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/ pn~v~rrw~ MEOICI,~E I0/270--276 (1981) Risk Reduction in the U.S. Air Force Prir~ary Prevention HEART Prog,ram~.2 )~J.)~ £" ~'] American Health Fonndalion. 320 East 43rd Street, New York. New York 10017 Sigh:-~iSk act[~,e-duFy 13a-JA.g pe~fffieI to modify specie health behaviors associated with arteriosclerotic disease: cigarette smoking, and food patterns high in calories from fat and exogenous cholesterol. Also, education is offered to confirmed hypterlensives, whose pharmacological treatment is provided by the base}medical facility. The RRC strategy is being tested at two air bases, Pease, Hew Hampshire, and Charleston, South Carolina. Designated airmen are invited to participate in RRC on these bases after notification of their risk status. Voluntary participation is. encouraged at two levels: orientation sessions; and at subsequent focal groups in smoking cessation and/or food pattern modification. Focal groups emphasize techniques of self-management in smoking cessation and eating behavior, including post-treatment maintenance behavior for ,Iong-te~m risk reduction. 'INTRODUCTION The p~7~se Of ~ Risk R~duetion ~omp0n~t (l~l~C)..of HEART is to lower the measured cardiovascular disease risk in aetive-du~y personnel on two. Air Force bases~ Identified high-risk individuals are invited to participate in a behavior modification group counseling program for their specific risk faetor(s)~smoking cessation and/or blood lipid/weight reduction. Group counseling for smoking ces- sation and blood lipid/weight reduction utilizes group behavioral modification tech- niques. Additionally, hypertension treatment is provided. The Base Medical Fa- cility treats such persons ehemotherapeutically, if clinically indicated. The- HEART program offef~ hypertension education se~slons which focu~ on informa- tion and compliance techniques. General self-help techniques designed to encour- age behavioral adherence are also taught to participants. Aversive techniques are specifically avoided throughout this risk reduction program. The primary educational objective of the risk reduction system is to help partici- pants learn new (i.e., lower risk) health behaviors. These changes are encouraged through group behavior modification methods. That is, learning primarily focuses on acquiring new behaviors rather than knowledge gain, or understanding group dynamics. Behavior modification in this context is defined as the application of learning theory and other experimentally devised psychological principles to the modification of specific health behaviors (e.g., smoking, overeating). Learning focuses on observable, measured behaviors requiring in each case a concrete ~ Project funded under Contract F33615-80-C-0611 for the U.S. Air Force. School of Aerospace Medicine. : Paper presented at the Annual Meeting of the American Public Health Association, October 22, 1980, Detroit, Mich. 270 0091.743518 Copyright ~ 1~1 NOTICE: NIS MATERIAL MAY B[ PRO~C~D ~4~ BY COPYRIGHT LAW (TITLE 17 U. S. CODE) (c) (d) The separat, the oth. comput bility risk pe~ future. e/sewh~ Orlenta The ticipam two ses lower t proces: To tl planne~ jective bodily cardim tion is mainta Duri their a change Muc smokie .existint learn s, and en they ar of rew.' At tl have it these r cause ( T!05280038

ith, nd is ,'~ao of l~wer vo Air _ :havior noking ng ces-. n tech- ~ cal Fa- FORUM." THE U.S. AIR FORCE HEART PROGRAM 271 description of a behavior to be altered. A treatment is considered effective to the extent that specific behavioral goals for individuals have been achieved. The basic straCegy for the Risk Red~ction Component consists of four steps: (a) Explanation of risk status; '(b) o:fie,nt~tion to risk reduc~tion behavior change; ,~(~. ~o:ca~l~g~r~trlaS t~e~ smok:~ cessation~ foodl ~a~ttern, a|t~ratioa, or kyp~¢~en- sion adherence; (d) maintenance. separate visit following screening when all laboratory results are integrated with the other examination data. This single session is scheduled to last 15 rain. A computer printout of clinical result, s with a &year cardiovascular disease proba- bility estimate is provided at that time. Questions are briefly answered with high- risk persons urged to attend the two orientation sessions scheduled in the near future. The full discussion of this explanatory methodology has been summarized elsewhere (1). Orientation Group "l~h~ od~nt~afion group consists of two 90-mi~ sessions intended to prepare par- ti~::~l~nts ~or ]i~e~styl~ ~ha.nges essent, ia[ to risk reduction. 'The strategy for these two sessions is to increase participants" awareness of specific high-risk behaviors, lower their resistance to accepting behavioral changes, and help them initiate the process of personal change. To these ends, the orientation group utilizes a structured program format with planned assignments and activities, using self-monitoring tools coupled whh oh- ..... jective feedback from the group leader. These activities are intended to facilitate :1. The . ~forma- ;neour- ues are partici- mraged focuses ~- group ~tion of s to the earning onerete ,erospaco -tober 22, bodily awareness of change= Additionally, there is instruction on the meaning of ..... Cardiovascular risk, and 06it~ relationship to existing life patterns. This instruc- ....... tion is designed to further motivate participants for short-term changes, and for maintaining long-term behavioral change. During these two orientation sessions, it is hoped that participants will increase their awareness of specific risk-factor-related personal change; expectation of change; and learn to value the recommended new behaviors as helpful to them. Much emphasis is laid on the importance of record keeping (i.e., eating and smoking behavior records) and of recognizing and dispelling rationalizations for existing behavior patterns (a form of self-deception). Additionally, participants learn self-management skills and are shown how to develop self-reward systems and environmental support systems, to counter any feeling they may have that they are punishing themselves by changing existing behavior. Through this system of rewards and support, long-term, sustained behavior change is facilitated. At the end of the second orientation session, they are told that it is normal to have impulses to quit the program. The group is strongly encouraged to stick with these risk-reduction activities because of their inherent personal value and be- cause of the expectations of their family and friends. After these two orientation TI05280039

272 ARNOLD AND ]ACOBSON sessions, participants next progress to either the smoking cessation or to the food pattern modification focal group. SMOKING CESSATION Concepts The smoking cessation program uses a multicomponent behavioral approach. It includes cessation activities preceded by several preparatory sessions, and a po~,t~atment maintenance phase ~ which an exsmoker i.s heltmd; tl~rough, am oppo~unity to reso'lve his ambiv~ence toward quitting, and thb0ugh the use of a prepa~tion st~tegy he is prepped for tot~ abstinence. Positive changes are reinforced and resistance to change is con~onted. An integ~l pa~ of this program involves persuading the smoker to use a variety of cognitive behavioral self- management techniques in order to deal with the recu~ent urge to smoke. These behavioral methods include: relaxation training, thought stopping, positive imag- ery, self-reinforcement, baselining, stimulus control, deconditioning, eating man- agement, and goal setting, The cessalion phase of the treatment merges into one for maintenance which provides this new e~smoker with continual supoo~ through scheduled group dis- eus~on, and also periodic review of self-managem;ent techniques with the therapist. Some smokers may not be interested in joining a group Smoking Cessation progr~, but wish to quit at their own pace,:They are encouraged to do so and are offered a 2t-day "Quit Plan Booklet." Methodology This 5-week program has a I-~ session each week during which the majority of smokers are expected to alter their smoking behavior-or quit altogether. While each group session has its own specific behaviorally-oriented objectives, the program is structured so that pa~icipants should stop smoking by the end of the third focal group session. This is to provide the oppo~unity to share exsmok- ing experience with other group members, After completing the five sessions, those in the group who continue to smoke have the following options: quit smoking and be eligible for the full maintenance program; not quit and enter single-session individual counseling or tar/nicotine reduction program; or, not quit and have no luther contact with the program. The individoal focal group session for smoking cessation thematically focuses on one of the following topics: I. Introduction to Smoking Cessation I1. ~eparing for Quit Time II1. Quit Time IV. The Two-Pa~ Pr~ess of Behavior Change: Change and Maintaining Change V. Graduation and Maintenance At the self-man~. Maintent. The so. p-on avai presente< Clinical cnr_rP~t s smoking For s~t exclusivt rides ea~ tion in ot na~ce cc havior, a Concept: The be for long- calories, monitori oriented vidual te the healt intended -~ toward ~ foster cc- decrease The fc • Rec • Rec Fourt~ consiste a. Intrc b. Cue c. Beh~ d. Chin e. Pruc f. Rea~ g. Mort h. MoP T!05280040

.he food ,oach. It • and a ,ugh an- FORUM: TIlE U.S. AIR FORCE HEART PROGRAM 273 At the end of the formal program, each exsmoker is urged to rely primarily on self-management skills learned in this program to reach his ultimate goal. Maintenance Program The smoking cessation maintenance program emphasizes the continuing sup- p0.~ avgi, lable ,to ~pa~i~an,ts~, iacl:uding further education for b~havlora|• skills presented earlier; clifi~cal follow-up; and the self-help maintenance program. Clinical follow-up primarily measures each participant's carbon monoxide level monthly for the first 4 months after treatment,. ~n~ q.uartedy thereafter. At each lges are program ,ral self- 3. These ve imag- -rig man- 'e which • oup dis- uith the essation , and are • sin. X~ki-n-g b-ehavior~ .... For situational or for psychosocial reasons, an exsmoker may want to use an exclusively self-help maintenance method. If so, a program is available. It pro- vides each former smoker with the chance to use continuing support and educa- tion in order to strengthen newly acquired behavioral changes. Self-help mainte- nance consists of taped telephone messages, which reinforce nonsmoking be- ~havior, and ad hoc maintenance group sessions, if needed. FOOD. PATTERN MODIFICATION Con~cepts 'The b~¢havioral strategy used in the food pattern ,modification focal groups~aim.s for long-term, balanced food pattern change, emphasizing reduction in total calories_, fat calories,~ exogenous cholesterol, and saturated fat calories. Self- -monitoring/management tools ar~-an essential component of this behaviorally- oriented prggram. Coupled with diet, related learning, these tools enable an indi- vidual to achieve the desired ieating pattern; Support and guidance is provided by the health-counselor and, by- design,- from other-group- members=The ~strategy is jectives, ~e end of exsmok- o smoke atenance /nicotine ogram. , focuses ,jority of intended to encourage individuals to set realistic goals,.and take necessary action tow/i~d achi~vin~~ them~ Foll0~=~up find m/iintenance actix/i~i~s foster continual practice of newly acquired eating patterns. As a result, long-term decreases in blood lipid levels and weight are expected to occur. The food pattern modification program has the following objectives: • Reduce participants' serum cholesterol levels to goal levels. • Reduce participants' weight to 115% of ideal body weight or less. Fourteen sessions focus on specific topics designed to promote the food pattern consistent with lower serum cholesterol levels. These include: .intaining a. Introduction/orientation b. Cue elimination c. Behavior chains d. Change in the act of eating e. Prudent diet f. Reading food labels g. Monitoring portions an'd calories h. Monitoring physical activity T10528,00~1

274 ARNOLD AND JACOBSON i. Planning ahead j. Recipe modification k. Special situations I. Eating out En~ironmomal/social support Mai~ten~ Methodology health counselor, or a media presentation to introduce the topic area. In combina- tion with learning assignments from p~vious sessions, this opening activity trig- gers the next pa~ of the session. Group discussion is designed for maximum problem-solving and s~iM reinforcement t~ough group interaction. Learning emphasizes stimulus control, selGmonitofin#management, and alternate be- havioral patterning. Next, a section of time is designated for the explanmion of the specific skills to be learned by a~ group members before the following session. The concepts behind these new skiBs are presemed to participants in order to catalyze group discussion. These new skills are presemed in the form of "probMm-solvi~g" exercises. ~ter, these become pa~ of focal group evaluation, so their assigB~ent to p~icipants is stron'gly a.rged~ bef*ve th~ next session~. The end of each session is devoted to participant weigh-in. This ,linical activity pro- vides a chance for objective clinical assessment and evaluation of each person's progress. Maintenance The maintenance stage provides p~icipants with ongoing en~ouragemrht continue practicing the recommended food pattern. Specifically, encouragement and suppo~ is provided by aiding pa~icipants in: eliminating exposure to social situations which trigger inappropriate behaviors (e.g., dining out); altering reac- tions to situations by breaking the behavioral chains resulting in inapprop~ate behaviors (e.g., personally distressing situations); and changing personal food selection, preparation, and eating styles to correspond with food pattern guidelines. In addition, energy balance is encouraged so that there is self- monitoring of personal food consumption plus physical activity. Personal social planning is emphasized, to solve problems like dining out, and making appropriate food choices in different social situations. Fuaher, groups are encouraged to formulate personal rewards to reinforce behavior change and to seek suppoa from family or friends so that their new behaviors become inte~a~zed. Maintenance suppo~ is provided via two systems. One is taped telephone messages consisting of behavior reinforcing messages. The second is through weekly group meetings. One day a week a health cdunselor is" available at an announced time in the HEART clinical center for dro~in individual coun~ling (i.e., information, reinforcement, and suppo~). CORC~ The with t rat~ ,e ity fo guidel begin Meth, All (diast, and/o: orient pant r In ~ focal strate adher provi, sion. sion,_. Tw These that ~ I. Ja Bandu Bandu Black~ Blackt '~rowr, Carrol Doyle. Dubre Easty. Hadat T!05280042

rig- be- "the ion. r to t of ioll, The 3to- eac- riate food tern self- ~cial riate d to .from "lone ~ugh tt an eling FORUM: THE U.S. AIR FORCE HEART PROGRAM 275 HYPERTENSION Concepts The responsibility and authority for hypertension treatment resides primarily with the Base Medical Facility (BMF). Currently the HEART program is a sepa- rate elinica| entity as a demo~tration. The BMF determi~nes/,n: eacl~ ease eligibil- ity for chemotherapy, a~ev ~'eferral is made by ~EAR~ .dl~,i'eal~ a~s~ssmernt guidelines. In the HEART protocol, airmen eligible for hypertension control can begin with we~ht reduction and salt restriction in the HEART program with BMF la tam, ~2~o~.~i~isa~ Imt~e~.ea ~~ H~A~, ~_ ~li~t~j,aed in Methodology All participants who meet the criteria for weight reduction and salt restriction (diastolic blood pressure under 105 mm Hg) are given guidelines for a low-sodium and/or low-calorie diet as appropriate. The strategy is explained in two initial orientation sessions after the diagnosis of hypertension is confirmed. The partici- pant may be referred to the food pattern modification focal groups, if appropriate. In addition, a hypertensive airman is invited to attend hypertension education foea, i' groups, which are informational rather than behavioral in nature. This strategy is used because it is assumed that with more knowledge a pa~icipant's adherence with hypertension treatment regimen will' be better. Thus, thg~ groups ~provlde information on. the ~,a~ural history ~nd pathol~ogie sequelae o'f hypenem sion. At the same time, participants learn about effective treatment of hyperten- sion, and successful adherence to medication regimens, if they become necessary. Two taped telephone messages are also available for hypertensive airmen.- These messages review some basic information regarding hypertension disease that was covered in the focal sessions. REFERENCE .... i. Jacob~n. L. The UIS. Air Force HEART Piogram Model~-Prey. MedJ iO, 265-269 (1981). BIBLIOGRAPHY Bandura, A. "Principles of Behavior Modification." Holt, Rinehart and Winston, New York, 1969. Bandura, A. "'Social Learning Theory." Prentice-Hall, Englewood Cliffs, N.J., 1977. Blackburn, H., Lewis, B., Wissler. R. W., and Wynder, E. L. Health effects of blood lipids: Optimal distributions for populations. Prey. Med. 8, 609-759 (1979). Blackburn, G. L., and Greenburg, I. Multidisciplinary approach to adult obesity therapy. Int. J. of Obesity 2, 133-142 (1978). Brown, H. B. Food patterns that lower blood lipids in man../. Amer. Diet. As~:oc. 58, 303 (1971). Carroll, K. K., Muff, M. W., and Roberts, D. C. K. Dietary protein, hypercholesterolemia ano ath- erosclerosls, in "Atherosclerosis" (G. Sehenler, Y. Goto, Y. Hara, and G. KIose, Eds.). Springer-Verlag, Berlin, 1977. Doyle, J. T., Dawber, T. R., Kannel, W. B,, et aL The relationship ofeigarette smoking to coronary heart disease. The second report of the combined experience of the Albany, New York and I~ramingham, Massachusetts, studies. JAMA 190, 886-890 (1964). Dubren, R. Self-reinforcement by recorded telephone messages to mainlain nonsmoking behavior. J. Consult. Clin. Psychol. 45(3), 358-360 (1977). Easty, D. L. The relationship of diet to serum cholesterol levels in young men in Antarctica. Brit. J. Nutr. 24, 307-312 (1970). Hai'lan, W, R., Oberman, A., Carlson, S., et al. Longitudinal assessment of serum cholesterol and lipoproteins. Paper presented at 18th Annual Conference on Cardiovascular Disease Epidemi- ology, Orlando, Florida. March 13-18, 1978. TIO5280043

276 ARNOLD AND JACOBSON Hjermann, I. Smoking and diet intervention in healthy coronary heart risk men. Methods and 5-year Follow-up of risk factors in a randomized trial, duurnal oJ the Oslo City Hospital 30, 3-17 (!980). Hypertension Detection and Follow-Up Collaborative Group. Five-year findings of the Hypertension detection and follow-up Prosram. 1. Reduction in mortality of persons with high blood pressure, including mild hypertension. JAMA 242, 2562-25"/? Inter-Society Commission for Heart Disease Resources, A~heroselerosis Study Group, and E~idemiol- ogy Study Group. Prim~ ,pmvent~or~ o~' a~he~os~]~oti¢ dis~ases~ 'C~t~¢ut~t~m 42, A~5-~ (1970). Jenkins. C. D.. Rosenman, R. H., and Zyzanski. S. J. Cigarette smoking. Its relationship to coronary heart .disease and t'elated risk factors in Western Collaborative Group study. Circulation 38, Keys, A. Coronary heart disease in 7 countries. Circulation 91 (Supplement D, (1970).. Keys, A. "'Seven Countries." Harvard University Press, Cambridge, 1980. Knowles, M. S. "'The Modern Practice of Adult Education." Association Press, New York, 1970. Laird, D. "Approaches to Training and Development." Addison-Wesley Publishing Company, Read- ing, Mass., 1978. Lichtenstein, E., and Danahar0 B, G. Modification of smoking behavior:, a critical analysis of theory, research and practice, in "Progress in Behavior Modification" (M. Hersen, R. M. Eisler and P. M. Miller, Eds.). Academic Press, New York~ 1976. Mahoney, M. J., and Mahoney, K. "Permanent Weight Control." W. W. Norton, New York, 1976. Marston, A. R., and McFall, R. M. Comparison of behavior modification approaches to smoking reduction, J. Consult. Clin. Psych~ 36, 153-162 MeAllster, A., Puska, P,, Koskela, K., P~llonen, U., and Ma¢coby, N. Mass communication and c~ommunity organization for pubIM .hearlth education. ~mer. P~volWL 3~5, 375-379 (1980), McFall, R. M., and Hammen, C. L. Motivation, structu_re ~and self-monitoring: Role of nonspecffic factors in smoking reduction../. Con~nh. Clin. Psychol. 37, 80-86 Miettienen, M., Turpeln, O., Karvonen, M. J., EIosuo, R., and Paavilalnen, E. Effect of choMsterol- lowering diet on mortality fi'om coronm'y heart disease and other causes. Lancet 2, 835 (1972). Morgan. T., Gillies, A., Morgan, G., Adam, W., Wilson, M. and Carney, S. Hypertension treated by salt restriction. Lancer 1~ 227-230 (i978). National Diet-Heart Study Research Group. The National Diet-HearLStudy.Final Report. Cireulati~qn 37, (Suppl. lj l (1961). Puska, P, J, Tuomilehto, Nissinen, A., and Saionen, J.~ Changing the cardiovascular r~sk in an community: The North Karelia Project~ ~n "'Childhood Prevention of Atherosclerosis and Hypertension." Raven Press, New York, 1980. Schwartz, J. A critical review and evaluation of smoking control methods. Pabl. Health Rep. 84, 489-306 <1969). Tongas, P. N., Goodkind, S.D., and Patterson, J. L. The long-term maintenance of n0nsmoking behavior, in "'Research on Smoking Behavior" (M. E. Jarvils, J. W. Cullin, E. R. Gritz, T. M. Vogt, and L. West, Eds.), Monograph 17, National' Institi~te on Drug Abuse Research. U.S. Government Printing Office, Washington, D.C., 1977. Truett, J., Cornfield, ~., and KanncL W. A multivariate analysis of the risk of coronary heart disease in Framingham. J. Chron. Dix. 20, 511-524 (1957). U.S. Department of Health, Education, and Welfare. "Smoking and Health: Report of the Advisory Committee to the Surgeon General of the Public Health Service." Public Health Service Bulle. tin 1103, Washington.. D.C., 1954. U.S. Department of Health, Education, and Welfare. "'Adult Use of Tobacco: 1975." Public Health Service, Washington, D.C., 1976. O.S. Department of Health, Education, and Welfare. "'Arteriosclerosis." DHEW Publication No. {NIH) 78-1~26. Public Health Service, Washington, D.C., 1977. U.S. Department of Health. Education, and Welfare. "'Smoking and Health: A Report to the Surgeon GeneraL" DHEW Publication No. (PHS) 7%30066. Public Health Service, Washington, D.C., 1979. Wynder, E,, and Hoffmann, D. Tobacco and health. A societal ~hallenge. lVe|t. Eogl..!. Med, 300, 894 - 903 (1979). PREVE~ as.- A, qu, det air Th Whi worth,. also b compz prove! gains t for th~ the ty planni progre mined Purdu, addre: tO date For from t Rest Medicir