Perceived barriers and facilitators for adherence to lifestyle prescription: Perspective of obese patients with non alcoholic fatty liver disease from north India

Lifestyle intervention for metabolic dysfunction-associated fatty liver disease: a 24-h integrated behavior perspective

INTRODUCTION

The prevalence, health and socioeconomic burden of metabolic dysfunction-associated fatty liver disease (MAFLD) is growing, increasing the need for novel evidence-based lifestyle approaches. Lifestyle is the cornerstone for MAFLD management and co-existing cardiometabolic dysfunction. The aim of this review was to evaluate the evidence for lifestyle management of MAFLD, with a specific lens on 24-hour integrated behaviour and provide practical recommendations for implementation of the evidence.

RESULTS

Weight loss ≥ 7-10% is central to lifestyle management; however, liver and cardiometabolic benefits are attainable with improved diet quality and exercise even without weight loss. Lifestyle intervention for MAFLD should consider an integrated '24-h' approach that is cognisant of diet, physical activity/exercise, sedentary behavior, smoking, alcohol intake and sleep. Dietary management emphasises energy deficit and improved diet quality, especially the Mediterranean diet, although sociocultural adaptations to meet preferences should be considered. Increasing physical activity and reducing sedentary behavior can prevent MAFLD, with strongest evidence in MAFLD supporting regular structured moderate-vigorous aerobic exercise for 150-240 min/week. Resistance training in addition to aerobic exercise should be considered and prioritised for those who are losing body mass via diet and/or pharmacological approaches and those with sarcopenia, to minimise bone and lean mass loss. Limited evidence suggests that sleep is important for MAFLD prevention. Emerging novel approaches to diet and exercise may address some of the key barriers to behaviour change (e.g. lack of time, access to resources and social support).

FUTURE DIRECTIONS

Large-scale multidisciplinary trials in people with MAFLD with long-term follow-up, that can be scaled up into mainstream healthcare, are required. Future management guidelines should consider the heterogeneity of MAFLD and specialised models of care that coordinate the health workforce to manage the increased and growing MAFLD population.

A qualitative study of perceived barriers and facilitators to interrupting sedentary behavior among adults living with obesity

Introduction

Both obesity and sedentary behavior (SB) are associated with negative health consequences including cardiovascular disease, diabetes, certain cancers and all-cause mortality. To date, perceived barriers and facilitators to interrupting SB in adults living with obesity have not been identified.

Objective

This study aimed to identify these perceived barriers and facilitators by conducting a behavioral analysis underpinned by the theoretical domains framework (TDF) and the Capability, Opportunity, Motivation-Behavior (COM-B) model to enhance knowledge and inform future intervention development.

Methods

A purposive and snowball sample (N = 21) of adults living with obesity took part in semi-structured interviews, guided by the TDF, to investigate perceived barriers or facilitators to interrupt SB. Transcribed interviews were inductively coded using reflexive thematic analysis. Key themes and subthemes were generated by grouping similar and recurring codes. Finally, subthemes were mapped to the TDF and COM-B.

Results

Five key themes were identified, which influence SB across all domains of living. These relate to (i) physical and mental wellbeing; (ii) motivational readiness; (iii) roles, responsibilities and support; (iv) weight bias and stigma; and (v) the environment. These themes were then deductively mapped to all 14 TDF domains and all six of the COM-B constructs.

Conclusion

A complex interplay of individual, societal and policy factors contributes to the development and habituation of SB patterns in adults living with obesity. Factors identified in this study could assist in the development of interventions, strategies and policies designed to interrupt or reduce sedentary behavior in this population.

Barriers to lifestyle modification in patients with non-alcoholic fatty liver disease: a scoping review

Objective: Non-alcoholic fatty liver disease is common worldwide, and lifestyle modifications are key to its treatment. This study aimed to identify the barriers to lifestyle modifications in patients with non-alcoholic fatty liver disease and to organize the results using the Capability Opportunity Motivation-Behavior (COM-B) model. Materials and Methods: The framework of Arksey and O' Malley was used in this scoping review. We searched PubMed, Scopus, and the Cochrane Library without language restrictions for reports published up to September 11, 2022, including peer-reviewed literature reporting barriers to lifestyle modifications in patients with non-alcoholic fatty liver disease. Patient-reported barriers were analyzed inductively and organized into the components (capability, opportunity, and motivation) of the COM-B model. Results: The literature search yielded 583 articles, of which seven qualitative studies, four quantitative studies, and one mixed-methods study met the inclusion criteria. Lack of time, lack of information on the diagnosis and management of non-alcoholic fatty liver disease, negative perceptions of the prescribed exercise and diet, physical symptoms interfering with the behavior, presence of comorbidities, and lack of family cooperation were frequently reported as barriers. Conclusion: The results of this study may contribute to the development of appropriate care and education strategies to promote behavioral changes in patients with non-alcoholic fatty liver disease.

Cross-sectional study on stigma and motivation to adhere to lifestyle modification among vulnerable populations with fatty liver disease

Objectives

Adherence to lifestyle modification (diet, exercise, and alcohol cessation) for fatty liver disease (FLD) management remains challenging. The study examined stigma, barriers, and factors associated with motivation to adhere to lifestyle modification in a diverse and vulnerable population with FLD.

Methods

From 2/19/2020 to 2/28/2022, 249 FLD patients within San Francisco safety-net hepatology clinics were surveyed along with clinical data taken from medical records. Multivariable modeling assessed factors associated with motivation to adhere to lifestyle modification in a cross-sectional study.

Results

Median age was 53 years, 59% female, 59% Hispanic, 25% Asian/Pacific Islander, 9% White, and 2% Black, 79% were non-English speakers, 64% had ≤ high school education, and 82% reported <$30,000 annual income. Common comorbidities included hyperlipidemia (47%), hypertension (42%), diabetes (39%), and heavy alcohol use (22%). Majority (78%) reported experiencing stigma, 41% reported extreme motivation, and 58% reported ≥ two barriers. When controlling for age, sex, Hispanic ethnicity, alcohol consumption, BMI, >high school (coef 1.41, 95% CI 0.34-2.48), stigma (coef 0.34, 95% CI 0.07-0.62), and depression (coef -1.52, 95% CI -2.79 to -0.26) were associated with motivation.

Conclusions

Stigma is commonly reported among FLD patients. Interventions to enhance patient education and mental health support are critical to FLD management, especially in vulnerable populations.

Factors influencing adherence to lifestyle prescriptions among patients with nonalcoholic fatty liver disease: A qualitative study using the health action process approach framework

Background and objective

Lifestyle modifications aimed at weight loss have been introduced as a cornerstone of nonalcoholic fatty liver disease (NAFLD) management. However, very few patients follow the doctor's prescription to change their lifestyle to achieve weight loss in the real world. The purpose of this study was to use the Health Action Process Approach (HAPA) model to examine the factors that affect adherence to lifestyle prescriptions among patients with NAFLD.

Methods

Semi-structured interviews were conducted with patients with NAFLD. Reflexive thematic analysis and framework analysis were used to determine naturally identified themes and allocate them to theoretically driven domains.

Results

Thirty adult patients with NAFLD were interviewed, and the identified themes were mapped directly onto the constructs of the HAPA model. This study revealed that key barriers to adhering to lifestyle prescriptions are related to the coping strategy and outcome expectation constructs of the HAPA model. For physical activity, conditional limits, lack of time, symptoms such as fatigue and poor physical fitness, and fear of sports injury are the primary barriers. Barriers to diet are mainly diet environment, mental stress, and food cravings. Key facilitators for adherence to lifestyle prescriptions include developing simple and specific action plans, coping strategies to flexibly deal with obstacles and difficulties, receiving regular feedback from doctors to improve self-efficacy, and using regular tests and behavior recording to enhance action control.

Conclusions

Future lifestyle intervention programs should pay particular attention to the planning, self-efficacy, and action control-related constructors of the HAPA model to promote the adherence of patients with NAFLD to lifestyle prescriptions.

Effect of intensive weight-loss intervention on metabolic, ultrasound and anthropometric parameters among patients with obesity and non-alcoholic fatty liver disease: an RCT

Background

Lifestyle intervention is the mainstay therapy for Non-Alcoholic Fatty Liver Disease (NAFLD). We aimed to assess the efficacy of an intensive (9 contact points in 6 months) weight-loss intervention among patients with obesity (BMI 25–39.9 kg/m²) and NAFLD in north India.

Methods

A total of 140 patients (18–60 years) with obesity and NAFLD were randomized into intervention (n = 70) and control (n = 70) groups, at a tertiary-care hospital. Weight, anthropometric parameters, Controlled Attenuation Parameter (CAP), Liver Stiffness Measurement (LSM), liver enzymes, grade of fatty liver and HOMA-IR were measured at baseline (T₀) and 6 months (T₆). There was a high drop-out, exacerbated by the Covid-19 pandemic. Completers comprised of 59 participants (n = 30 intervention, n = 29 control). Intention to treat analysis was done.

Results

At T₆, ALT normalized in significantly higher (p = 0.03) number of cases in the intervention arm (66.7%) versus control arm (18.2%). No significant improvement was seen in other metabolic, ultrasound or anthropometric outcomes. Weight (p < 0.001), AST (p = 0.01), ALT (p = 0.02), body fat% (p < 0.001), WC (p < 0.001) and CAP (p < 0.001) significantly improved within the intervention arm along with a trend of improvement in steatosis and HOMA-IR. Control group showed significant decrease in weight (p < 0.001), WC (p < 0.001) and CAP (p = 0.02). Twice the number of patients in intervention arm (46.7%) lost ≥5% weight, compared to control arm (24.1%) (p = 0.07).

Conclusion

The intensive weight-loss intervention was not effective in improving the treatment outcomes among patients with obesity and NAFLD. However, given the potential of our intervention, we recommend larger trials with more intensive weight-loss interventions.

Perceived risk factors for weight gain, barriers, and facilitators related to weight loss experienced by perimenopausal women: focus group discussion and thematic analysis

OBJECTIVE

This study aims to understand middle-aged perimenopausal women's perspectives and beliefs regarding their body weight status, and evaluate the barriers, and facilitators associated weight loss.

METHODS

Five focus group discussions were conducted with perimenopausal women (aged 40-55 y) who were recruited through convenience and snowball sampling. Discussions were conducted to understand their experiences related to weight management during the perimenopausal period. The discussions were audio-recorded and transcribed and data analysis was done using Atlas.ti software to generate codes, subthemes, and themes from the discussions.

RESULTS

A total of 23 women with a mean age of 46.6 ± 5.6 years were recruited. Several themes of risk factors of weight gain emerged like difficulty in physical activity, unhealthy eating, overeating, and religious and cultural practices. Appearance and prevention of health-related issues emerged as motivators of initiating weight loss. Barriers faced during weight loss included themes like difficulty in managing diet and activity, stress, socialization, and lack of time. Facilitators of weight loss included intrinsic motivation, experiencing early results and confidence in self-regulation.

CONCLUSION

Women during their perimenopausal phase of life encounter a range of barriers and challenges related to weight loss. An understanding of these barriers might be useful to consider while planning strategies to regulate their weight.