The effectiveness and applicability of different lifestyle interventions for enhancing wellbeing: the study design for a randomized controlled trial for persons with metabolic syndrome risk factors and psychological distress

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The effectiveness and applicability of different lifestyle interventions for enhancing wellbeing: the study design for a randomized controlled trial for persons with metabolic syndrome risk factors and psychological distress Lappalainen, Raimo; Sairanen, Essi; Järvelä, Elina; Rantala, Sanni; Korpela, Riitta; Puttonen, Sampsa; Kujala, Urho; Myllymäki, Tero; Peuhkuri, Katri; Mattila, Elina; Kaipainen, Kirsikka; Ahtinen, Aino; Karhunen, Leila; Pihlajamäki, Jussi; Järnefelt, Heli; Laitinen, Jaana; Kutinlahti, Eija; Saarelma, Osmo; Ermes, Miikka; Kolehmainen, Marjukka Lappalainen, R., Sairanen, E., Järvelä, E., Rantala, S., Korpela, R., Puttonen, S., Kujala, U., Myllymäki, T., Peuhkuri, K., Mattila, E., Kaipainen, K., Ahtinen, A., Karhunen, L., Pihlajamäki, J., Järnefelt, H., Laitinen, J., Kutinlahti, E., Saarelma, O., Ermes, M., & Kolehmainen, M. (2014). The effectiveness and applicability of different lifestyle interventions for enhancing wellbeing: the study design for a randomized controlled trial for persons with metabolic syndrome risk factors and psychological distress. BMC Public Health, 14(310). https://doi.org/10.1186/1471-2458-14-310 2014 STUDY PROTOCOL Open Access The effectiveness and applicability of different lifestyle interventions for enhancing wellbeing: the study design for a randomized controlled trial for persons with metabolic syndrome risk factors and psychological distress Raimo Lappalainen 1* , Essi Sairanen 1† , Elina Järvelä 2† , Sanni Rantala 3† , Riitta Korpela 3 , Sampsa Puttonen 4 , Urho M Kujala 5 , Tero Myllymäki 1 , Katri Peuhkuri 3 , Elina Mattila 6 , Kirsikka Kaipainen 6 , Aino Ahtinen 6 , Leila Karhunen 2 , Jussi Pihlajamäki 2 , Heli Järnefelt 4 , Jaana Laitinen 4 , Eija Kutinlahti 7 , Osmo Saarelma 7 , Miikka Ermes 6 and Marjukka Kolehmainen 2 Abstract Background: Obesity and stress are among the most common lifestyle-related health problems. Most of the current disease prevention and management models are not satisfactorily cost-effective and hardly reach those who need them the most. Therefore, novel evidence-based controlled interventions are necessary to evaluate models for prevention and treatment based on self-management. This randomized controlled trial examines the effectiveness, applicability, and acceptability of different lifestyle interventions with individuals having symptoms of metabolic syndrome and psychological distress. The offered interventions are based on cognitive behavioral approaches, and are designed for enhancing general well-being and supporting personalized lifestyle changes. Methods/Design: 339 obese individuals reporting stress symptoms were recruited and randomized to either (1) a minimal contact web-guided Cognitive Behavioral Therapy-based (CBT) intervention including an approach of health assessment and coaching methods, (2) a mobile-guided intervention comprising of mindfulness, acceptance and value-based exercises, (3) a face-to-face group intervention using mindfulness, acceptance and value-based approach, or (4) a control group. The participants were measured three times during the study (pre = week 0, post = week 10, and follow-up = week 36). Psychological well-being, lifestyles and habits, eating behaviors, and user experiences were measured using online surveys. Laboratory measurements for physical well-being and general health were performed including e.g. liver function, thyroid glands, kidney function, blood lipids and glucose levels and body composition analysis. In addition, a 3-day ambulatory heart rate and 7-day movement data were collected for analyzing stress, recovery, physical activity, and sleep patterns. Food intake data were collected with a 48 -hour diet recall interview via telephone. Differences in the effects of the interventions would be examined using multiple-group modeling techniques, and effect-size calculations. (Continued on next page) * Correspondence: [email protected] † Equal contributors 1 Department of Psychology, University of Jyväskylä, Ylistönmäentie 33, P. O. Box 35, 40014 Jyväskylä, Finland Full list of author information is available at the end of the article © 2014 Lappalainen et al.; licensee BioMed Central Ltd. This is an Open Access article distributed under the terms of the Creative Commons Attribution License (http://creativecommons.org/licenses/by/4.0), which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly credited. The Creative Commons Public Domain Dedication waiver (http://creativecommons.org/publicdomain/zero/1.0/) applies to the data made available in this article, unless otherwise stated. Lappalainen et al. BMC Public Health 2014, 14:310 http://www.biomedcentral.com/1471-2458/14/310 (Continued from previous page) Discussion: This study will provide additional knowledge about the effects of three low intensity interventions for improving general well-being among individuals with obesity and stress symptoms. The study will show effects of two technology guided self-help interventions as well as effect of an acceptance and value–based brief group intervention. Those who might benefit from the aforesaid interventions will increase knowledge base to better understand what mechanisms facilitate effects of the interventions. Trial registration: Current Clinical Trials NCT01738256, Registered 17 August, 2012. Keywords: Lifestyle, Well-being, Obesity, Stress, Acceptance and Commitment Therapy, Cognitive behavioral therapy, Mobile application, Web-based intervention, Technology-aided interventions Background Obesity is increasing globally and is correlated with a variety of health problems. Consequences of being overweight might result in the metabolic syndrome, which is a set of medical features such as impaired glucose metabolism, dyslipidaemia and hypertension that are risk factors for cardiovascular disease and type-II diabetes [1,2]. Lifestyle changes have proven to be an efficient way to counter obesity and related disorders [3,4], however it is challenging to achieve long-term lifestyle changes using limited resources in real-life health care systems. Individuals having problems related to overweight also experience additional health issues such as stress. Psychological stress is known to be related with increased body mass. In addition psychological stress also contributes to weight gain [5-7]. The fourth European Survey of Working Conditions reported that 22% of working European individuals suffers from stress. It is important to note that the annual financial cost for work-related stress within the EU was estimated at €20,000 million [8]. Much of existing health service models have problems in supporting long-term lifestyle changes required for managing of weight and stress. In addition, existing disease prevention and management models are not cost effective and do not necessarily reach those individuals who need them the most. A large number of studies indicate that lifestyle changes could be promoted by using different types of Internet-based technologies [9-14]. Available literature provides significant evidence that supports the effectiveness of web-based interventions of lifestyle and behavioral changes [15,16], however what type/s of webbased interventions could be beneficial for individuals with chronic health disorders is vaguely reported and need further investigation. In addition, little is known about the relevance of low intensity programs using novel interactive technologies offering minimal contact for those reporting both obesity and stress. Additional controlled studies are necessary to evaluate different types of low intensity intervention models for prevention and treatments based on self-management. There are several options to facilitate development of low intensity self-management approaches for lifestylerelated chronic conditions, for example, use of Internetadministrated assessment, online health screening and coaching approaches based on current knowledge of Cognitive Behavioral Therapies (CBT). Low intensity CBT-based interventions use a minimum level of intervention essential to enhance mental health and wellbeing [17]. Much of the low intensity interventions use novel interactive communication technologies. They might support long-term lifestyle changes because they deliver swift and easy access to early intervention and preventive programs. In addition to investigating the effect of low intensity web-based health screening and coaching application, we wanted to explore the effect of third wave CBT methods by applying mindfulness and acceptance-based interventions for individuals with obesity and stress. There has been an increasing interest towards these novel approaches lately with an aim to improve psychological flexibility for promoting life style changes. It has been proposed that psychological flexibilityisoneofthekeyrequisites for psychological health [18]. Psychological flexibility is reflected by how a person: adapts to inconsistent situations, reconfigures mental resources, modifies viewpoints, and balances competing desires and needs. For example, interventions that include components of psychological flexibility have demonstrated significant benefits when compared with controlled conditions on measures of depression and anxiety [19]. Additionally, there is evidence suggesting that lower psychological flexibility and burnout increase the risk of unstable emotional state of mind and adverse eating habits [20]. These results among others indicate that improvement of psychological flexibility is undoubtedly beneficial for individuals suffering from obesity and/or stress. Mindfulness, acceptance and value-based methods targeting psychological flexibility include psychological interventions such as Acceptance and Commitment Therapy (ACT) [21]. There are few studies that have investigated the effect of novel mindfulness and acceptance-based interventions such as ACT for chronic health conditions [22,23]. An increasing number of studies indicate that ACT is conceivably effective for a wide range of psychological Lappalainen et al. BMC Public Health 2014, 14:310 Page 2 of 16 http://www.biomedcentral.com/1471-2458/14/310 and health disorder, such as chronic pain, smoking, diabetes, epilepsy and work-related stress [24,25]. Yet further studies are desirable to prove the effectiveness of ACT-based interventions such as mindfulness and acceptance practices in improving deteriorated metabolic indicators, such as dyslipidemia, low-grade inflammation or deficiencies in glucose metabolism. ACT has mainly been investigated using face-to-face interventions, and there are only few studies that have studied the effect of ACT-based approaches for health disorders using web or mobile-based interventions. Web-based ACT interventions have been developed e.g. for tinnitus distress [26], chronic pain [27], and psychological stress [28]. Furthermore, ACT-based mobile apps have been studied on small scale [29,30]. To the best of our knowledge, there are very few controlled trials that have been conducted to investigate the effectiveness of ACT-based mobile interventions [29]. Overall, there are a limited number of controlled studies that have investigated the effects and feasibility of smartphone solutions for chronic health disorder [31]. Aim and main hypotheses The overall aim of the present study was to investigate the effect of three novel low intensity psychological interventions for metabolic syndrome risk factors, psychological flexibility and general well-being among obese individuals experiencing stress. The purpose was to study (a) the effects of minimal contact web-based CBT intervention including an approach of health assessment and coaching methods (Internet), (b) the effects of mobile-based intervention containing mindfulness, acceptance and value-based exercises (Mobile), and (c) the effects of face-to-face group intervention using mindfulness, acceptance and value-based approaches (Face-to-Face) in a controlled study design, where control (Control) received no treatment, but the same measurements were completed for all the groups. Thus, both technology-based low intensity self-help interventions offered minimal contact, and they were compared to a brief group intervention. Moreover, we were interested in studying acceptability, applicability, perceived benefits, user experiences, and usage of the said interventions. The three interventions groups, and the control group were compared based on changes in lifestyle measures (e.g. food and nutrition intake, meal patterns, physical activity, sleeping habits), psychological measures (e.g. psychological flexibility, perceived stress, depression symptoms, quality of life, perceived quality and quantity of sleep), clinical and biochemical variables (e.g. BMI, body composition, circulating glucose, insulin, lipids, stress and inflammation indicators), other physiological measurements (e.g. objective sleep measurements, heart rate variability-based recovery from stress), and user experiences (e.g. experiences with the interventions, actual usage, realization of exercises presented in interventions). We formulized the following hypotheses: H1: Participants who receive any of the three interventions would show improvements in lifestyle and psychological measures, and clinical, biochemical, and physiological variables ascomparedtothecontrol group. Each intervention group is compared with the control condition separately. H2: Participants who receive any of the three interventions will show equal positive changes in lifestyle, and psychological measures, and clinical, biochemical, and physiological variables when the interventions are compared with each other. We also wanted to examine demographics and psychological variables that could predict change over time (Pre, Post and Follow-up) including age, gender, initial BMI, physical activity, psychological flexibility, stress and depressive mood and psychological symptoms. Further, we would examine potential mediators on the effect of the interventions including psychological flexibility and mindfulness skills. Secondary objectives include analyses of the user experiences and validity of used measurement and intervention methods. Methods/Design Study design This study was a randomized controlled trial (RCT) (Figure 1). Main outcome measures were psychological flexibility, weight, diet quality, eating behavior, perceived stress, depression symptoms, and sleeping habits. Several other variables associated with lifestyle changes, psychological and physiological health was assessed during the study. We were also interested in user experiences of the three novel interventions. The interventions are described below in detail. The study was performed at three cities in Finland (Helsinki, Jyväskylä, and Kuopio) by the local universities (University of Helsinki, University of Jyväskylä, and University of Eastern Finland, Kuopio). In addition, VTT Technical Research Center of Finland (Tampere, Finland), Finnish Institute of Occupational Health (Helsinki and Oulu), and companies Duodecim Medical PublicationsLtd.(Helsinki,Finland), Firstbeat Technologies Ltd. (Jyväskylä, Finland), Vivago Ltd. (Espoo, Finland), Finnish Red Cross Blood Service (Helsinki, Finland), and Valio Ltd. (Helsinki, Finland) participated in performing the study. The study was approved by the ethics committee of the Central Finland Health Care District, and registered with ClinicalTrials.gov with the identifier NCT01738256. The study was carried out in two phases. The first phase started in September 2012 and the second phase in January 2013. The study included pre-measurements before the 8-week interventions, post-measurements 10 weeks after the pre-measurements, and follow-up measurements six months after the post measurements Lappalainen et al. BMC Public Health 2014, 14:310 Page 3 of 16 http://www.biomedcentral.com/1471-2458/14/310 (36 weeks from pre-measurement). The last measurements were collected in December 2013. Study population The recruited participants (n = 339, Figure 1) were either overweight or obese and reported psychological stress symptoms. The inclusion criteria were: 1) Body Mass Index (BMI) 27–34.9 kg/m 2 , 2) perceived psychological stress (at least 3/12 points in General Health Questionnaire [32], and 3) the possibility to use computer with internet connection. The exclusion criteria were: diagnosed severe chronic illness (symptomatic cardiovascular disease, Type I or II diabetes, severe psychiatric conditions or substance abuse), medical surgery within the past 6 months, heart attack/stroke within past 6 months, kidney disease requiring dialysis or other disabilities/illnesses affecting substantially physiological or mental health, regular use of cortisone pills, pacemaker, eating disorder (bulimia), disability pension for psychological reasons, pregnancy or breastfeeding within the past 6 months, shift work (in three shifts) or night work, psychotherapy or other psychological or mental treatment at least twice a month, and participation in other intervention studies during the present study. Procedure for recruitment, randomization and allocation The participants were recruited by using advertisements in local newspapers. All the participants took part in the study on volunteer basis. The initial exclusion criteria were assessed through phone calls and by using electronic questionnaire for reported distress. The participants who passed the initial screening were randomly allocated into one of the three intervention groups (Internet, Mobile, Face-to-Face), or into a control group. After randomization, participants with predetermined abnormalities in baseline laboratory examinations were excluded from the study(seeFigure1).Atthebaselinevisittothestudy center the blood samples were drawn for determining health status and excluding volunteers with unknown/ undiagnosed chronic disease or other health problem. The measurements for liver, thyroid glands and kidney function as well as glucose and lipid metabolism were taken. If there was a value outside reference values, the participant was excluded before starting the actual interventions. Written informed consent was obtained during the laboratory examination. Randomization was done by a university statistician using a table of random numbers (in batches of four). An independent person outside of the research group prepared envelopes containing the randomization number, study ID and group number by center. The envelopes were Assessed for eligibility (n=645) Excluded (n=306) Not meeting inclusion criteria Declined to participate Other reasons Randomized (n=339) Lost to post intervention measurement (n=3) Reasons: noncompliance (n=2), medical condition (n=1) Lost to post intervention measurement (n=8) Reasons: noncompliance (n=5), medical condition (n=3) Participated in the follow up measurement (n=60) Lost to follow up measurement (n=2) Reasons: noncompliance (n=1), medical condition (n=1) Participated in the follow up measurement (n=73) Lost to follow up measurement (n=2) Reasons: noncompliance (n=2) Participated in the follow up measurement (n=64) Lost to follow up measurement (n=6) Reasons: noncompliance (n=4), medical condition (n=2) Participated in the follow up measurement (n=67) Lost to follow up measurement (n= 1) Reasons: medical condition (n=1) Follow up measurement (week 36) Post intervention measurement (week 10) Lost to post intervention measurement (n=2) Reasons: noncompliance (n=1), medical condition (n=1) Lost to post intervention measurement (n=6) Reasons: noncompliance (n=6) Mobile (n=85) Received allocated intervention (n=78) Did not receive allocated intervention (n=7): Reasons: not meeting inclusion criteria (n=5), noncompliance (n=2) Internet (n=85) Received allocated intervention (n=78) Did not receive allocated intervention (n=7): Reasons: not meeting inclusion criteria (n= 1), noncompliance (n=5), medical condition (n=1) Control (n=85) Participated in the control group (n=70) Did not participate in the control group (n=15): Reasons: not meeting inclusion criteria (n=7), noncompliance (n=7), medical condition (n=1) Face-to-face (n=84) Received allocated intervention (n=68) Did not receive allocated intervention (n=16): Reasons: not meeting inclusion criteria (n=6), noncompliance (n=10) Allocation and pre intervention measurement (week 0) Figure 1 Flow chart of the study design. Lappalainen et al. BMC Public Health 2014, 14:310 Page 4 of 16 http://www.biomedcentral.com/1471-2458/14/310 opened in the order participants passed the initial screening following ‘concealment of allocation’principle. Interventions Internet-based coaching The Internet-based intervention (Table 1) consisted of a 12-week program without any face-to-face contact (Duodecim Virtual Health Check and Coaching program). The intervention combined the assessment of psychological resources and health related behavior to provide users with a comprehensive view of their health and life situation and ways to improve it. With the support of the assessment, the users could choose between coaching programs to improve positive life skills and to change health related behaviors. In the Health Check, the users filled out a health questionnaire assessing key health determinants, lifestyle factors, emotional well-being, and performance (Figure 2). On the basis of the assessment, the users received estimations, including a prognosis of average life expectancy, coronary heart disease, stroke and diabetes risk, as well as a description of their habits and behaviors impacting their health (Figure 3). The questionnaire and algorithms assessing health risks were based on the Finnish health check and follow-up study Finriski, having up to 30 years follow-up data on a population sample more than 10 000 people [33]. On the basis of the health check feedback, users could choose optional coaching programs for weight management, healthy diet, exercise, sleep improvement, alcohol consumption management, smoking cessation, and mental well-being (stress management, gratitude, forgiveness, good actions, optimism, positive interaction in relationships and resolving conflicts in relationship). Participants were nonetheless commended to choose primarily from the following three programs: Stress and life management, Nutrition, and Exercise. The programs were designed to support improvements in the health and well-being habits and behaviors. In the coaching program, users received a weekly coaching message including information about the chosen topic and a link to further information. In addition, the message contained advice or exercise, through which an individual could improve awareness of his/her behavior and practice skills to develop habits that support wellbeing. The weekly message also included feedback based on entries made by the respective user. The users had an option to record follow-up information about their lifestyles (weight, physical activity, nutrition, alcohol consumption and smoking). During the program, users could monitor their progress through graphs, make new health checks, and choose new coaching programs (Figure 4). Coaching programs for weight management, sleep improvement, exercise, alcohol consumption management, and smoking cessation were based on cognitivebehavioral practices on lifestyle changes [34-37]. The test and coaching programs for mental well-being have been developed along the outlines described by several authors [38-40] showing that the cognitive behavioral coaching program to develop optimism, gratitude and other life skills are effective in traditional writing exercise and web-based coaching programs [38,41]. The validity of the variables has been tested in a large Table 1 Content of the Internet intervention Content Key points Health questionnaire Estimate of life expectancy, coronary heart disease, stroke and diabetes risk. Description of one’s life habits and behaviors impacting on health and ways to influence them Coaching programs Each program includes a weekly message. In weight management, healthy diet, exercise, sleep improvement and alcohol use management programs the user has an option to record follow-up information about relevant behavior or parameter: a) Weight management Messages consist of information, practical advice and exercises on weight management (e.g. managing appetite, eating, portion size, buying food), and link to further readings. b) Healthy diet Messages about healthy diet and practical advice for improvement, and also links to further readings. c) Exercise Messages include information about health related physical activity and link to further readings. Message contains also advice or practice. d) Stress and life management Optional: Stress management, Good deeds, Optimism, Human relations, Social relations, Positive interaction in relationships, Resolving conflicts in relationships, Coaching exercises for families with children. The weekly coaching message includes information, practical advice, and exercise about stress or life management and link to further readings. Optional: e) Sleep improvement Information, practical advice and exercises on good sleep (e.g. sleep hygiene, environment, relaxation) and link to further readings. Message contains also advice or practice. f) Alcohol use management Cognitive behavioral program to analyze reasons and situations of alcohol use and advice to avoid excess use. g) Smoking cessation Cognitive behavioral program to analyze reasons and situations of smoking, mental exercise, and support for quitting. Lappalainen et al. BMC Public Health 2014, 14:310 Page 5 of 16 http://www.biomedcentral.com/1471-2458/14/310 cross-sectional study where more than 130 000 Finns completed the questionnaire [42]. Mobile-based intervention The participants in the Mobile-based intervention were invited in a group meeting that consisted of a brief overview of Acceptance and Commitment Therapy (ACT) principles. In the meeting, the participants were given Android smartphones that were pre-installed with a stand-alone mental wellness training application called Oiva. They were instructed to use Oiva for the upcoming 8 weeks at their own. The application contained short exercises that taught ACT skills to be applied in daily life. The mobile application delivered an ACTbased intervention program similar to the Face-to-Face group. Prior to the present trial, the application had been piloted in a feasibility study with a sample of office workers with stress symptoms [29]. The content of the application was divided into four intervention paths: Mindful Mind, Wise Mind, Values, and Healthy Body (Table 2). The first three paths demonstrate core processes of ACT and the fourth path applies ACT-based approach on physical well-being. The application contained altogether 46 exercises in text and audio formats, as well as introduction videos for each path and section. The program did not include psychoeducation on healthy diet or physical activity, only a hyperlink to a public nutritional website was provided. Figure 5 presents examples of the user interface of the application. The main screen (Figure 5a) contained a flower-shaped menu through which different paths could be accessed. The main screen also provided access to a diary (Figure 5b), list of favorite exercises, and introduction to the application in text and video formats (Figure 5c). Each petal represents one of the paths, which were numbered according to their recommended order. Each path consisted of 1–4 subsections (“steps”), which included 5–8 exercises (Figure 5d). There was an introduction in text and video formats to each path and step, informing users about the processes and skills. Most of the exercises were short and took about 1– 3 minutes to be completed (Figure 5e-h). This aimed at making exercises easy to perform in any situation. Each exercise began with an introduction presenting the purpose, duration and instructions of the exercise (Figure 5e). The users could choose to exercise by listening (Figure 5f) or by reading (Figure 5g). After each exercise, a reflection screen (Figure 5h) summarized the skills learned from the exercise andenableduserstowritenotesandreflectionsintheir diary(Figure5b).Thenotesweresavedinthediaryand could be accessed later. The application smoothly guided users through the intervention program without restricting free navigation. Paths, steps, and exercises were numbered Figure 2 Screenshots of the internet application. Lappalainen et al. BMC Public Health 2014, 14:310 Page 6 of 16 http://www.biomedcentral.com/1471-2458/14/310 in the recommended order and the next suggested item was dynamically highlighted (Figure 5a and d). However, all paths and exercises were accessible from the very beginning. Face-to-face group intervention (Face-to-Face) The ACT-based face-to-face group intervention consisted of six group sessions during 8-week period of time, with each session lasting for about 90 minutes (see Table 3). Each group consisted of 6–12 participants and was instructed by a psychologist. Three psychologists acted as coaches. All of them were trained in ACT approach, had experience in ACT interventions, and had a manual of the program to follow. The participants were given a workbook that contained short descriptions of the sessions, exercises, and individual reflections and notes. The intervention program aimed to support lifestyle changes and to enhance well-being through committed and concrete actions based on the personally important values –the most important directions in life. The program started with an analysis of own life situation and reflections about values and important things in life. After the value clarification, the participants made concrete action plans and defined their own goals. The emphasis was placed on small and feasible actions that lead to better life according to personally chosen values. In order to achieve the set goals, the participants were taught acceptance and mindfulness skills and new ways to deal with the barriers of action. The purpose of teaching acceptance and mindfulness skills was to increase Figure 3 Screenshots of the internet application. Lappalainen et al. BMC Public Health 2014, 14:310 Page 7 of 16 http://www.biomedcentral.com/1471-2458/14/310 Figure 4 Screenshots of the internet application. Table 2 Content of the four paths in the mobile intervention Topic of the path Content Key points Mindful mind Five mindfulness exercises Contact with the present moment. Focusing fully on one’s inner or outer experiences. Acting mindfully. Wise mind Observation: six exercises Observing thoughts without being caught up in them. Acceptance: four exercises Making room for unpleasant feelings, sensations, urges, and other private experiences; allowing them to come and go without struggling with them. Values Values: seven exercises How I use my time in my current life? How mindfulness-skills can improve wellbeing? What are the most important values for me? Am I living according to my values? Value based actions: seven exercises What are my specific goals and actions that support my valued behavior? Healthy body Relaxation: six exercises Relaxing and listening to my body. Mindful eating: six exercises Exercising mindful eating. What is my typical meal rhythm? 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