Does physical activity predict depression? Or does depression predict physical activity?: Findings from breast cancer survivors

As more and more individuals are surviving cancer, interventions to promote mental health and quality of life in cancer survivors are growing. It is well established that physical activity is an appropriate intervention for preventing and treating depression in cancer survivors, who are frequently at risk of developing multiple depressive episodes following treatment. Unfortunately, the interplay between depression and physical activity in cancer survivors is unknown. Specifically, it is unclear whether physical activity buffers against depression or whether depression leads to low physical activity. Perhaps both are true. By answering this question, researchers can help determine whether targeting depression before physical activity (or physical activity before depression) can benefit cancer survivors’ quality of life. Ultimately, understanding this phenomenon will enhance the effectiveness of mental and physical health interventions for this growing population.

In a longitudinal observational study involving 201 female breast cancer survivors, the women completed measures of depression and wore a physical activity monitor to measure daily physical activity at five time points. A few methodological strengths are apparent in this study, including the longitudinal design and the objectively measured physical activity level. Longitudinal designs are considered strong research designs because they allow researchers to determine the temporal order of associations between variables. In addition, using an activity monitor to measure physical activity instead of using self-reported activity levels allows researchers to avoid biases in participants’ recall of their own activity level.

Brunet et al. (2018) found unexpected results. Mainly, previous depression did not predict future physical activity, and previous physical activity did not predict future depression. In addition, these effects did not vary across the multiple time points. These findings are counter-intuitive because previous research has shown predictive associations between depression and physical activity. But given that the researchers did not necessarily expect any change in physical activity or depression over time (i.e., there was no intervention), it is possible that the study did not include a large enough sample to detect subtle changes. Greater statistical power (which is typically achieved by including more participants) would allow researchers to detect smaller effects.

Given that physical activity has been shown to reduce depression in community and cancer survivor samples, it will be important to determine why these associations have been found and in what ways these associations may be different in cancer survivors. In order to prevent and treat depression in cancer survivors, clarifying the barriers to physical activity that these individuals face during their transition to survivorship will inform intervention development. Ultimately, physical activity and depression interventions may need to be artfully combined in order to enhance quality of life for cancer survivors.

Reference: Brunet, J., O’Loughlin, J. L., Gunnell, K. E., & Sabiston, C. M. (2018). Physical activity and depressive symptoms after breast cancer: Cross-sectional and longitudinal relationships. Health Psychology, 37(1), 14-23.

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The Importance of Measure in Psychology

Developing adequate measures is essential for the advancement of psychology as a science. Without the ability to adequately measure intended constructs, it is difficult for scientists to conduct experiments, form theories, or improve interventions. How do we know if a measure is adequate? Construct validity is the extent to which a measure actually measures what it is intended to measure. For example, an IQ test with high construct validity would actually measure intelligence and not something else.

In a large online sample and a college sample, our research group examined the construct validity of multiple forms of affective judgments of physical activity. Affective judgments of physical activity are the overall pleasure, enjoyment, and feelings associated with the experience of exercise or physical activity. Affective judgments have received recent attention because they are strong predictors of the amount of physical activity an individual engages in, and interventions targeting affective judgments appear to be a promising approach to increasing physical activity. We found that the majority of physical activity measures have substantial construct validity limitations. First, although the scales had adequate measurement consistency across items, most measures did not provide consistent results from one test occasion to the next. Second, these measures lacked convergent validity (i.e., the correlations among these measures were lower than would be expected if these measures were measuring the same construct). Third, they failed to demonstrate discriminant validity from some other exercise-related measures. However, the measures had adequate criterion validity (i.e., they predicted physical activity). Of note, scales with stronger psychometric properties demonstrated a stronger association with physical activity.

There are important implications from this study. Overall, affective judgment measures, and particularly those with stronger psychometric properties, are able to predict physical activity, suggesting affective judgments are an important construct to study. Focusing on improving psychometric properties of affective judgment measures could increase the predictive validity of affective judgment measures. However, it appears that the various affective judgment of physical activity measures have substantial construct validity limitations, suggesting that future research should focus on improving these measures. The lack of reliability limits our ability to know whether any changes observed in research are due to actual changes or a lack of precision in the measures. The lack of convergent validity suggests that future research needs to clarify whether enjoyment, motivation, affective attitudes, and affective associations are distinct constructs. This is important because if it is not clear regarding which construct we are measuring, we won’t know which construct might be changing.

Overall, these findings suggest that there should be a future focus on developing better affective judgment measures. If we have better measures of affective judgments, we will be in a better position to understand why people have the affective judgments they do and how to effectively intervene to increase physical activity. A focus on construct validity will allow us to identify the many possible dimensions of affective judgments of physical activity (e.g., enjoyment vs. satisfaction) and will allow us to identify when affective judgments change. A focus on construct validity can also improve interventions by allowing us to target specific affective judgment dimensions as well as allow us to more accurately evaluate which affective judgment dimensions are changing.

Chmielewski, M., Sala, M., Tang, R., & Baldwin, A. (2016). Examining the construct validity of affective judgments of physical activity measures. Psychological Assessment, 28(9), 1128-1141

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Thinking about Benefits and Obstacles to Regular Exercise

Have you ever set your alarm to exercise in the morning but didn’t get out of bed, or planned to go to the gym in the evening but ended up going home instead? The key to following through on plans and intentions may be quite simple. Mental contrasting is a simple cognitive technique in which people specify a goal they are trying to reach, and then they identify and imagine the most positive outcome they expect from reaching their goal and the most relevant obstacle they are likely to face in trying to realize their goal. This simple technique was recently tested in a randomized controlled trial (RCT) and the results were published in Health Psychology.

Theoretically, mental contrasting works because the contrasting of benefits and obstacles makes an individual’s efforts to change their behavior more realistic and helps to maintain motivation when challenges inevitably occur. Mental contrasting has previously been shown to be effective in a number of different contexts. In this study, the researchers tested whether adding a mental contrasting task to making plans and setting goals for regular exercise would lead to more exercise over a four-week period. In addition, they tested the possibility that focusing the mental contrasting on the affective benefits and obstacles of exercise (e.g., it will result in more energy, it will be unpleasant while doing it) would be more effective than either focusing on instrumental benefits and obstacles (e.g., it will improve my health, it will require too much time) or a standard mental contrasting without any particular focus. This hypothesis is based in the growing evidence showing that affective factors, such as how people feel during and after exercise, are critical determinants of regular exercise.

Participants who were randomly assigned to do the mental contrasting with an affective-focus reported significantly more weekly minutes of physical activity at the end of four weeks than participants in the instrumental benefits-focused condition or the standard condition. On average, they reported nearly 300 more metabolic equivalent of task (MET) minutes than the other two groups, the equivalent of about 60 additional minutes per week of brisk walking.

The findings from this study are valuable for at least three reasons. First, this was a well-designed RCT. To test the effects of intervention techniques on behavior, the RCT is the gold standard design. Thus, we can have greater confidence that the affect-focused mental contrasting has a causal effect on exercise behavior. Second, the mental contrasting technique used here is simple and straightforward, and it could easily be used as standard practice to increase the likelihood that people follow through on their exercise plans. Third, the findings add to the growing body of evidence for the importance of affective factors in the decisions people make about exercise.

Reference. Ruissen, G.R., Rhodes, R.E., Crocker, P.R.E., & Beauchamp, M.R. (2018). Affective mental contrasting to enhance physical activity: A randomized controlled trial. Health Psychology, 37, 51-60.

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Can mindfulness meditation reduce chronic pain?

If you have suffered from chronic pain, you have likely tried several strategies to relieve the pain. One strategy that has recently become popular for pain relief is mindfulness meditation. Mindfulness meditation refers to a process of developing the skill of bringing one’s attention to whatever is happening in the present moment.

In a recently published meta-analysis, Hilton and colleagues (2017) examined the effectiveness and safety of mindfulness meditation interventions for the treatment of chronic pain in adults. A meta-analysis is a research methodology in which the findings from several studies on the same topic are combined and analyzed together. It is considered the gold standard of evidence for understanding the robustness of an effect. In addition, this meta-analysis is particularly valuable because researchers only included randomized controlled trials, which means that participants were randomly assigned to a mindfulness meditation condition or a control condition. Because this meta-analysis included only randomized controlled trials, findings from this meta-analysis shed light on the extent to which mindfulness meditation treatments lead to decreases in chronic pain.

There were 38 studies included in the meta-analysis that had patients reporting chronic pain for at least 3 months. The patients were then randomized to either a formal mindfulness meditation treatment or a control treatment. Control treatments included no intervention, an education support group, or treatment as usual. Researchers coded for the effect of each intervention. In addition, researchers rated quality of evidence for each study as high, medium, low or very low. A study was rated lower quality if, for example, it did not report important pieces of the study methodology or did not include participants who dropped out of the study in analyses.

The results indicated that mindfulness meditation was more effective than control treatments in reducing chronic pain. However, the effect size was small and the quality of evidence was considered low due to publication bias (a bias where findings with significant results are more likely to get published) and inconsistency of results among the studies. In addition, 13 out of the 38 studies were rated as poor quality. Mindfulness meditation was also associated with improvement in depression, physical health-related quality of life (e.g., ability to engage in physically demanding activities), and mental-health related quality of life (e.g., having emotional problems that interfere with daily functioning).

Overall, findings suggest that mindfulness meditation results in improvements in chronic pain, depression, and quality of life. However, the weaknesses in the body of evidence (e.g., publication bias, inconsistencies among studies, large number of poor quality studies) prevent strong conclusions. Future researchers should conduct more rigorous randomized controlled trials examining the effect of mindfulness meditation on chronic pain. The trials should report all important pieces of study methodology, have longer follow-up, and include all participants who were randomized into the study when analyzing the results.

Hilton, L., Hempel, S., Ewing, B. A., Apaydin, E., Xenakis, L., Newberry, S., … Maglione, M. A. (2017). Mindfulness meditation for chronic Pain: Systematic review and meta-analysis. Annals of Behavioral Medicine, 51(2), 199–213.

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Do you think you are more or less physically active than others?: The influence on mortality

Inadequate physical activity levels are associated with a shorter lifespan because inadequate physical activity can increase an individual’s risk of developing chronic illnesses, like diabetes. Although the evidence is clear that increasing physical activity levels is important for preventing illness and premature mortality across the lifespan, do individual’s perceptions of their physical activity levels compared to others influence mortality? Prior work suggests that individual’s perceptions of their own health behaviors influences actual health behavior engagement leading to health outcomes.

A study recently published in Health Psychology examined whether adults’ perceptions of their physical activity levels predicted mortality. Data for this study came from the National Center for Health Statistics (NCHS), and included 61,141 participants across three nationally representative samples with follow-up time points up to 21 years later. One of the most important advantages of analyzing data from large-scale epidemiological studies is greater confidence in the accuracy of results by reducing the likelihood for error. Participants were asked to rate whether they perceived themselves as a lot more active, a little more active, as active, a little less active, and a lot less active than other people their same age. In addition, participants provided data on their actual physical activity levels via self-report or an accelerometer. Mortality was measured as death from any cause collected from the 2011 National Death Index. The authors chose to control for demographics variables, perceived health, number of illnesses, disability, mental health, smoking, body mass index, and actual physical activity levels in analyses to rule out alternative explanations for the effect.

This study found that, even after controlling for many variables influencing mortality, those who perceived themselves as a little more active or as active as others had an 8% increased likelihood of having died than those who perceived themselves as a lot more active than others. In addition, those who perceived themselves as a lot less active had an 18% increased likelihood of having died than those who perceived themselves as a lot more active. These results replicated in two additional samples, which provides evidence that these findings were not due to chance.

Taken together, this study supports a growing body of evidence that an individual’s perception of their own physical activity levels compared to others influences mortality. The authors suggest that perceptions predict mortality by influencing actual physical activity engagement. Future research will need to examine this mechanism. Given that physical activity interventions focus on increasing actual rates of physical activity, this study suggests that interventions may also want to target individual’s perceptions of their physical activity levels by informing people of their actual physical activity levels compared to others. Future research will need to assess the reasons why perceptions and social comparisons influence behavior.

Reference: Zahrt, O.H., & Crum, A.J. (2017). Perceived physical activity and mortality: Evidence from three nationally representative US samples. Health Psychology, 36, 1017-1025.

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Mindful Eating Training Can Help Reduce Impulsive Eating Habits

Do you find yourself eating even when you are not hungry? Do you have trouble resisting impulsive eating throughout the day? Overweight and obese individuals tend to be more impulsive and sensitive to food rewards compared to normal weight individuals. Obesity is a growing health concern, with over 2/3 of the U.S. population being overweight or obese (CDC, 2015). A recent study published in the journal Health Psychology investigated the effects of a mindful-eating training on impulsive food choice in both adolescents and adults. Mindful eating is an approach to eating where you learn to pay attention to your thoughts, feelings and sensations both during and after eating.

In this study, 348 adults and adolescents participated in two study sessions. The first session was to measure the baseline discounting rate. The baseline rate was compared to the discounting rate after the intervention in order to determine the amount of change. During the first session, participants completed a delayed discounting task, a task that measures impulsivity by comparing the preference for smaller, more immediate rewards over larger, delayed rewards. For the second session, participants were randomized to a mindful eating group, DVD control, or a standard control group. The mindful-eating group completed a 50-min workshop on mindful eating where they applied their newly learned skills while eating four types of foods. The DVD control group watched a 50-min DVD about nutrition and the food pyramid. The standard control group did not participate in any training or standardized activity.

Both adolescents and adults who participated in the mindful-eating session experienced reduced impulsivity towards food choices from the baseline session. In addition, consistent with prior research individuals, both adolescents and adults, with higher percent body fat had higher food impulsivity than healthy weight individuals.

Strengths of this study include the randomized control design. This means that there was a control group and an intervention group. Also, participants were randomly assigned to their group, which ensures that the groups are equal on everything except the intervention. This design allows for more conclusive evidence about the effect of mindful eating training on impulsive eating compared to other designs. Findings from this study suggest that mindful eating interventions can decrease impulsive food choices, which could lead to weight loss. Mindful-eating training could also be a potential prevention strategy for impulsive eating, thus preventing obesity. Future research should investigate the long-term effects of mindful-eating interventions since this study only looked at short-term effects.

Hendrickson, K. L., & Rasmussen, E. B. (2017). Mindful eating reduces impulsive food choice in adolescents and adults. Health Psychology36(3), 226.

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What Explains How People Feel During and After Exercise?

We all know that exercising is good for us. Yet, few of us engage in regular exercise. One reason individuals may choose to exercise or to not to exercise is that an individual may feel good or bad during exercise. For example, the better someone feels during exercise, the more likely they are to exercise regularly.

In a recently published study from our lab we identified factors that help explain how people feel during and after exercise. Specifically, we had healthy young adults complete measures of anticipatory affect factors (affective attitudes, implicit associations, and affective associations), anticipated affect factors (anticipated regret, anticipated pride), and cognitive factors (self-efficacy, intentions). Anticipatory affect is the experience of pleasant or unpleasant feelings while thinking about or anticipating exercise. Anticipated affect is the expectation of how one will feel after completing an exercise session, such as anticipated pride or anticipated regret. Cognitive factors include self-efficacy (i.e., the belief that one is able to perform a specific behavior) and behavioral intentions (i.e., a belief about one’s readiness to perform a behavior). After completing measures, participants ran or walked for 20-minutes on a treadmill and answered questions on how they were feeling during and after the exercise.

We found that both regret and pride (anticipated affect) and anticipatory affect variables accounted for unique aspects of how people feel during and after exercise. Only anticipatory affect uniquely accounted for affective response immediately post-exercise. There were no associations between the affective and cognitive factors and affective response 5-10 minutes post-exercise. We also found that the associations between exercise self-efficacy and how people feel during exercise was due to the overlap that self-efficacy has with affective factors.

Overall, we found unique associations between affective, but not cognitive, factors and affective response to exercise. Findings from this study highlight the importance of considering multiple factors simultaneously to understand unique predictors to affective response. Future research should identify the extent to which these various factors overlap and the extent to which they are distinct.  Findings also suggest that it is possible that intervening on affective factors may result in improved affective response to exercise, which could increase exercise behavior. Future research should examine this possibility.

Sala, M., Baldwin, A. S., & Williams, D. M. (2016). Affective and cognitive predictors of affective response to exercise: Examining unique and overlapping variance. Psychology of Sport and Exercise, 27, 1-8.

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Do Family Members of Melanoma Patients Use Sun Protection Behaviors?

The American Cancer Society estimates that 10,000 people a year will die from melanoma, a deadly form of skin cancer primarily caused by sun exposure. First-degree relatives of melanoma patients, such as parents and children, are at particularly high risk for developing melanoma themselves. One would imagine that with higher risk of developing skin cancer, first-degree relatives of melanoma patients would be more likely to engage in sun protective behaviors than others. However, is this actually the case?

A study recently published in Health Psychology examined the use of four sun-protective behaviors: sunscreen usage, shade-seeking, hat wearing, and protective clothing use among first-degree relatives of melanoma patients. The researchers assessed these behaviors twice a day in 59 participants over 14-days using an automated phone call system. Data collected from daily surveys over multiple days allows researchers to examine and understand behavior in real-time, and allows for exploring changes in behavior within individual participants that increases confidence in the reliability and robustness of the findings.

Among the four behaviors examined, sunscreen use was most frequent, followed by shade seeking, wearing hats, and wearing protective clothing. However, the majority of participants reported inconsistent use of these behaviors meaning most participants used each sun protection behavior less than 80% of the time. In addition, the study found that the factors leading to sun protective behaviors were different for different participants. This means that different environmental factors, such as time of day and level of sun exposure, influenced individual’s use of sun protection behaviors. This finding is important because it indicates that sun protection interventions may need to target people’s own reasons for using sun protection behavior.

Taken together, sun protection behaviors are inconsistently used in individuals at increased risk of developing skin cancer. Moreover, factors leading to sun protective behaviors vary for different individuals. Future research should examine associations between multiple sun protection behaviors, and develop personally tailored interventions to increase individuals’ use of sun protection behaviors.

Reference: Hay, J.L., Shuk, E., Schofield, E., Loeb, R., Holland, S., Burkhalter, J., & Li, Y. (2017). Real-time sun protection decisions in first-degree relatives of melanoma patients. Health Psychology, 36, 907-915.

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An App to Help Parents Make a Decision about the HPV Vaccine

Although the Food and Drug Administration (FDA) has approved a vaccine that protects against the human papillomavirus (HPV) – a sexually transmitted virus that can cause several cancer types, including cervical cancer, current vaccination rates for the 3-dose series among US adolescents are low (39.7% for girls, 21.6% for boys).

In a recent paper our group published in the journal Patient Education and Counseling, we describe a new mobile app-based intervention we developed to address the problem of low HPV vaccination rates. The app is based on self-persuasion, the process of generating one’s own arguments for engaging in a specific behavior. Self-persuasion may be a particularly useful strategy for increasing adolescent HPV vaccination rates because many parents of adolescents are undecided or hesitant about the vaccine, and using parents’ own arguments for the vaccine may help them decide.

In this paper, we report on the development of the mobile app to promote parental self-persuasion for adolescent HPV vaccination and the evaluation of whether the app is easy and practical for parents to use. As part of the research study, parents viewed an informational video about HPV and the vaccine, answered a number of questions about different topics related to the vaccine, and then verbalized in their own words why it is important for their adolescent to get the vaccine.

We found that parents rated the app as easy to use and helpful for thinking about the HPV vaccine. In addition, although most of the parents were undecided about the vaccine when they began the study, 82% of parents reported deciding to get their adolescent vaccinated after using the app.

The self-persuasion app we developed is an excellent example of translating an established and effective behavior change approach – self-persuasion – into an innovative and effective way to impact population health. By developing the intervention within a mobile app, there is strong potential to make the intervention widely available to parents of adolescents who are making decisions about the HPV vaccine.

Reference. Baldwin, A.S., Denman, D.C., Sala, M., Marks, E.G., Shay, L.A., Fuller, S., Persaud, D., Lee, S.C., Skinner, C.S., Wiebe, D.J., & Tiro, J.T. (2017). Translating self-persuasion into an HPV vaccine promotion intervention for safety-net patients. Patient Education and Counseling, 100, 736-741.

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Daily Self-Weighing: The Secret to Successful Weight Loss Maintenance

Is it useful to step on the scale every day? Findings from a recent study suggest that daily self-weighing might be the key to successful weight loss maintenance.

In a recently published study in Annals of Behavioral Medicine  researchers examined why a successful weight loss maintenance intervention –“Keep it Off – Guided Intervention”– has been successful. Keep it Off is an intervention designed to help people who have already lost weight to maintain their weight loss. Participants in the Keep it Off Guided intervention received 16 coaching sessions over two years targeting several factors that have been suggested to influence weight-loss maintenance. This intervention was compared to a control condition where participants received two phone coaching sessions and a course book with the topics key to weight loss-maintenance. This study focused on identifying mediators of the intervention – variables that account for the success of the intervention. Possible mediators included: starting self-weighting, stopping self-weighting, minutes of physical activity, calorie consumption, using weight-control strategies, amount of meals eaten at fast food venues, body image, and TV-related eating.

Of note, an important strength of this study was that participants were randomly assigned to the control or intervention groups, and the potential mediators for maintained weight loss were measured every 6 months over two years. These study design strengths increase confidence in the findings.

The researchers found that starting daily self-weighing and not stopping daily self-weighing were the only significant mediators of the intervention. Given the findings from this study and other studies which have documented the benefits of daily self-weighing, individuals who have lost weight and are seeking to maintain it should consider starting and not stopping self-weighing. In addition, several potential explanations for weight loss maintenance emerged, including eating away from home, dietary intake, and body satisfaction. These variables were predictive of weight changes but did not mediate the effect of the intervention. The lack of intervention effect on these factors that were associated with weight change could be due to a lack of emphasis on these behaviors in the intervention. Focusing on targeting these factors could strengthen future weight loss maintenance interventions, and these pathways should be investigated in future weight loss maintenance interventions.

Crain, A.L., Sherwood, N.E., Martinson, B.C., & Jeffery, R.W. (2017). Mediators of weight loss maintenance in the Keep It Off Trial. Annals of Behavioral Medicine, 1-10.

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