnesses. Diabetes prevalence-related comorbidities such as diabetic retinopathy, cardiovascular disease, peripheral vascular disease, and congestive heart failure may result in decreased usual activity and limit activities of daily living, including transportation, shopping for food, and ability to read food labels and restaurant menus. Given the high rates of depression in the diabetes population, careful assessment of depressive symptomology and its impact on dietary intake, diabetes self-care, and health outcomes is critical.

This study investigated the extent to which habitual cigarette smoking relates to physical and psychological indices of chronic pain. From a review of patient records, 54% of back pain patients referred for treatment of their pain admitted to smoking cigarettes. Response from a smoking questionnaire showed that 57% of the patients who smoked reported having a need to smoke when they were in pain. Most patients (91%), however, believed that smoking had no effect on their pain intensity. When smoking and nonsmoking back pain patients were compared, the smokers showed significantly higher levels of emotional distress, they tended to remain inactive, and they relied on medication more often than the nonsmoking patients. The results further suggest that pain patients are at risk for increasing smoking behavior when they are experiencing periods of heightened pain intensity.

This study examined the effect of significant weight gain on physical, demographic, behavioral, and psychosocial factors in a representative sample of chronic pain patients. One hundred fifty-five chronic pain patients who reported gaining more than 15 pounds since the onset of their pain were compared with 341 pain patients who stated that their weight had remained the same since the onset of their pain. All patients were given a medical examination and each patient completed a comprehensive pain questionnaire and an SCL-90. Results showed that a significant relationship exists between weight gain and decreased physical activity, increased emotional distress, and accident liability. This study suggests that the inclusion of weight management training in multidisciplinary pain centers may play an important part in the rehabilitation of chronic pain patients.

Background: Key factors in successful long-term exercise maintenance are not well understood. The Relapse Prevention Model (RPM) may provide a framework for this process.Purpose: The purpose of this study was to examine the relationships among characteristics of exercise high-risk situations, components of the RPM relevant to exercise slips, and follow-up exercise outcomes in long-term community exercisers.Methods: We obtained long-term exercisers’ (N=65) open-ended responses to high-risk situations and ratings of obstacle self-efficacy, guilt, and perceived control. High-risk situation characteristics, cognitive and behavioral coping strategies, and exercise outcomes were examined.Results: High-risk situation characteristics included bad weather, inconvenient time of day, being alone, negative emotions, and fatigue. Being alone was associated with lower incidence of exercise slip. Positive cognitive coping strategies were most commonly employed and were associated with positive exercise outcome for both women and men. Guilt and perceived control regarding the high-risk situation were associated with exercise outcomes at follow-up, but only among the men (n=28).Conclusions: Findings confirm and extend previous work in the application of the RPM in examining exercise slips and relapse. Measurement issues and integration approaches from the study of relapse in addiction research are discussed.

Diabetes mellitus (diabetes) is a major health problem in the United States, affecting an estimated 16 million individuals, of whom 5 million are undiagnosed. Type 2 diabetes disproportionately affects minority populations, including African Americans, Hispanics, Native Americans, Asian Americans, and Pacific Islanders. The Pima Indians of Arizona have one of the highest rates of diabetes in the world. Risk factors for diabetes that are specific to these populations include genetic, behavioral, and lifestyle factors (1).

Numerous data demonstrate the importance of physical activity in reducing obesity and cardiovascular mortality and morbidity. Research demonstrates the beneficial impact of physician counseling on health promoting behaviors. Unfortunately, few physicians or medical students receive formal training in exercise counseling. We describe an educational activity used to provide medical students with the tools needed to begin to engage patients in activity counseling.

Psychologists working in health promotion and rehabilitation settings can often use their evaluation and intervention skills to help individuals adopt and maintain healthier lifestyles, including increased physical activity. Their expertise in theories and methods of behavior change can also make an important contribution to the design and implementation of specialized exercise and physical activity programs for high-risk groups and even entire communities. We begin this chapter with a brief discussion of physical activity behavior in the United States today and its importance in public health. We describe methods of assessing health-related physical activity and exercise that can be useful in different settings and applications. We briefly describe two behavioral models we believe will lead to improved exercise-promotion interventions. In the final two sections, we briefly present examples of interventions to increase physical activity and discuss physical activity promotion in groups that have until recently received little attention from researchers in this area: minorities, women, and the elderly.

Effective Patient Teaching (EPT), a health professions continuing education course, improves educators' teaching skills when presented by its developers. This study aimed to determine whether others could teach EPT with similar effectiveness. Four nurse mnagers who provide stafftraining and supervision for multiple hospital diabetes care units presented EPT to health care professionals at seven such sites; another seven served as controls. The evaluation included observations of trainers conducting EPT programs in thefiel4 teaching shills ratings of health professionals in both groups, and bowledge tests administered to patients. Six months ter training, teaching skills scores of health professional EPT participants were better (p < .05) than controls. The EPT program improves participants' teaching skills and maintains these effects infield settings, when presented byfaculty not involved in its development.

Even following education sessions, dietary adherence among medical patients is generally poor. One contributor to this problem may be the quality of teaching and adherence promotion skills employed by Registered Dietitians, whose behavior during routine patient interactions was evaluated in this observational study. Thirty dietitians were videotaped with one of their patients. Twenty operationally defined skills were rated on a scale from 0 (skill absent) to 3 (excellent). Dietitians' interpersonal skills were good (mean = 2.1, S.D. = 0.35), but all other skills were performed significantly less well (mean scores less than 1.0). Adherence promotion skills were rarely observed. Dietitians need supplemental training to improve teaching and adherence promotion skills.

This study evaluated the psychological effects of aerobic conditioning in 40 moderately obese, sedentary women participating in a 12-week behavioral weight loss program. Participants were randomly assigned to a no-exercise or moderate walking condition. Emotional impact of the treatment was assessed in two ways: (1) Subjects reported subjective mood prior to each eating episode and (2) the SCL-90-R was administered before and after the program. Exercisers lost more weight and body fat than non-exercisers. Both groups of subjects showed numerous improvements in mood as a result of participating in the weight loss program. Exercise had no specific differential effect on emotions as measured by daily mood ratings or the SCL-90-R. Exercise did not appear to add appreciably to the psychological benefits of losing weight in this sedentary obese population. Future studies utilizing longer periods of aerobic exercise training, larger sample size, and exercise specific measures are recommended.

The present study was designed to explore the relationship between cigarette smoking and headache activity in a sample of patients presenting for treatment. Subjects completed various self-report measures and monitored headache activity four times per day over a 4-week period. Analyses revealed that smokers experienced greater weekly peak headache intensity, and reported higher levels of depression and general physical symptoms. Among smokers, nicotine content of the preferred brand was associated with mean headache index and weekly headache-free days, as well as depression and anxiety scores. Daily smoking rate and pack-year history were related to level of general physical symptoms only. Thus, both smoking status and the nicotine content of the preferred cigarette appear to adversely impact headache activity. Further, smokers who are more anxious or depressed may increase their headache activity via their preference for higher nicotine-content cigarettes. These results are discussed in the context of possible mechanisms underlying these effects, and implications for the clinical management of headache suffers who smoke.

To the Editor. —The importance of identifying persons at increased risk for developing coronary artery disease is highlighted in the article on evaluating coronary heart disease (CHD) risk by Dr Hoeg. 1 The author advocates that examination of an individual patient's risk factors is essential in planning effective treatment. Both nonmodifiable risk factors such as a family history of heart disease and potentially modifiable factors such as cigarette smoking and obesity were described as "established" CHD risk factors. In addition to conventional risk factors, a list of 17 particularly promising proposed CHD risk factors was presented. We were surprised to note that none of the listings or case conceptualizations included psychosocial risk factors that have been shown to play an important role in the progression of coronary artery disease. 2 In particular, low levels of social support and economic resources 3 and depression 4 have been shown to be strongly

Patient adherence is one determinant of the success of medical therapy, but little is known about the extent to which health professionals routinely assess adherence. This study evaluated the extent of patient adherence assessment by senior medical students in an outpatient diabetes clinic. The number of adherence questions students asked was low in all areas of the patients’ diabetes regimen. The number of questions asked did not relate to patients’ clinical status or their self‐reported regimen adherence. Findings suggest a need for systematic attention to adherence issues in physician education.

This study examined the effects of calorie alternation and exercise on weight loss. Moderately obese women (130-160% of ideal body weight) were randomly assigned to an alternating- or constant-calorie diet with or without aerobic exercise. Both diets provided an average of 1200 kcal/d over a 12-wk period; daily intake of subjects in the alternating-diet condition varied in a prescribed pattern from 600 to 1800 kcal/d. Exercising subjects walked 5 d/wk. All subjects participated in an intensive outpatient behavior-modification program. At the end of the study, exercised subjects had greater reductions in body weight and body fat percentage than did nonexercised subjects. The type of caloric restriction did not affect weight or fat loss. Changes in resting metabolic rate did not differ among groups. Alternating calories was neither beneficial nor detrimental as a weight-loss strategy whereas exercise was clearly beneficial in weight-loss therapy.