Changes in Physical Activity Among Participants of the Traditions of the Heart Intervention Traditions of the Heart is a CDC funded cardiovascular screening and intervention program know as the WISEWOMAN program. Well-Integrated Screening and Evaluation for Women Across the Nation. At Southcentral Foundation we have named this program Traditions of the Heart. Southcentral Foundation

Statement of Problem Cardiovascular disease (CVD) is the leading cause of death among women in the United States Mortality rates are particularly high in women of low socio-economic status or from ethnic minority groups Lifestyle related risk factors such as physical inactivity and diet are important causes of CVD and are key targets for intervention projects Regular PA reduces the risk of obesity, abnormal blood lipid values, hypertension and blood glucose levels Primary and secondary prevention strategies for women are essential to improve CVD health because major established risk factors for CVD are increasingly prevalent in women To address the increasing prevalence of heart disease in the female Alaska Native population, SCF developed TOTH within a primary care setting in Anchorage, AK to test an intervention approach adapted for Alaska Native women Southcentral Foundation

TOTH Intervention Intervention Components: Physical Activity Diet Stress Management Tobacco cessation Roughly 1/3 of the intervention devoted to imparting knowledge, skills, and self-efficacy related to low impact physical activity Intervention duration- 12 weekly 2 hour sessions SCF’s Traditions of the Heart Intervention (TOTH) Ix targeted 4 risk factor areas: PA, nutrition, stress and tobacco (stress and tobacco combined for 1/3 time) Southcentral Foundation

Physical Activity Components Strength exercise with therabands Stretching Tips Making a plan for physical activity Activity pyramid Chair exercises Becoming more active Checking your heart rate Safety tips for exercise Using your pedometer Beginning a walking program Tools provided: ice grippers, therabands and pedometers Also provided resources for PA in community (example: mall walking hours) Southcentral Foundation

Activities Secondary Data Analysis of the TOTH dataset from 2000-2005 Describe population characteristics Determine changes at pre and post intervention related to: Level of physical activity Perceived barriers to physical activity Southcentral Foundation

Hypothesis There is a statistically significant increase in standard metabolic equivalent (MET) level from pre to post intervention in those participants who attended at least half (6 or more) intervention sessions Regardless of change in MET level, individual perceived barriers to physical activity will decrease Southcentral Foundation

Study Sample Criteria Enrolled in TOTH study from 2000-2005 Attended at least 1 intervention session Completed both pre and post intervention assessment Completed baseline clinical screening Completed baseline screening questionnaire Of the 1334 enrolled, 269 met the study sample criteria. Characteristics of the entire WISEWMOAN pop and study sample were similar (high proportion of college educated, same age) but did not look at employment status, family size, past disease history which could have impacted willingness to participate in intervention Southcentral Foundation

Study Population for Secondary Data Analysis Alaska Native or American Indian Female Eligible to receive services at the Alaska Native Medical Center Age 40-64 years Community of residence in the Anchorage Bowl Eligible to participate in the National Breast and Cervical Cancer Early Detection Program Southcentral Foundation

Study Variables and Measures Baseline clinical assessment ‘How Active Are You?’ questionnaire Frequency and duration assessment 31 questions Algorithm yielding weekly energy expenditure and time spent in moderate activity ‘What Makes It Hard To Keep Active’ questionnaire Barrier Assessment 16 questions ‘Food, Activity and You’ questionnaire Stages of change assessment 1 question Baseline clinical assessment- wt, used in calculation of weekly energy expenditure Also baseline characteristics: BP, CHOL, BMI, ed level and age Southcentral Foundation

Statistical Analyses ‘How Active Are You?’ Demographic characteristics Calculation of weekly energy expenditure One-sided paired t-test Demographic characteristics Descriptive statistics with cross tabulations by activity level at baseline ‘What makes it hard to keep active’ Cross tabulations by barrier compared to education level, total # sessions attended, and activity level at baseline ‘Food activity and You’ Southcentral Foundation

Results- Demographics 67% college educated or higher 22% current smokers 3.72% current smokeless tobacco users 41% history of hypertension, with 15% having blood pressure values indicating hypertension 41% history of hypercholestermia with 23% blood total cholesterol values above 200mg/dL Average BMI was 31.28 (SD of 6.55) 44.25% BMI indicating overweight 9.29% BMI indicating obesity Average age 50.81 years (younger women) High % overwt/obese (roughly 55% above normal recommended wt High % (71%) with weekly energy expenditure at a level according to US Surgeon General to be high or vigorously active. Note: 59% all AK reported meeting CDC PA recommendations in the 2004/5 AK BRFSS. Southcentral Foundation

Southcentral Foundation

Southcentral Foundation

Southcentral Foundation

Results- Activity Level   T-tests of weekly energy expenditure showed statistically significant change in activity level -as calculated as estimates of Kcal/kg/week and Kcal/week for: -those attending 1 or more -those attending 6 or more It was found that attendance in either one or more or six or more intervention sessions yielded a statistically significant increase in standard metabolic equivalent, or MET, level from pre-intervention to post-intervention but no change was found in individuals attending the complete (12 sessions) intervention. Southcentral Foundation

Southcentral Foundation Regardless of change in level of PA, the level of individual perceived barriers decreased for all sixteen barrier categories The findings from this secondary analysis indicate that participants in the women in the TOTH WISEWOMAN were found to have decreased barriers to physical activity and increased energy expenditure in the week 12 questionnaire compared to the week 1 questionnaire. Interestingly, the participants reported being highly active at baseline, despite having high rates of CVD risk factors, which made it impossible to determine if the TOTH WISEWOMAN intervention assists sedentary women in decreasing barriers to physical activity and increasing energy expenditure. Southcentral Foundation

Discussion Indications that the intervention promoted positive movement… along the continuum of stage of change, in perceived barriers to physical activity, in time spent engaged in physical activity, and increases in actual energy expenditure. However, difficult to determine if the TOTH intervention assists sedentary women Health behaviors are difficult to measure, and this is certainly true for the behavior of physical activity. Of particular concern is how well self-reported physical activity accurately represents a person’s habitual activity status. Factors that interfere with obtaining accurate assessments include incomplete recall, exaggeration of amount of activity or social desirability, and non-representative sampling of time intervals during which activity is assessed. The majority of the sample was in the vigorous or high activity level at baseline. Despite the high frequency of vigorous activity level, there remain high levels of CVD risk factors in the sample. Additionally, despite the high frequency of vigorous activity level, many women reported barriers to physical activity at baseline. Participants in the TOTH WISEWOMAN intervention were found to have decreased perceived barriers and increased energy expenditure at the end of the 12-week intervention . When measured at the end of the twelve week sessions participants were noted to make positive changes along the stages of change, regardless of the level of physical activity of the women at baseline. The social support that the women experienced during the twelve week intervention could have contributed to the results of this study, however social support was not studied in this analysis nor was it a variable considered in the TOTH WISEWOMAN study design. It is important to note that the study population was not representative of Alaska Native women in urban Alaska making these results ungeneralizable. Southcentral Foundation