Skip to main content

Behavioral Impacts of Sequentially versus Simultaneously Delivered Dietary Plus Physical Activity Interventions: the CALM Trial



Few studies have evaluated how to combine dietary and physical activity (PA) interventions to enhance adherence.


We tested how sequential versus simultaneous diet plus PA interventions affected behavior changes.


Two hundred participants over age 44 years not meeting national PA and dietary recommendations (daily fruit and vegetable servings and percent of calories from saturated fat) were randomized to one of four 12-month telephone interventions: sequential (exercise first or diet first), simultaneous, or attention control. At 4 months, the other health behavior was added in the sequential arms.


Ninety-three percent of participants were retained through 12 months. At 4 months, only exercise first improved PA, and only the simultaneous and diet-first interventions improved dietary variables. At 12 months, mean levels of all behaviors in the simultaneous arm met recommendations, though not in the exercise- and diet-first arms.


We observed a possible behavioral suppression effect of early dietary intervention on PA that merits investigation.

This is a preview of subscription content, access via your institution.

Fig. 1
Fig. 2
Fig. 3
Fig. 4


  1. 1.

    Physical Activity Guidelines Advisory Committee. Report of the Physical Activity Guidelines Advisory Committee, 2008. Washington, DC: U.S. Dept. of Health & Human Services; 2008.

    Google Scholar 

  2. 2.

    U.S. Department of Health and Human Services and U.S. Department of Agriculture. Dietary Guidelines for Americans, 2005. 6th ed. Washington, DC: U.S. Govt. Printing Office; 2005.

    Google Scholar 

  3. 3.

    U.S. Department of Health & Human Services. Healthy People 2010, Final Review. Washington, DC: US Department of Health and Human Services, Office of Disease Prevention and Health Promotion; 2011.

    Google Scholar 

  4. 4.

    Bandura A. Social cognitive theory: An agentic perspective. Ann Rev Psychol. 2001;52:1-26.

    Article  CAS  Google Scholar 

  5. 5.

    Kremers SPJ, de Bruijn GJ, Schaalma H, Brug J. Clustering of energy balance-related behaviours and their intrapersonal determinants. Psychol Health. 2004;19:595-606.

    Article  Google Scholar 

  6. 6.

    Mata J, Silva MN, Vieira PN, et al. Motivational “spill-over” during weight control: Increased self-determination and exercise intrinsic motivation predict eating self-regulation. Health Psychol. 2009;28:709-716.

    PubMed  Article  Google Scholar 

  7. 7.

    Emmons KM, Marcus BH, et al. The relationship between smoking, physical activity, and dietary fat intake among manufacturing workers. Prev Med. 1994;23:481-489.

    PubMed  Article  CAS  Google Scholar 

  8. 8.

    Wilcox S, King AC, Castro C, Bortz W II. Do changes in physical activity lead to dietary changes in middle and older age? Am J Prev Med. 2000;18:276-283.

    PubMed  Article  CAS  Google Scholar 

  9. 9.

    Wansink B, Sobal J. Mindless eating: The 200 daily food decisions we overlook. Environ Behav. 2007;39:106-123.

    Article  Google Scholar 

  10. 10.

    King AC, Frey-Hewitt B, Dreon DM, Wood PD. Diet vs exercise in weight maintenance. The effects of minimal intervention strategies on long-term outcomes in men. Arch Intern Med. 1989;149:2741-2746.

    PubMed  Article  CAS  Google Scholar 

  11. 11.

    Hagger MS, Wood C, Stiff C, Chatzisarantis NL. Ego depletion and the strength model of self-control: A meta-analysis. Psychol Bull. 2010;136:495-525.

    PubMed  Article  Google Scholar 

  12. 12.

    Baumeister RF, Vohs KD, Tice DM. The strength model of self-control. Curr Dir Psychol Sci. 2007;16:351-355.

    Article  Google Scholar 

  13. 13.

    Kiernan M, King AC, Stefanick M, Kraemer HC. Characteristics of successful and unsuccessful dieters: An application of signal detection methodology. Ann Behav Med. 1998;20:1-6.

    PubMed  Article  CAS  Google Scholar 

  14. 14.

    Kendzierski D. A self-schema approach to healthy eating. J Am Psychiatr Nurses Assoc. 2007;12:350-357.

    Article  Google Scholar 

  15. 15.

    Wood W, Neal DT. A new look at habits and the habit–goal interface. Psychol Rev. 2007;114:843-863.

    PubMed  Article  Google Scholar 

  16. 16.

    Oman RF, King AC. The effect of life events and exercise program format on the adoption and maintenance of exercise behavior. Health Psychol. 2000;19:605-612.

    PubMed  Article  CAS  Google Scholar 

  17. 17.

    Hypertension Prevention Trial Research Group. The Hypertension Prevention Trial: Three-year effects of dietary changes on blood pressure. Arch Intern Med. 1990;150:153-162.

    Article  Google Scholar 

  18. 18.

    Young DR, Vollmer WM, King AC, et al. Can individuals meet multiple physical activity and dietary behavior goals? Am J Health Behav. 2009;33:277-286.

    PubMed  Google Scholar 

  19. 19.

    Lluch A, King NA, Blundell JE. Exercise in dietary restrained women: No effect on energy intake but change in hedonic ratings. Eur J Clin Nutr. 1998;52:300-307.

    PubMed  Article  CAS  Google Scholar 

  20. 20.

    Vandelanotte C, Bourdeaudhuij ID, Brug J. Two-year follow-up of sequential and simultaneous interactive computer-tailored interventions for increasing physical activity and decreasing fat intake. Ann Behav Med. 2007;33:213-219.

    PubMed  Article  Google Scholar 

  21. 21.

    Hyman DJ, Pavlik VN, Taylor WC, Goodrick GK, Moye L. Simultaneous vs sequential counseling for multiple behavior change. Arch Intern Med. 2007;167:1152-1158.

    PubMed  Article  Google Scholar 

  22. 22.

    Aspinwall LG, Taylor SE. A stitch in time: Self-regulation and proactive coping. Psychol Bull. 1997;121:417-436.

    PubMed  Article  CAS  Google Scholar 

  23. 23.

    King AC, Kiernan M, Oman RF, et al. Can we identify who will adhere to long-term physical activity? Signal detection methodology as a potential aid to clinical decision making. Health Psychol. 1997;16:380-389.

    PubMed  Article  CAS  Google Scholar 

  24. 24.

    King AC, Baumann K, O'Sullivan P, Wilcox S, Castro C. Effects of moderate-intensity exercise on physiological, behavioral, and emotional responses to family caregiving: A randomized controlled trial. J Gerontol: Med Sci. 2002;57A:M26-M36.

    Article  Google Scholar 

  25. 25.

    National Center for Health Statistics. National Health Interview Survey. Washington, DC: National Center for Health Statistics; 2002.

    Google Scholar 

  26. 26.

    Block G, Gillespie C, Rosenbaum EH, Jenson C. A rapid food screener to assess fat and fruit and vegetable intake. Am J Prev Med. 2000;18:284-288.

    PubMed  Article  CAS  Google Scholar 

  27. 27.

    Cohen S, Williamson G. Perceived stress in a probability sample of the United States. In: Spacapam S, Oskamp S, eds. The social psychology of health: Claremont Symposium on applied social psychology. Newbury Park: Sage; 1988:31-67.

    Google Scholar 

  28. 28.

    Efron B. Forcing a sequential experiment to be balanced. Biometrika. 1971;58:403-417.

    Article  Google Scholar 

  29. 29.

    King AC, Oman RF, Brassington GS, Bliwise DL, Haskell WL. Moderate-intensity exercise and self-rated quality of sleep in older adults. A randomized controlled trial. JAMA. 1997;277:32-37.

    PubMed  Article  CAS  Google Scholar 

  30. 30.

    Eakin EG, Lawler SP, Vandelanotte C, Owen N. Telephone interventions for physical activity and dietary behavior change: A systematic review. Am J Prev Med. 2007;32:419-434.

    PubMed  Article  Google Scholar 

  31. 31.

    King AC, Friedman RM, Marcus BH, et al. Ongoing physical activity advice by humans versus computers: The Community Health Advice by Telephone (CHAT) Trial. Health Psychol. 2007;26:718-727.

    PubMed  Article  Google Scholar 

  32. 32.

    Castro CM, Pruitt LA, Buman MP, King AC. Physical activity program delivery by professionals vs volunteers: The TEAM randomized trial. Health Psychol. 2011;30:285-294.

    PubMed  Article  Google Scholar 

  33. 33.

    Wilcox S, Dowda M, Leviton LC, et al. Active for life: Final results from the translation of two physical activity programs. Am J Prev Med. 2008;35:340-351.

    PubMed  Article  Google Scholar 

  34. 34.

    Marcus BH, Simkin LR. The transtheoretical model: Applications to exercise behavior. Med Sci Sports Exerc. 1994;26:1400-1404.

    PubMed  CAS  Google Scholar 

  35. 35.

    Bassett DR Jr, Ainsworth BE, Leggett SR, et al. Accuracy of five electronic pedometers for measuring distance walked. Med Sci Sports Exerc. 1996;28:1071-1077.

    PubMed  Article  Google Scholar 

  36. 36.

    Pearson TA, Bazzarre TL, Daniels SR, et al. American Heart Association guide for improving cardiovascular health at the community level: A statement for public health practitioners, healthcare providers, and health policy makers from the American Heart Association Expert Panel on Population and Prevention Science. Circulation. 2003;107:645-651.

    PubMed  Article  Google Scholar 

  37. 37.

    King AC, Winett RA. Tailoring stress-reduction strategies to populations at risk: Comparisons between women from dual-career and dual-working families. Fam Commun Health. 1986;9:42-50.

    Article  Google Scholar 

  38. 38.

    Luskin F, Pelletier K. Stress Free for Good: 10 Scientifically Proven Life Skills for Health and Happiness. New York: Harper Collins; 2005.

    Google Scholar 

  39. 39.

    Fisher JD, Fisher WA. Changing AIDS-risk behavior. Psychol Bull. 1992;111:455-474.

    PubMed  Article  CAS  Google Scholar 

  40. 40.

    Sallis JF, Haskell WL, Wood PD, et al. Physical activity assessment methodology in the five-city project. Am J Epidemiol. 1985;121:91-106.

    PubMed  CAS  Google Scholar 

  41. 41.

    Pruitt LA, King AC, Obarzanek E, et al. Reliability of the 7-day physical activity recall in a biracial group of inactive and active adults. J Phys Act Health. 2006;3:423-438.

    Google Scholar 

  42. 42.

    Stewart AL, Mills KM, King AC, et al. CHAMPS physical activity questionnaire for older adults: Outcomes for interventions. Med Sci Sports Exerc. 2001;33:1126-1141.

    PubMed  CAS  Google Scholar 

  43. 43.

    Prochaska JJ, Velicer WF, Nigg CR, Prochaska JO. Methods of quantifying change in multiple risk factor interventions. Prev Med. 2008;46:260-265.

    PubMed  Article  Google Scholar 

  44. 44.

    Block G, Thompson FE, Hartman AM, Larkin FA, Guire KE. Comparison of two dietary questionnaires validated against multiple dietary records collected during a 1-year period. J Am Diet Assoc. 1992;92:686-693.

    PubMed  CAS  Google Scholar 

  45. 45.

    Boucher B, Cotterchio M, Kreiger N, et al. Validity and reliability of the Block98 food-frequency questionnaire in a sample of Canadian women. Public Health Nutr. 2006;9:84-93.

    PubMed  Article  Google Scholar 

  46. 46.

    Block G, Coyle LM, Hartman AM, Scoppa SM. Revision of dietary analysis software for the Health Habits and History Questionnaire. Am J Epidemiol. 1994;139:1190-1196.

    PubMed  CAS  Google Scholar 

  47. 47.

    Sallis JF, Grossman RM, Pinski RB, Patterson TL, Nader PR. The development of scales to measure social support for diet and exercise behaviors. Prev Med. 1987;16:825-836.

    PubMed  Article  CAS  Google Scholar 

  48. 48.

    Garcia AW, King AC. Predicting long-term adherence to aerobic exercise: A comparison of two models. J Sport Exerc Psychol. 1991;13:394-410.

    Google Scholar 

  49. 49.

    Wilcox S, Castro C, King AC. Outcome expectations and physical activity participation in caregiving and non-caregiving women. J Health Psychol. 2006;11:65-77.

    PubMed  Article  Google Scholar 

  50. 50.

    Kraemer HC, Thiemann S. How many subjects? Statistical power analysis in research. Newbury Park: Sage; 1987.

    Google Scholar 

  51. 51.

    Spector PC, Goodnight JH, Sall JP, Sarle WS. The GLM procedure. SAS user's guide: Statistics. Version 5. Cary: SAS Institute Inc; 1985:433-506.

    Google Scholar 

  52. 52.

    Wood AM, White IR, Hillsdon M, Carpenter J. Comparison of imputation and modelling methods in the analysis of a physical activity trial with missing outcomes. Int J Epidemiol. 2005;34:89-99.

    PubMed  Article  Google Scholar 

  53. 53.

    SAS Institute Inc. SAS/STAT 9.2 User's Guide. 2nd ed. Cary: SAS Institute; 2009.

    Google Scholar 

  54. 54.

    Singer JD, Willett JB. Applied Longitudinal Data Analysis: Modeling Change and Event Occurrence. New York: Oxford University Press; 2003.

    Book  Google Scholar 

  55. 55.

    Hooker SP, Seavey W, Weidmer CE, et al. The California active aging community grant program: Translating science into practice to promote physical activity in older adults. Ann Behav Med. 2005;29:155-165.

    PubMed  Article  Google Scholar 

Download references


The research was supported by a Public Health Service Grant R01AG021010 from the National Institute on Aging (King) and a Public Health Service Training Grant 5T32HL007034 from the National Heart, Lung, and Blood Institute. The authors thank Carolyn Prosak, Catharine Cassayre, Julia Wu, Arturo Fernandez, Susannah Belding, and Sarah French for implementing the interventions; Dr. Leslie Pruitt and Stephanie Koltiska for their work with respect to study evaluations; and Dr. Judith Prochaska for comments on the manuscript.

Conflict of Interest

The authors have no conflicts of interest to disclose.

Author information



Corresponding author

Correspondence to Abby C. King PhD.

About this article

Cite this article

King, A.C., Castro, C.M., Buman, M.P. et al. Behavioral Impacts of Sequentially versus Simultaneously Delivered Dietary Plus Physical Activity Interventions: the CALM Trial. ann. behav. med. 46, 157–168 (2013).

Download citation


  • Physical activity
  • Dietary change
  • Multiple health behaviors
  • Sequential
  • Simultaneous
  • Stress