 So, my great pleasure to introduce Tom Robinson. He's internationally renowned for his solution-oriented research, developing and evaluating effective health promotion and disease prevention interventions for children and adolescents and their families. He's been the director of the LPCH Center for Healthy Weight since 2005, and he's an extraordinary publication and grant record. For our purposes today, he was notably the PI of the 2009 NORC application as proposed center director. He earned the only exceptional review of any of the different categories that we were ranked on. So, he was our highest-ranking player. He's agreed to do it again, and he's going to share some of his thoughts now and come back and actually close out the whole session in the afternoon with some clinical insights. And I think we're ready to go. Okay. All right. I was going to move on to talking a little bit about behavior, and in particular, one area of the work that we've been doing that I call stealth interventions. So to cut to the chase, what I've been working on is really motivation, motivation to change behavior. And there are really two types of motivation in the way we see it. The first is motivation to adopt the new behavior or the outcome, and I refer to that as outcome motivation. And the second is motivation to participate in the intervention itself that produces that change, and I call that process motivation. Now in general, I think we do a pretty good job of focusing on outcome motivations to try and get people to achieve the ultimate outcomes of the interventions. But I think in general, our interventions have not been particularly successful at focusing on process motivation. So some examples, motivation for physical activity and eating behaviors. In general, from a medical and public health perspective, we focus on the things that are important to us, obesity, diabetes, hyperlipidemia, hypertension, risk for future disease, and those are the outcomes. And we tell our patients and we tell the public that they need to change their behavior because they want to prevent these things, and these are the terrible things that we worry about. Well, it turns out, and it's sort of obvious from looking at the population and what's happened to our health status, is that these things have not been particularly motivating for people or sufficiently motivating to change their behavior. And so when you look at other areas of research where they study in the laboratory, for example, motivation, and in particular something that's been referred to as intrinsic motivators, you see these type of things come up. And regardless of the ultimate behavioral outcome you're interested in, these types of things tend to be intrinsically motivating to get people to participate in intervention. Things like fun and taste in our area of obesity or physical activity and diet. Seed choice and perceived control of behavior, goals, curiosity and challenge and setting appropriate challenges, cooperation and competition, social interaction, pride and sense of accomplishment, peer social approval and disapproval, parent or adult approval or disapproval when you're dealing with kids, and also even personal appearance, which is something we frequently stay away from, especially in pediatrics because we're worried about eating disorders. These are things that are highly motivating or intrinsically motivating to change behavior and have been demonstrated across a whole bunch of different areas of behavior. So as you'll notice, none of those things on the right side actually are linked at all to health or to health outcomes. So I've asked the question, does a health behavior change intervention need to look, feel, sound, smell, or taste like health education? In fact, you have to deal with the issue of health at all to change behaviors that would produce outcomes related to health. And so that's why I call these stealth interventions because from the perspective of the participant, physical activity or reduced inactivity or changes in diets are really side effects of the intervention. From us, that's our primary objective, but from the participant's point of view, they're side effects of what they're doing if you're not focusing on those as the primary outcome. So the goal in developing interventions around this is that if we can identify target behaviors that are really motivating in themselves. So can we have healthful behaviors that people will participate in because they want to or because of other reinforcing aspects or properties of them as opposed to because it's good for them? Because in fact, telling people that it's good for you doesn't seem to be doing the job. So first example, and I'm glad that Barr Taylor is here because he was an inspiration for this study many years ago. And this is, I like to show this because this is a medical students project, Rose Flores, who is a medical student here about 10 or 15 years ago. And Barr was her advisor and she also worked with Larry Hammer. And she was a dance instructor and wanted to substitute dance for PE in local schools. So with her, we helped her do this project in McNair Middle School in East Palo Alto, where she randomized children to either be in their standard PE or be in a special dance class. And it only lasted for 12 weeks. It was still three times per week, 40 to 50 minutes per day, just during the regular PE period of time. And first of all, we found that with seventh graders, there were no effects in boys. But in girls, if you had them dance, which is something that's highly much more motivating to them than being part of the PE class and exercising because it was PE, found over just 12 weeks significant differences between the group randomly assigned to the dance class and a group who was continued in the regular PE program just over a 12-week period of time. We extended that to some other studies where we were doing, this is a study in African-American girls called GEMS where, again, just over a 12-week period of time, we saw substantial changes in between girls who were randomized to a dance, after-school dance program, which focused on hip-hop, step, and African dance, and also reducing their television time at home compared to girls who were randomized to just receiving education about nutrition or what we would standardly treat people with. So nutrition education, we use as a control group here, and we see about half as much of an increase in body mass index or waist circumference. We extended this to a two-year study in Oakland with 260 families, and actually we had a lot of implementation challenges. So not everything we do works as smoothly as we would like, but we did not see actually differences in BMI or waist circumference in that study in Oakland. But in fact, we did see significant reductions to this intervention with dance and screen time reduction in total cholesterol, LDL cholesterol, and related to the last talk, to Dr. Reven's talk in fasting insulin rates, even without changes in the BMI from this intervention increasing dance or using dance as a form of physical activity and reducing screen time. In fact, it was significant. We chose, as Dr. Reven talked about, there's no standard definition for what insulin should be. But for kids, we often use a cutoff of 30 milligrams per deciliter at that level with significant difference between the treatment group and the control group. And you can see here that if you look at the two green lines, which were the baseline measures of fasting insulin for the two groups, and then you look at the blue lines, which were the post-test two years later, the follow-up measures, with the dash line being health education, the solid line being the dance and TV reduction intervention, you can see how those distributions shift quite a bit just with this real public health intervention focusing on this stealth intervention as opposed to focusing specifically on health. I wanted to give you a little taste of this, and this is another study that we've been doing that is actually we just finished that was doing the same type of intervention with Mexican American girls in Redwood City, and this is using ballet folklorico, which is traditional Mexican folk dances. I don't know if you can hear the sound, but the idea is developing this program for the after-school sites, focusing on the culture, focusing on the costumes, focusing on the choreography, focusing on being in a group, learning new dance steps from instructors, learning the importance of dance in your culture. The colored ribbons in their hair actually refer to how many weeks they've stayed under their TV budget too, so that's built in. And here you can see how much they improved over a couple of months, but the idea was not to get them into a competitive situation where we're trying to turn them into dancers for a lifetime, but provide them with fun activities that they can do and continue, and in fact most of their parents, fathers and mothers would have done these dances as kids growing up in Mexico. Yeah, fun, huh? Another fun one is something, this is a project that Dana Weintraub has been spearheading in which we've identified team sports programs just for overweight children. So a lot of us have had very positive experiences with team sports growing up because of the competition, because of being a part of a team. Well overweight kids often don't get to participate in that because it's too intimidating for them often. They don't want to be the last one picked or the slowest one on the field, or they don't have time to gain the skills, especially this competitive world. So with Dana, we developed an after-school soccer program just for overweight kids. This was again in East Palo Alto. And we did this study with over a six-month period of time, and here the results presented as in standard deviation units, so I could put them all in the same slide. But over a six-month period of time, kids randomized, all overweight kids, randomized to access to a team sports program versus nutrition education. And we saw significant benefits in BMI as well as physical activity measured objectively. So next idea is to take stealth interventions to our next level, and that is social and ideological movements. And that's when we look at ideas of where people change their behavior and sustain that behavior over time. It tends to be in things like religious movements, social and ideological movements. And we've identified quite a number working with Christopher, in fact, on some stuff that actually overlap with obesity. So the one that's most obvious, environmental sustainability and climate change, what you do to save the planet is the same thing you would do to improve your health. So you get out of your car and walk and bike more, and you start eating lower on the food chain, less meat, more fruits and vegetables. And in fact, all of these have overlap in similar ways. So we've done at least one pilot of this, and this is from a course that Christopher and I lead for human biology called Food and Society, in which students who took this course, we actually measured their eating behavior before and after the course and compared it to students who were taking courses that were more directly human biology courses and were directly related to obesity and nutrition and public health. And we found that even though there were no differences at baseline in their behaviors or their attitudes, that we had significant improvements in their healthful, a total healthful diet score and in the amount of vegetables they ate, and you can see reductions in high-fat dairy, meats, sweets, increases in fruits, decrease in processed foods, although those were not significant in the small sample, and also changes in their perceived importance of eating a healthful diet, environmental sustainability, and animal rights compared to students taking regular courses around health, even though their motivation at the beginning was the same. So here's our first sort of foray into doing, systematically studying this, we're doing some other work on this as well, in which we're identifying these stealth interventions that have nothing to do ostensibly with health, but really produce the same behavior changes. OK, so that's I think the end of my 10 minutes. And yeah. The preceding program is copyrighted by the Board of Trustees of the Leland Stanford Junior University. Please visit us at med.stanford.edu.