1. Strong Bodies - Strong Minds Integrated Therapy An Interactive e-Health Prescribed & Monitored PA Program for Clinically Obese Geriatric Patients with Depression Robelyn Garcia, PhD, MA, MS Arizona State University _______________________________ Doctor of Behavioral Health Program College of Health Solutions

2. NEED FOR INTERVENTION INTRODUCTION > Obesity is costing the United States $605 billion annually, including over $200 billion in direct healthcare costs (Pianin & Ehley, 2014). > More than one-third (78.6 Million) of American adults are obese (Ogden, Carroll, Kit, & Flegal, 2014). > The highest rates of obesity are found among senior adults (Hojjat, 2013; Smith et al., 2011). > The most significant prevalence rate of comorbid depression and obesity is 66% reported in obese older adults (Preiss, Brennan, & Clarke, 2013).

3. CLINICAL SETTING North Scottsdale Primary Health Care Clinic > Positioned in community with a large and growing demographic of retirees, seniors aged 50-70 years, and older seniors aged 70-105 years (Scottsdale Senior Services, 2014). > Intervention setting has availability of computer and adequate space for presentation. > Standalone medical clinic with onsite laboratory and integrated Behavioral Health Consultant (BHC).

4. POPULATION Clinically Obese Geriatric Patients with Depression > By the year 2030, a 132 million Americans will be older than 50 yrs (Housing Studies of Harvard University, 2014). > It is projected that half of the elderly population will be obese in 2030 (Hojjat, 2013). > The most significant increase in depression and obesity in the U.S. has been among senior adults (Older Americans Update, 2012; Preiss et al., 2013).

5. REVIEW OF LITERATURE > According to the Surgeon General of the United States, lack of Physical Activity (PA) and exercise is the number one health concern facing this country (U.S. Department of Health, 2010). > Health professionals from multiple disciplines concur on the myriad of mental health benefits that a PA program can provide (Corbin, Welk, Corbin, & Welk, 2013; Dias, Dias, & Ramos, 2003). > PA has been shown as one of the most effective treatments for obesity and depression in elderly people (Dias et al., 2003; Garcia, 2011; Meltzer & Jena, 2010; Smith et al., 2011).

6. REVIEW OF LITERATURE 8 week online PA class decreases depression scale mean scores in Seniors (Garcia, 2011). GDS Scores Normal >

7. REVIEW OF LITERATURE 8 week online PA class decreases depression scale range scores in Seniors (Garcia, 2011).

8. REVIEW OF LITERATURE > Clinical obesity, one of the major causes of preventable disease, has more than doubled in the last three decades (Preiss et al., 2013). > The World Health Organization labels obesity as a public health pandemic (epidemic of world-wide proportions) and predicts that 700 million people will be obese by the year 2015 (Hojjat, 2013). > 87 percent of the United States population has Internet access (Pew Research, 2014a). > Based on review of literature, a monitored e-Health PA program will have a beneficial effect on obesity and depression among geriatric patients (Garcia, 2011; Ogden et al., 2014).

9. INTERVENTION DESIGN PROGRAM IMPLENTATION: TREATMENT STEPS

10. INTERVENTION DESIGN > OBJECTIVE: The purpose of this 16 wk intervention is to access a BHC prescribed and monitored e-Health PA program for the treatment of obesity and depression in geriatric patients. > PATIENT SELECTION: Patients are referred to the BHC by his/her Primary Care Physician (PCP) after they have been diagnosed with clinical obesity and depression.

11. INTERVENTION DESIGN Cooperating Website: Senior University > The online (e-Health) portion of the intervention is accessed at Senior University online website. > The patient enters data and receives feedback within 24 hours from the behavioral health consultant via computer or smartphone browser. > This organization serves older adults in the Scottsdale, Phoenix, and Paradise Valley areas. www.SeniorUniversity.us

12. INTERVENTION DESIGN > Obesity is categorized by a Body Mass Index (BMI) of 30 and above (Corbin et al., 2013; Cordes, 2014). > The presence and severity of obesity will be assessed by using the BMI measurement of [weight (lb)/height (inches)2] X 703 (Cordes, 2014). > BMI will be measured at onset of intervention, at the midpoint of intervention (8 weeks) and at the conclusion of the intervention (16 weeks). > Patients can also calculate his/her BMI at will using the e-Health interactive Strong Bodies - Strong Minds BMI calculator via the Senior University Website.

13. INTERVENTION DESIGN BMI population weight categories Category BMI Underweight The presence and severity of depression will be assessed by using THE MERCK MANUAL OF GERIATRICS (GDS) Geriatric Depression Scale. Assessments will be performed at baseline before and after the intervention PA program.

15. INTERVENTION DESIGN THE MERCK MANUAL OF GERIATRICS Geriatric Depression Scale (GDS) QUESTIONNAIRE Circle the best answer for how you have felt over the past week: 1. Are you basically satisfied with your life? YES / NO 2. Have you dropped many of your activities and interests? YES / NO 3. Do you feel that your life is empty? YES / NO 4. Do you often get bored? YES / NO 5. Are you in good spirits most of the time? YES / NO 6. Are you afraid that something bad is going to happen to you? YES / NO 7. Do you feel happy most of the time? YES / NO

16. INTERVENTION DESIGN THE MERCK MANUAL OF GERIATRICS (GDS) 8. Do you often feel helpless? YES / NO 9. Do you prefer to stay at home, rather than going out and doing new things? YES / NO 10. Do you feel you have more problems with memory than most? YES / NO 11. Do you think it is wonderful to be alive now? YES / NO 12. Do you feel pretty worthless the way you are now? YES / NO 13. Do you feel full of energy? YES / NO 14. Do you feel that your situation is hopeless? YES / NO 15. Do you think that most people are better off than you are? YES / NO

17. INTERVENTION DESIGN GERIATRIC DEPRESSION SCALE SCORING ---------------------------------------------------------------------------------------------------------------------------------------------- DEPRESSION CRITERIA: SCORE Normal: 3 Mildly depressed: 7 - 4 Moderately depressed: 8 - 11 Very depressed: 12 ---------------------------------------------------------------------------------------------------------------------------------------------- (Adapted from Sheikh JI, Yesavage JA: "Geriatric depression (GDS)." Edited by TL Brink, A Guide to Assessment and Intervention, Clinical Gerontology, pp. 165 -173. Haworth Press Inc., Binghampton, N.Y., 1986.)

18. INTERVENTION DESIGN 16 wk e-Health PA program best practices > Motivational Interviewing Design > Pre-Test / Post-Test Design > One Treatment e-Health Therapy Design > Interactive Design - Intervention website is optimized to be accessed via computer or smartphone-mobile phone browser. > Interactive Design - Patients can e-mail BHC anytime during intervention program with questions. BHC will respond within 24 hrs.

19. INTERVENTION DESIGN Baseline: Before Intervention Program Prior to participating in the treatment intervention PA program patients complete the following: 1. The PAR-Q. 2. Adherence to PA treatment contract. 3. A basic minimal risk consent form. 4. A personal information patient form.

20. INTERVENTION DESIGN Intervention Treatment PA Program On completion of the baseline assessments, patients complete the following PA program, with a frequency of 5 times per week for 16 weeks: 1. Warm-up Flexibility Exercises 2. PA Prescription Cardiovascular Endurance Activity (30 minutes) 3. Cool-down Flexibility Exercises

21. INTERVENTION DESIGN Treatment PA Program Flexibility Exercises for Warm-up & Cool-down 1. Inverted Hurdler 6. Bicep Stretch 2. Butterfly Stretch 7. Tricep Stretch 3. Pretzel Stretch 8. Shoulder Crosses 4. Straddle Stretch 9. Chest Door Stretch 5. Quadricep Stretch 10. Calf Stretch

22. INTERVENTION DESIGN STRONG BODIES - STRONG MINDS Exercise Prescription: Cardiovascular Endurance PA Patients complete 30 minutes of one the following Cardiovascular Endurance Aerobic Activities of choice: 1. Brisk Walking 2. Stationery Bicycle 3. Elliptical Machine 4. Swimming *Frequency of 5 times per week for a total of 150 minutes of PA each week per CDC guidelines (Corbin et al., 2013).

23. RECOMMENDATIONS FOR FUTURE INTERVENTION > Future intervention PA programs could incorporate a muscular strength training exercise program in addition to the cardiovascular training exercise program. > CDC recommends weight training twice a week (Corbin et al., 2013).

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