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August 2002, Volume 26, Number 8, Pages 1023-1029
Table of contents    Previous  Article  Next   [PDF]
Paper
Effects of distraction on treadmill running time in severely obese children and adolescents
I De Bourdeaudhuij1,2, G Crombez2, B Deforche1, F Vinaimont3, P Debode3 and J Bouckaert1

1Ghent University, Faculty of Medicine and Health Sciences, Department of Movement and Sport Sciences, Ghent, Belgium

2Ghent University, Faculty of Psychology and Educational Sciences, Department of Behaviour Therapy and Counseling, Ghent, Belgium

3Medical Pediatric Center (Medisch Pediatrisch Centrum), Zeepreventorium, De Haan, Belgium

Correspondence to: I De Bourdeaudhuij, Ghent University, Faculty of Medicine and Health Sciences, Department of Movement and Sport Sciences, Watersportlaan 2, 9000 Gent, Belgium. E-mail: Ilse.Debourdeaudhuij@rug.ac.be

Abstract

OBJECTIVE: (1) To examine the effects of attentional distraction on running time in an incremental treadmill test in obese youngsters; (2) to investigate whether distraction works at the same extent at the beginning and at the end of residential treatment; and (3) to explore the underlying mechanisms of the possible distraction effects.

METHODS: Thirty severely obese youngsters (10 boys, 20 girls, age range 9-17) who were following a 10 month residential treatment, performed a treadmill test until exhaustion in four different sessions using a within subjects design. The two sessions at the beginning of the treatment and the two sessions at the end the treatment were counterbalanced, one with attentional distraction (music) and one without distraction.

RESULTS: Obese youngsters ran significantly longer during distraction. This distraction effect seemed to be larger at the beginning compared to at the end of obesity treatment. The absence of differences between the condition with music and the condition without music on perceived bodily symptoms is in line with the idea that it took longer to perceive sufficient bodily sensations to decide to stop the treadmill test in the distraction condition. This interpretation is further corroborated by the physiological data indicating a superior peak performance in the condition with distraction.

CONCLUSIONS: Attentional distraction has a positive effect on perseverance in obese youngsters. Further research has to show the usefulness of attentional distraction as a technique to increase exercise adoption and adherence in obesity treatment.

International Journal of Obesity (2002) 26, 1023-1029. doi:10.1038/sj.ijo.0802052

Keywords

obesity; distraction; treadmill running; music; endurance

Introduction

The prevalence of obesity in children and adolescents is increasing.1,2,3 Moreover the proportion of severe obesity in this group is growing.4 An intervention combining diet and physical activity using behavioral change techniques has proven to be the most effective treatment.5,6,7 Increasing physical activity in obese children has, however, been difficult to accomplish.8,9 A key element in activity promotion is exercising for a sufficiently long period of time which results in an increase in energy expenditure, and a decrease in excess body mass and body fat.10,11,12 In this respect duration is emphasized rather than intensity. In treatment, frequency and time per activity session are gradually increased until the child can be active for 30-45 min daily.10,12 Research reveals that obese children/adults often fail to carry on with physical activity for a long period of time.13,14,15,16,17 One important reason why they stop exercising is because of the perception of body symptoms or body sensations such as pressure on chest, suffocating feeling, pounding heart, dizziness, knee pain, etc or because physical activity is aversive for them.10,17,18,19,20

It is possible that attentional distraction facilitates perseverance of physical activity. In one of the first papers on the relationship between attentional distraction and physical activity, Pennebaker and Lightner21 reported two experiments with students. In a field experiment they found that focusing attention on external stimuli while running led to faster running compared to the processing of internal stimuli while running. In a treadmill study, subjects who were forced to process internal sensory information, such as their breathing rate, reported a large number of symptoms relative to subjects which processed external sensory information (headphones with street noises) or no information (wearing headphones but hearing no sounds). They explained the beneficial effects of attentional distraction by a higher perception threshold for bodily information that normally inform participants to stop. The beneficial effects of distraction on exercise and running were recently confirmed by a literature review of Masters and Ogles.22 Although the effect is well established in students and athletes, the authors also point out that distraction might be useful to increase adherence in specific populations. As yet, there is no study that addresses this issue in obese youngsters. As a first step, an experimental design was chosen to study the mechanism of attentional distraction in obese youngsters in a controlled environment. Once the robustness of the phenomenon is proven and responsible mechanisms have been identified, further research is needed to investigate the possible effects of attentional distraction as a technique to increase exercise adoption and adherence.

Therefore the aims of the present study were (1) to examine the effects of distraction on running time in a treadmill experiment in obese children and adolescents, (2) to investigate the robustness of this effect by examining whether distraction works to the same extent at the beginning and at the end of a residential treatment program, and (3) to explore the underlying mechanisms of the possible distraction effects.

Method

Sample

Thirty participants were randomly selected from a group of 50 severely obese children and adolescents following a 10 month residential treatment program. The sample consisted of 10 boys and 20 girls with a mean age of 13.1 y±2.0 (range 9-17). At pretreatment, mean percentage of overweight was 180%±24.3, mean body mass index was 33.5±4.9, mean adjusted body mass index23 was 181±26.4.

All children followed a multicomponent obesity treatment program24,25 which consisted of a 1400 kcal low-fat diet, physical activity, physical education, sports, exercises and active games. In addition, children received group and individual psychological treatment and medical supervision. The goals of the treatment were losing weight, developing new eating and physical activity habits, and increasing self-esteem. More specifically the physical activity program consisted of developing positive attitudes towards physical activity and increasing frequency and duration of physical activity of moderate intensity. During treatment youngsters continued their education in a school for chronically ill children. Further details about the treatment effects will be reported (Braet et al, unpublished data).

Procedure

Each participant performed a treadmill test in four different sessions. Two sessions were at two consecutive days at the beginning of the treatment (at the end of the second month of treatment), and two sessions were at two consecutive days at the end of the treatment (the end of the eighth month of treatment). At both the beginning and the end of treatment, one session consisted of a test performed with distraction and one session consisted of a test performed without distraction. Tests were scheduled at the same time of day. To control for order effects, at both the beginning and the end of treatment, half of the subjects started with a session with distraction, half with a session without distraction (counterbalanced design). Each participant was asked to bring along a tape with a favorite piece of music. During the distraction condition, the participants heard their favorite piece of music by loudspeakers from the beginning of the treadmill test until the end of cooling down.

All self-report instruments were completed immediately after cooling down. Treadmill tests were performed at the end of the second month of treatment and not before the beginning of treatment (before the first month) as it was considered a risk for cardiovascular disfunctioning and joint load in this group of severely obese children who had not participated in any physical activity for years. Treadmill tests were performed at the end of the eighth month of treatment and not after the end of treatment (after the 10th month) as most participants had to study for their exams at that time.

Physical test

An incremental treadmill protocol was used to determine participant's running time to exhaustion (Jaeger LE 2000). Starting from 3 km/h, the workload was increased every 1.5 min by 1 km/h, until the maximum individual workload was attained. After 1 min, the initial 0% grade was raised to a 1% grade. To recover, children walked for 6 min at a speed of 3 km/h and 0% inclination.

Prior to the measurements, the subjects were instructed about the protocol and carefully familiarized with breathing through the mouthpiece and running on the treadmill. During testing children were not encouraged.

The oxygen uptake (VO2) and respiratory exchange ratio (R) was calculated by measuring 'breath by breath' oxygen and carbon dioxide concentrations in the expired air, as well as volume of the expired air (Oxygen Alpha). Mean values for every 30 s were calculated. VO2 peak was determined as the largest value in any 30 s period. Heart rate was monitored by a small portable cardio tachometer (Polar Sport Tester, Polar Electro, Finland), consisting of an electrode-belt transmitter and a wrist microcomputer receiver. Peak heart rate was defined as the highest heart rate achieved during the test.

Self-report measures

The current intensity of 20 bodily sensations was assessed using a five-point scale (0=not, 5=very much). Body sensations were selected and adapted from Stegen et al.26 The body sensations questionnaire consisted of six a priori subscales (Alpha's of present study): respiratory sensations (four items, Cronbach alpha=0.56), cardiac sensations (two items, Cronbach alpha=0.90), arousal/anxiety (four items, Cronbach alpha=0.86), gastro-intestinal (two items, Cronbach alpha=0.46), dizziness (two items, Cronbach alpha=0.35), and pain (four items, Cronbach alpha=0.58). Subjects completed the bodily sensations questionnaire immediately after the end of the treadmill test. They were instructed to report the current intensity of bodily sensations.

How participants experienced the experiment was assessed by seven additional questions using a five-point scale (1=not/no, 5=very much/a lot). Participants reported (1) to what extent they liked the music, (2) to what extent they could listen to the music during the treadmill test, (3) how pleasant they found the treadmill test while listening to music, (4) to what extent they believed they could run longer while listening to music, (5) how annoying they experienced the treadmill test, (6) how much attention was given to body sensations during the treadmill test, and (7) how often they had thoughts about being able to carry on with the test. The first four questions were only assessed in the condition of the treadmill test with music as distraction. The latter three questions were assessed after treadmill tests with and without music as distraction.

Statistical analyses

As all youngsters performed a treadmill test both with and without distraction at the beginning and at the end of treatment, a within-subject design was used. A 2 (condition: no distraction vs distraction)´2 (time: beginning vs end of treatment) repeated measures analyses of variance was performed upon running time, physiological measures, body sensations subscales and three self-report items (annoyance, attention to body sensations, thoughts about carrying on). Results from items only obtained during treadmill test with distraction were analyzed with paired t-tests.

Results

Self-reports

As a manipulation check, subjects were required to answer several questions about the self-selected music. Subjects reported that they liked the self-selected music during the treadmill test (beginning of treatment: 4.07±1.10; end of treatment: 4.00±0.96). They reported to be quite able to listen to the music during the test (beginning: 3.24±0.95; end: 3.34±1.08), and reported that performing the treadmill test while listening to music was a rather pleasant experience (beginning: 3.48±1.12; end: 3.44±1.29). However, they did not strongly believe they could run longer while listening to music (beginning: 2.62±1.21; end: 2.59±1.27). All these effects were stable across time as none of the paired t-tests revealed significant differences between mean scores at the beginning and at the end of treatment (all t<1). Table 1 summarizes the means, standard deviations and the ANOVA results of the self-reports obtained during each of the four treadmill tests. Overall, participants perceived the treadmill tests as very little annoying. Participants did not experience the treadmill test with distraction less annoying than the treadmill test without distraction. There was no significant difference in annoyance between the beginning and the end of treatment. The interaction between time and condition was not significant. A trend for significance was found between both conditions for attention to body sensations (P<0.10). Subjects report less attention to bodily sensations in the distraction condition in comparison with the condition without distraction. There were no other significant effects for attention to bodily sensations (all F<1). Finally, analyses of the thoughts about carrying on with the test revealed a main effect of time and condition (both P<0.05). Participants in the distraction condition had fewer thoughts about carrying on in comparison with the condition without distraction. They had also more of these thoughts at the end compared to the beginning of treatment.

Means and standard deviations of the reported bodily sensations are reported in Table 2. Overall, mean scores are low, indicating few bodily sensations after participation in a treadmill test until exhaustion. Highest mean scores were found for cardiac sensations, but there were also high standard deviations indicating large heterogeneity. ANOVAS upon reported bodily sensations revealed only significant effects for the arousal/anxiety scale and the pain scale. For the pain scale a significant time effect revealed more pain at the end compared to at the beginning of treatment (P<0.05). For the arousal/anxiety scale, the time effect approached significance indicating more sensations at the beginning of treatment in comparison with the end of treatment (P<0.10). All other effects were not significant (F<1.80).

Running time

As predicted distracting participants during treadmill test had a pronounced effect on running time (P<0.01). Overall, when severely obese children and adolescents were distracted they ran almost 40 s longer (Table 3). The distraction effect appeared to be stronger at the beginning of treatment than at the end of treatment. The interaction between time and condition however failed to reach significance (P<0.10). Also as expected, participants ran longer at the end of treatment in comparison with the beginning of treatment (P<0.01).

Considering the effects of distraction upon physiological parameters in combination with the results on running time it seems reasonable that the obese youngsters were performing submaximally in the condition without distraction. Indeed, physiological parameters revealed a lower peak heart rate (P<0.01), R (P<0.05), VO2 peak (P<0.05) and VO2 peak/kg (P<0.01) in the condition without distraction compared to the condition with distraction. No significant interactions between time and condition appeared for the physiological parameters. Between the beginning and the end of treatment, an increase in R (P<0.01) and VO2 peak/kg (P<0.05) was found. No significant time effect was found for peak heart rate and VO2 peak (F<1).

Discussion

In this study the effect of attentional distraction upon running time in severely obese youngsters was investigated using a within subjects design. Results clearly indicated that obese youngsters run longer when they listened to their favorite piece of music in comparison with a treadmill test without music distraction. It is highly implausible that this effect is owing to demand characteristics: the effect of attentional distraction on running time was observed although participants indicated that they did not strongly believe they could run longer while listening to music. These findings are in line with previous studies showing superior performance under distraction in running and nonrunning samples.22

A further aim of this study was to investigate whether attentional distraction works to the same extent at the beginning and at the end of a residential treatment program. Results seemed to indicate that the effect of distraction upon running time is stable across a treatment period of 10 months. There was, however, a trend that this distraction effect was larger in the beginning of treatment than at the end of treatment. Further research will have to investigate whether a differential effect of distraction is a robust phenomenon. Although this study was not specifically designed to investigate the efficacy of the treatment program, our results are indicative that the treatment program has profound effects upon the performance on the treadmill test. Participants ran longer and several physiological parameters are improved at the end in comparison with the beginning of the treatment. This is in line with previous studies showing positive effects on physical tests after following a childhood obesity treatment program including physical activity.27,28,29,30 Although these mprovements are often viewed as genuine improvements in aerobic fitness, other explanations cannot be entirely ruled out. A particular intriguing explanation might be related to a change in the interpretation of bodily sensations. As argued before, obese children often interpret bodily sensations during physical exercise as negative and aversive. It is therefore reasonable to assume that the decision to stop the treadmill test might not only be based upon physical exhaustion but also upon the interpretation of bodily sensations. To the extent that treatment programs are successful in changing the aversive and catastrophic nature of bodily sensations and pain, obese children may be more inclined to tolerate these sensations and to engage longer in physical activities at the end of treatment. In line with this argument are the findings of this study that participants reported being less anxious/aroused and experienced more pain during the treadmill test at the end of treatment than at the beginning of treatment.

A final aim of this study was to explore the processes explaining the distraction effects upon running time. A straightforward explanation is the hypothesis of attentional competition between internal and external cues.31,32 Pennebaker has argued that bodily sensations are not easily selected as the focus of attention and do not easily enter awareness in environments with multiple external information. This is also the case when individuals are engaged in external tasks. The competition between external and internal cues is then resolved by an attentional priority for external cues, resulting in the perception of less bodily symptoms. Investigating the idea of competition between internal and external cues, Pennebaker and Lightner21 found that joggers running 1800 m in an environment with multiple external information (cross country) were faster than joggers running 1800 m in an environment lacking in external information (lap track) in the absence of differences in perceived fatigue and bodily symptoms. As there were indications that joggers had set their pace in line with their perception of fatigue and bodily symptoms, faster running in joggers running cross country was explained by a diminished perception of fatigue and bodily symptoms. This reasoning was confirmed in later studies investigating the relationship between distraction and perceived exertion: distraction was related to less physiological awareness and lower perceived exertion ratings.22,33,34,35,36,37,38 The distraction results of our study are in line with this interpretation. Obese youngsters run longer in the treadmill test until exhaustion while distracted from bodily sensations (listening to music) than in the treadmill test without distraction in the absence of significant differences in perceived bodily sensations. It is reasonable to assume that it took longer to perceive sufficient bodily sensations to decide to stop the treadmill test in the distraction condition. This interpretation is further corroborated by the physiological data indicating a superior peak performance with higher metabolic stress in the condition with distraction. Another explanation, which is not entirely incompatible with the idea of cue competition, is that distraction inhibits and stops ruminative and worrisome thinking about bodily sensations39 and, hence, postpones the decision to stop the treadmill test. The latter was confirmed by self-reports: participants reported more thoughts about carrying on in the condition without distraction than in the condition with distraction.

As it is known that increasing physical activity in obese children and adolescents is difficult to accomplish, our results indicate that taking attention away from bodily sensations may be helpful in promoting a longer physical endurance. However, we do not argue for the unduly implementation of distraction techniques in physical activities. First, similar effects may be expected in natural environments with multiple external information (eg cross country). A particular advantage of these natural environments is that distraction is automatically installed instead of intentionally and controlled. Second, on some occasions attentional distraction will not work or is not adaptive. It is well established that high intensity bodily sensations, such as pain, unconditionally demand attention and cannot be ignored.40 Furthermore bodily sensations might provide functional information, eg heartbeat, aches, muscle twitches, pain, in order to adapt activity pace and intensity. In that respect attentional distraction can be viewed as a continual process of switching of attention to and disengagement from bodily information.22,40 In line with this idea, Stevinson and Biddle41 state that dichotomous thinking about distraction is often too simplistic to account for the complex reality of cognitions and attentional processes. They argue for classification of attentional processes in terms of task relevance (task-relevant vs task-irrelevant) and direction of attention (internal vs external). They showed that marathon runners switch between those cognitions during the race and could detect a relationship between strategy use and performance.42

This study has some limitations. First, the bodily sensations questionnaire was adapted from a scale used to measure psychosomatic symptoms in daily life. It is uncertain whether our adaptation adequately covered the most important bodily sensations after exercise in obese youngsters. Second, our interpretation of findings is partly based upon the absence of differences in reported bodily sensations after the maximal exercise test with or without distraction. Therefore it is yet unknown whether distraction leads to the perception of fewer symptoms at the same point in time. Other running paradigms eg submaximal exercise with limited duration, may further corroborate our interpretation. Third, as type of music was not manipulated but self-selected, it is unknown which variables in the distraction were critical in obtaining the effect. Possibilities are emotional significance43 and type of music (slow vs fast).37,44,45 Finally, our results can only be interpreted within the context of a laboratory setting. As Epstein et al11 argued, lifestyle physical activities are perhaps more important than programmed aerobic exercise in the treatment of childhood obesity. Further research is needed to investigate whether attentional distraction is clinically useful in obese subjects as a technique to increase exercise adoption and adherence.

In conclusion, the present study showed that obese youngsters run significantly longer on a treadmill test until exhaustion under distraction. This distraction effect seems to be larger at the beginning compared to at the end of obesity treatment. The beneficial effect of distraction was explained by arguing that it took longer to perceive sufficient bodily sensations to decide to stop the treadmill test in the distraction condition. This interpretation is further corroborated by the physiological data indicating a superior peak performance in the condition with distraction. These findings may have implications for perseverance, adoption and adherence in physical activity in obese youngsters.38,46 However, further research has to disentangle the relative importance of several attentional components such as engagement, disengagement and switching in the efficacy of attentional distraction in the complex reality of obesity treatment.

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Tables

Table 1 Means, standard deviations and summary of repeated measures analyses for questions asked about annoyance, body sensations and perceived perseverance

Table 2 Means, standard deviations and summary of repeated measures analyses for perceived bodily sensations

Table 3 Means, standard deviations and summary of repeated measures analyses for running time and physiological parameters

Received 24 September 2001; revised 5 February 2002; accepted 15 March 2002
August 2002, Volume 26, Number 8, Pages 1023-1029
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