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Summary: Background & Aims: Low physical activity (PA) levels and a poor-quality diet are common in chronic obstructive pulmonary disease (COPD) patients eligible for pulmonary rehabilitation (PR). PR may improve short-term nutritional status and exercise capacity but generally not long-term lifestyle outcomes. We hypothesized that healthy lifestyle motivation is related to PA levels and dietary quality before PR and the responsiveness thereof after PR. Methods: Before and after standardized outpatient PR, 81 COPD patients with low muscle mass completed validated motivational regulation self-reports. Physical (in)activity was assessed before and after PR through 7-day accelerometry (GT3X Actigraph). Dietary quality was assessed using a validated cross-check dietary history before and after PR and quantified as the Mean Adequacy Ratio (MAR). Results: Patients' baseline motivational profile was unrelated to dietary quality or PA. Baseline integrated motivation and its change during PR significantly predicted MAR change during PR and its levels after PR. Baseline introjected motivation and its change during PR significantly predicted PA change during PR and its levels after PR. Conclusions: Specific motivational regulations predict dietary quality and PA improvements of patients with COPD admitted to PR. Therefore, targeting integrated and introjected motivation may be key to achieving lasting behavior change after PR. Registry site: Maastricht University Medical Centre+. Clinical trial identifier number: NCT01344135.

Objectives To explore determinants of behavior change maintenance of a physically active lifestyle in patients with chronic obstructive pulmonary disease (COPD) 8–11 months after completion of a 4-month outpatient pulmonary rehabilitation program. Design A qualitative descriptive study of semistructured interviews. Setting Pulmonary rehabilitation assessment center. Participants Patients with COPD. Measurements Semistructured interviews until data saturation, coded by 2 independent researchers. Patients were classified as responder (maintenance or improvement) or nonresponder (relapse or decrease), based on 3 quantitative variables reflecting exercise capacity (Constant Work Rate Test), health-related quality of life (Short-Form health survey [SF-36]), and self-management abilities (Self-Management Ability Scale [SMAS-30/Version 2]). Results Mean (SD) forced expiratory volume in the first second (FEV 1 ) among interviewees was 52.5% (14.4%) predicted and the mean age was 63.5 years (range: 45–78). The group consisted of 15 responders and 7 nonresponders. Physical limitations reduced competence to engage in an active lifestyle and responders appeared to experience higher levels of perceived competence. Social support was found important and the experienced understanding from fellow patients made exercising together enjoyable. Particularly, responders expressed autonomous motivation and said they exercised because of the benefits they gain from it. Unexpectedly, only responders also experienced controlled motivation. Conclusion Perceived competence and autonomous motivation are important determinants for maintenance of an active lifestyle in patients with COPD. In contrast to common theoretical assumptions, a certain threshold level of controlled motivation may remain important in maintaining a physically active lifestyle after a pulmonary rehabilitation program.

Summary Background The present study aimed to assess COPD patients' experiences during an in-patient pulmonary rehabilitation program and the guidance provided by healthcare professionals. A third aim regarded examining ways to anticipate the transfer to the home environment after completion of the program. Methods Focus groups and semi-structured interviews were used to collect data from seven COPD patients at the beginning and six other COPD patients at the end of an in-patient pulmonary rehabilitation program, supplemented by a focus group and semi-structured interviews with 14 healthcare professionals of the involved disciplines. Data were analyzed using a phenomenological approach. Results Starting out, patients displayed trouble with acceptance of their disease, they had insufficient knowledge, and showed difficulties in setting specific realistic goals. Seeing fellow patients struggle with similar problems and tailored counseling by healthcare professionals helped them to overcome these barriers. During rehabilitation, patients became more confident in exercising and managing their daily life activities. Many patients evolved a desire to self-regulate their lives. Incorporating health-enhancing behaviors after returning home into their usual daily routines was anticipated to be tough. Conclusion Patients undergoing pulmonary rehabilitation experience a complex health behavior change process, in which healthcare professionals fulfill a major contributing role. Therefore, guiding patients through this health behavior change process is a vital component of healthcare professionals' work, regarding which the present study made practical implications such as applying a personalized approach by giving tailored advices, applying an autonomy-supportive counseling style, teaching self-management skills, and referring patients to local exercise facilities.

BackgroundCombined lifestyle interventions (CLIs) have been advocated as an effective instrument in efforts to reduce overweight and obesity. The odds of maintaining higher levels of physical activity (PA) and healthier dietary behaviour improve when people are more intrinsically motivated to change their behaviour. To promote the shift towards more autonomous types of motivation, facilitator led CLIs have been developed including lifestyle coaching as key element. The present study examined the shift in types of motivation to increase PA and healthy dieting among participants of a primary care CLI, and the contribution of lifestyle coaching to potential changes in motivational quality.MethodsThis prospective cohort study included participants of 29 general practices in the Netherlands that implemented a CLI named `BeweegKuur inverted question mark. Questionnaires including items on demographics, lifestyle coaching and motivation were sent at baseline and after 4 months. Aspects of motivation were assessed with the Behavioural Regulation and Exercise Questionnaire (BREQ-2) and the Regulation of Eating Behaviour Questionnaire (REBS). We performed a drop out analysis to identify selective drop-out. Changes in motivation were analysed with t-tests and effect size interpretations (Cohen inverted question marks d), and multivariate regression analysis was used to identify predictors of motivational change.ResultsFor physical activity, changes in motivational regulation were fully in line with the tenets of Self Determination Theory and Motivational Interviewing: participants made a shift towards a more autonomous type of motivation (i.e. controlled types of motivation decreased and autonomous types increased). Moreover, an autonomy supportive coaching style was generally found to predict a larger shift in autonomous types of motivation. For healthy dietary behaviour, however, except for a small decrease in external motivation, no favourable changes in different types of motivation were observed. The relation between coaching and motivation appeared to be influenced by the presence of physical activity guidance in the programme.ConclusionsMotivation of participants of a real life primary care CLI had changed towards a more autonomous motivation after 4 months of intervention. Autonomy-supportive lifestyle coaching contributed to this change with respect to physical activity. Lifestyle coaching for healthy diet requires thorough knowledge about the problem of unhealthy dieting and solid coaching skills.

The present study explored which underlying motivations induced people to participate in a television exercise program called “The Netherlands on the Move!-television” (NOM-tv). A cross-sectional study was carried out among 1,349 viewers of NOM-tv. The respondents completed the intrinsic motivation inventory (IMI), assessing their levels of intrinsic motivation towards participating in the NOM-tv exercises. The results showed that higher levels of intrinsic motivation (i.e. enjoying the NOM-tv exercises, feeling competent to perform this activity, and willingness to put effort into the exercises) were the most important predictive factors of more frequent participation in the NOM-tv exercises. Future screen-based interventions to reduce sedentary behavior should aim especially at encouraging people's intrinsic orientations towards physical activity in an autonomy-supportive way.

Background The number of patients with diabetes is increasing. BeweegKuur (Dutch for 'Exercise Therapy') is a Dutch lifestyle intervention which aims to effectively and feasibly promote physical activity and better dietary behaviour in primary health care to prevent diabetes. Methods The goal of this paper is to present the development process and the contents of the intervention, using a model of systematic health promotion planning. The intervention consists of a 1-year programme for diabetic and prediabetic patients. Patients are referred by their general practitioner (GP) to a lifestyle advisor (LSA), usually the practice nurse or a physiotherapist. Based on specific inclusion criteria and in close collaboration with the patient, an individual exercise programme is designed and supervised by the LSA. This programme can be attended at existing local exercise facilities or (temporarily) under the supervision of a specialized exercise coach or physiotherapist. All participants are also referred to a dietician and receive diet-related group education. In the first pilot year (2008), the BeweegKuur programme was implemented in 7 regions in the Netherlands (19 GP practices and health centres), while 14 regions (41 GP practices and health centres) participated during the second year. The aim is to implement BeweegKuur in all regions of the Netherlands by 2012. Discussion The BeweegKuur programme was systematically developed in an evidence- and practice-based process. Formative monitoring studies and (controlled) effectiveness studies are needed to examine the diffusion process and the effectiveness and cost-effectiveness of the intervention.