A randomised controlled trial on the effectiveness of a primary health care based counselling intervention on physical activity, diet and CHD risk factors

Recommendations on self-management interventions for adults living with obesity: COMPAR-EU project

Self-management interventions (SMIs) may improve disease management in adults living with obesity. We formulated evidence-based recommendations for SMIs within the context of the COMPAR-EU project. The multidisciplinary panel selected critical outcomes based on the COMPAR-EU core outcome set and established decision thresholds for each outcome. Recommendations were informed by systematic reviews of effects, cost-effectiveness, and a contextual assessment. To assess the certainty of the evidence and formulate the recommendations, we used the GRADE approach guidance. Overall, SMIs were deemed to have a small impact, but the absence of harmful effects and potential cumulative benefits indicated a favourable balance of effects, despite low certainty. SMIs showed variations in structure, intensity, and resource utilisation, but overall are likely to be cost-effective. Adapting SMIs to local contexts would enhance equity, acceptability, and feasibility, considering patients' values, and availability of resources and teamwork. Consequently, the panel made conditional recommendations favouring SMIs over usual care. The rigorous and explicit recommendations demonstrated the effectiveness of SMIs for adults living with obesity. However, the gaps in the literature influenced the panel to make only conditional recommendations in favour of SMIs. Further research is needed to strengthen the evidence base and improve recommendations' certainty and applicability.

The burden of Cardiovascular diseases in Jordan: a longitudinal analysis from the global burden of disease study, 1990-2019

BACKGROUND

Cardiovascular Disease (CVD) is the leading cause of mortality worldwide. While countries in the Arab world continue to lack public health data and be severely understudied in health research, previous research has shown that compared to 1990, CVDs had a higher burden of disease in the Arab World in 2010. Jordan, a middle-income Arab country, is profiled with unique attributes such as a dual-sector healthcare system, political stability, and its role as a haven for refugees and migrants. These distinctive factors emphasize Jordan's suitability as a case study. This investigation aims to quantify CVD burden in Jordan and identify risk factors, contributing to a broader understanding of health challenges in the Arab region and beyond.

METHODS

The Global Burden of Disease (GBD) dataset was used to estimate prevalence, death, and disability-adjusted life-years (DALYs) as age-standardized rates from 1990 to 2019. We calculated percentage change for nine specific CVDs and reported trends by gender and age groups. Additionally, data on twelve a priori selected behavioral, clinical, and environmental risk factors attributing to overall age-standardized CVDs DALY were reported per 100,00 population.

RESULTS

In 2019, the age-standardized CVD prevalence, death, and DALYs rates in Jordan were 7980 (95% uncertainty interval [UI] 7629, 8360), 248 (95% UI 211, 288), and 4647 (95% UI 4028, 5388), respectively. Despite an increase in the absolute number of mortality and prevalence, between 1990 and 2019, the age-standardized prevalence, death, and DALYs rates all decreased by 5.5%, 45.1%, and 46.7%, respectively. In 2019, the leading risk factors contributing to overall age-standardized CVDs DALY per 100,000 population were high systolic blood pressure, high BMI, dietary risks, and high LDL cholesterol.

CONCLUSION

Despite decreasing burden rate of CVDs in Jordan between 1990 and 2019, CVDs remain the leading cause of mortality in Jordan, with an increase in the total number of prevalence and mortality. Overall, this contributes to increased healthcare costs. Further research is required to quantify the burden of CVDs and understand it better. Intervention measures and policies tailored to specific CVDs should be designed to reduce the burden of CVDs in Jordan.

Reported barriers to physical activity and the role of built environment among overweight and obese youth attending a Canadian pediatric weight management clinic

Objective

To assess activity levels and role of the built environment among overweight and obese youth referred to a pediatric weight management clinic.

Design

A cross-sectional study using a caregiver-administered survey was completed from October 2017 to February 2018.

Results

The study analyzed 210 surveys. Participants were 52 % male and average age was 11.6 years (3-18 years). Of those surveyed, 73 % of respondents reported ≥ 2 h of average daily screen time in the past 3 months, and 74 % of children partook in < 60 min of daily physical activity of any intensity. The most common location for physical activity was a recreational facility. The least common was nearby green spaces. Moreover, 77 % of caregivers felt that their child did not engage in enough physical activity, and the most common cited barrier was motivation. The built environment, however, was not cited as a barrier to active living as 90 % of caregivers reported their community was safe, and greater than 80 % of caregivers agreed their community was aesthetically beautiful, well connected with good infrastructure. The majority of commonly used spaces were located within 2 km of their home, however, it was uncommon for children to walk or bike to them.

Conclusion

Overweight and obese children referred to our clinic are not meeting national recommendations for physical activity and screen time. The built environment does not appear to be a large contributing factor to decreased physical activity in this population and the most common reason cited for lack of physical activity was motivation.

Weight Management Interventions Provided by a Dietitian for Adults with Overweight or Obesity: An Evidence Analysis Center Systematic Review and Meta-Analysis

BACKGROUND

Obesity is associated with a multitude of comorbidities and considerable health care costs.

OBJECTIVE

The objective of this review was to examine the efficacy of weight management interventions provided by a registered dietitian or international equivalent (referred to as "dietitian").

METHODS

This systematic review and meta-analysis of randomized controlled trials (RCTs) examined the effect of weight management interventions provided by a dietitian, compared with usual care or no intervention, on several cardiometabolic outcomes and quality of life in adults with overweight or obesity. MEDLINE, Embase, PsycINFO, Cochrane CENTRAL, Cochrane Database of Systematic Reviews, and CINAHL databases were searched for eligible RCTs published between January 2008 and January 2021 in the English language. Meta-analyses were conducted using a random-effects model, publication bias was assessed using funnel plots and Egger's statistics, and heterogeneity was assessed by interpreting I2 values. Efficacy of intervention components, such as telehealth or group contacts, were explored in sub-group analyses. Version 2 of the risk-of-bias tool for RCTs was used to assess risk of bias. The Grading of Recommendations Assessment, Development and Evaluation method was used to determine certainty of evidence.

RESULTS

This systematic review included 62 RCTs. Compared with control conditions, weight management interventions provided by a dietitian resulted in improved body mass index (mean difference [MD] -1.5; 95% CI -1.74 to -1.26; moderate evidence certainty); percent weight loss (MD -4.01%; 95% CI -5.26% to -2.75%; high evidence certainty); waist circumference (MD -3.45 cm; 95% CI -4.39 to -2.51 cm; high evidence certainty); blood pressure (MD -3.04 mm Hg; 95% CI -5.10 to -0.98 mm Hg and MD -1.99 mm Hg; 95% CI -3.02 to -0.96 mm Hg for systolic blood pressure and diastolic blood pressure, respectively; moderate and low evidence certainty); and quality of life using the 36-Item Short Form Survey (MD 5.84; 95% CI 2.27 to 9.41 and 2.39; 95% CI 1.55 to 3.23 for physical and mental quality of life, respectively; low and moderate evidence certainty).

CONCLUSIONS

For adults with overweight or obesity, weight management interventions provided by a dietitian are efficacious for improving several examined cardiometabolic outcomes and quality of life.

Medical Nutrition Therapy Interventions Provided by Dietitians for Adult Overweight and Obesity Management: An Academy of Nutrition and Dietetics Evidence-Based Practice Guideline

Overweight and obesity affect most adults living in the United States and are causally linked to several adverse health outcomes. Registered dietitian nutritionists or international equivalents (dietitians) collaborate with each client and other health care professionals to meet client-centered goals, informed by the best available evidence, and translated through a lens of clinical expertise and client circumstances and preferences. Since the last iteration of the Academy of Nutrition and Dietetics guideline on adult weight management in 2014, considerable research has been conducted and circumstances confronting dietitians have evolved. Thus, updated guidance is needed. The objective of this evidence-based practice guideline is to provide recommendations for dietitians who deliver medical nutrition therapy behavioral interventions for adults (18 years and older) with overweight and obesity to improve cardiometabolic outcomes, quality of life, and weight outcomes, when appropriate for and desired by the client. Recommendations in this guideline highlight the importance of considering complex contributors to overweight and obesity and individualizing interventions to client-centered goals based on specific needs and preferences and shared decision making. The described recommendations have the potential to increase access to care and decrease costs through utilization of telehealth and group counseling as effective delivery methods, and to address other barriers to overweight and obesity management interventions. It is essential for dietitians to collaborate with clients and interprofessional health care teams to provide high-quality medical nutrition therapy interventions using the nutrition care process to promote attainment of client-centered outcomes for adults with overweight or obesity.

A Mediterranean Diet and Walking Intervention to Reduce Cognitive Decline and Dementia Risk in Independently Living Older Australians: The MedWalk Randomized Controlled Trial Experimental Protocol, Including COVID-19 Related Modifications and Baseline Characteristics

BACKGROUND

Several clinical trials have examined diet and physical activity lifestyle changes as mitigation strategies for risk factors linked to cognitive decline and dementias such as Alzheimer's disease. However, the ability to modify these behaviors longer term, to impact cognitive health has remained elusive.

OBJECTIVE

The MedWalk trial's primary aim is to investigate whether longer-term adherence to a Mediterranean-style diet and regular walking, delivered through motivational interviewing and cognitive-behavioral therapy (MI-CBT), can reduce age-associated cognitive decline and other dementia risk factors in older, independently living individuals without cognitive impairment.

METHODS

MedWalk, a one-year cluster-randomized controlled trial across two Australian states, recruited 60-90-year-old people from independent living retirement villages and the wider community. Participants were assigned to either the MedWalk intervention or a control group (maintaining their usual diet and physical activity). The primary outcome is 12-month change in visual memory and learning assessed from errors on the Paired Associates Learning Task of the Cambridge Neuropsychological Test Automated Battery. Secondary outcomes include cognition, mood, cardiovascular function, biomarkers related to nutrient status and cognitive decline, MI-CBT effectiveness, Mediterranean diet adherence, physical activity, quality of life, cost-effectiveness, and health economic evaluation.Progress and Discussion:Although COVID-19 impacts over two years necessitated a reduced timeline and sample size, MedWalk retains sufficient power to address its aims and hypotheses. Baseline testing has been completed with 157 participants, who will be followed over 12 months. If successful, MedWalk will inform interventions that could substantially reduce dementia incidence and ameliorate cognitive decline in the community.

TRIAL REGISTRATION

Registered on the Australia New Zealand Clinical Trials Registry ANZCTR 12620000978965 (https://www.anzctr.org.au).

Offering a lifestyle intervention to women of premenopausal age as primary prevention for cardiovascular disease? - assessing its cost-effectiveness

BACKGROUND

There is limited evidence of cost-effective primary prevention interventions for cardiovascular disease (CVD) in young women. This study aimed to assess the value for money of primary prevention of CVD in this population.

METHODS

A Markov microsimulation model consisting of both first-ever and recurrent CVD events was developed to simulate the lifetime intervention impact on cost and health outcomes in women of premenopausal age (30 to 54 years) from the Australian healthcare system perspective. The latest wave of the Australian National Health Survey defined the modelled population's characteristics. The intervention effectiveness of a lifestyle modification program involving changes in diet and physical activity demonstrated to be effective in this population was sourced from a systematic review and meta-analysis. The first-ever and recurrent CVD probabilities were derived from the CVD risk calculators accounting for socio-demographic and clinical characteristics. Costs and utility weights associated with CVD events and long-term management post-CVD were informed by national statistics/published literature. Sensitivity analyses were undertaken to examine the robustness of base case results.

RESULTS

The lifestyle modification program was associated with both higher costs and benefits (in terms of quality-adjusted life years, QALYs) as a primary prevention measure of CVD in premenopausal women, with an ICER of $96,377/QALY or $130,469/LY. The intervention led to fewer first-ever (N = -19) and recurrent CVD events (N = -23) per 10,000 women over the modelled life horizon. The avoided cost due to reduced hospitalisations (-$24) and management (-$164) of CVD could partially offset the cost associated with the intervention ($1560). Sensitivity analysis indicated that time horizon, starting age of the intervention, discount rate, and intervention effectiveness were the key drivers of the results. If the intervention was scaled up to the national level (N = 502,095 at-risk premenopausal women), the total intervention cost would be $794 million with $95 million in healthcare cost-savings.

CONCLUSION

Offering a lifestyle modification program to premenopausal women in Australia as primary prevention of CVD is not cost-effective from a healthcare system perspective. We should continue to search for new or adapt/optimise existing effective and cost-effective primary prevention measures of CVD for women.

Systematic realist synthesis of health-related and lifestyle interventions designed to decrease overweight, obesity and unemployment in adults

Background

Obesity and unemployment are complex social and health issues with underlying causes that are interconnected. While a clear link has been established, there is lack of evidence on the underlying causal pathways and how health-related interventions could reduce obesity and unemployment using a holistic approach.

Objectives

The aim of this realist synthesis was to identify the common strategies used by health-related interventions to reduce obesity, overweight and unemployment and to determine for whom and under what circumstances these interventions were successful or unsuccessful and why.

Methods

A realist synthesis approach was used. Systematic literature searches were conducted in Cochrane library, Medline, SocIndex, Cumulative Index to Nursing and Allied Health Literature (CINAHL), Scopus, and PsychInfo. The evidence from included studies were synthesised into Context-Mechanism-Outcome configurations (CMOcs) to better understand when and how programmes work, for which participants and to refine the final programme theory.

Results

A total of 83 articles met the inclusion criteria. 8 CMOcs elucidating the contexts of the health-related interventions, underlying mechanisms and outcomes were identified. Interventions that were tailored to the target population using multiple strategies, addressing different aspects of individual and external environments led to positive outcomes for reemployment and reduction of obesity.

Conclusion

This realist synthesis presents a broad array of contexts, mechanisms underlying the success of health-related interventions to reduce obesity and unemployment. It provides novel insights and key factors that influence the success of such interventions and highlights a need for participatory and holistic approaches to maximise the effectiveness of programmes designed to reduce obesity and unemployment.

Trial registration

PROSPERO 2020 CRD42020219897.

Short-Term Pilot Study to Evaluate the Impact of Salbi Educa Nutrition App in Macronutrients Intake and Adherence to the Mediterranean Diet: Randomized Controlled Trial

Promoting a healthy diet is a relevant strategy for preventing non-communicable diseases. This study aims to evaluate the impact of an innovative tool, the SAlBi educa nutrition app, in primary healthcare dietary counseling to improve dietary profiles as well as adherence to the Mediterranean diet. A multi-center randomized control trial comprising 104 participants was performed. Both control (n = 49) and intervention (n = 55) groups attended four once-weekly sessions focusing on healthy eating habits and physical activity, over one month. As well as attending the meetings, the intervention group used the app, which provides self-monitoring and tailored dietary advice based on the Mediterranean diet model. In a second intervention (one arm trial), the potential of SAlBi educa was evaluated for three months during the COVID-19 pandemic. At 4 weeks, the intervention group had significantly increased their carbohydrate intake (7.7% (95% CI: 0.16 to 15.2)) and decreased their total fat intake (−5.7% (95% CI: −10.4 to −1.15)) compared to the control group. Significant differences were also found for carbohydrates (3.5% (95% CI: −1.0 to 5.8)), total fats (−5.9% (95% CI: −8.9 to −3.0)), fruits and vegetables (266.3 g/day (95% CI: 130.0 to 402.6)), legumes (7.7g/day (95% CI: 0.2 to 15.1)), starchy foods (36.4 g/day (95% CI: 1.1 to 71.7)), red meat (−17.5 g/day (95% CI: −34.0 to −1.1)), and processed meat (−6.6 g/day (95% CI: −13.1 to −0.1)) intakes during the COVID-19 pandemic. SAlBi educa is a useful tool to support nutrition counseling in primary healthcare, including in special situations such as the COVID-19 pandemic. Trial registration: ISRCTN57186362.

Healthy and unhealthy eating after a behaviour change intervention in primary care

BACKGROUND

To prevent and reduce non-communicable diseases, the Norwegian Directorate of Health encourages Healthy Life Centres (HLCs) in all municipalities.

AIMS

This study investigates whether the behaviour change interventions at HLCs positively affected participants' diet and to evaluate predictors for healthy and unhealthy eating. Our data are part of the Norwegian Healthy Life Centre Study, a 6-month, pragmatic randomised controlled trial (RCT).

METHODS

Totally, 118 participants ≥18 years old were randomised to an intervention group (n 57), or a waiting list (control group) (n 61). Eighty-six participants met at the 6 months follow-up visit. We merged the participants to one cohort for predictor analyses, using linear regressions.

FINDINGS

The RCT of the HLCs' interventions had no effect on healthy and unhealthy eating 6 months after baseline compared with controls. A short, additional healthy eating education programme produced a modest, statistically significant improvement in healthy eating compared with controls. This did not, however, reduce unhealthy eating. Higher income predicted unhealthier eating over time. Increasing body mass index and impaired physical functioning also led to an increase in unhealthy eating. Healthy eating at 6 months was predicted by self-rated health (SRH), vitality and life satisfaction, and hampered by musculo-skeletal challenges and impaired self-esteem (SE). SRH impacted improvement in healthy eating during the 6 months. The effect of interventions on healthier eating may be improved by an emphasis on developing positive self-concepts like better SRH, vitality, life satisfaction, and SE.

GPs' views on the implementation of combined lifestyle interventions in primary care in the Netherlands: a qualitative study

OBJECTIVES

Prevention and lifestyle support are emerging topics in general practice. Healthcare insurance companies reimburse combined lifestyle interventions (CLIs) in the Netherlands since January 2019. CLIs support people with overweight (body mass index, BMI 25-30) or obesity (BMI >30) to reduce weight in peer groups. General practitioners (GPs) are key in the successful implementation of lifestyle interventions in primary care. This study explored GPs' experiences and views on the implementation of CLIs to identify barriers and facilitators to the successful implementation in primary care.

DESIGN

Qualitative study using semistructured interviews. Content analysis consisted of thematic coding and mapping a first stage of predefined and second stage of iterative evolving set of themes.

SETTING

GPs were interviewed in a variety of primary care practices between February and April 2019.

PARTICIPANTS

Fifteen GPs were purposively recruited for semi-structured interviews through snowballing.

RESULTS

Experiences with lifestyle support among GPs ranged from referring patients to other healthcare professionals to taking a proactive role in lifestyle support themselves. Whether or not GPs took an active role in lifestyle support was related to their belief in the effect of lifestyle interventions. Overall, GPs had little experience with CLI in every day practice. Perceived barriers were a lack of availability of CLIs in the region and the potential lack of added value of CLIs on top of existing lifestyle support. Perceived facilitators were coordination of care provision by GP cooperatives and monitoring of the CLI implementation and their results. Reimbursement of CLIs without any costs for participants enabled application.

CONCLUSION

The importance of lifestyle interventions in primary care was acknowledged by all GPs, but they differed in their level of experience with providing lifestyle support and awareness of CLIs. Successful integration of CLIs with primary care requires a solid promotion, a well-coordinated implementation strategy and structural evaluation of long-term effectiveness.

Use of motivational interviewing in behavioural interventions among adults with obesity: A systematic review and meta-analysis

This review aimed to identify whether motivational interviewing (MI) (a counselling approach for supporting behaviour change [BC]) helps to reduce bodyweight and BMI in an adult obesity context. This included evaluating effectiveness of MI interventions within this population and reporting the methodology used, including theoretical underpinnings and identification of BC and MI techniques. Eight databases were searched using controlled vocabulary. Eligible studies included adults with obesity (BMI ≥30 kg/m² ), author-reported interventions using MI aiming to reduce body weight or BMI, and comparator groups not receiving an MI intervention. Data extraction and quality appraisal tools were used to identify study characteristics, intervention content was coded for techniques, and random-effects meta-analysis were conducted to investigate effects. Meta-analysis of 12 studies indicated no overall pooled effect on bodyweight and BMI outcomes between intervention and control groups (SMD = -0.01 [95%CI -0.13 to 0.12, P = .93]). Findings were limited by multiple sources accounting for risk of bias, and poor reporting of intervention fidelity and content. Intervention and control content descriptions indicated similar techniques, with social support, goal setting (behaviour) and self-monitoring of behaviour occurring most frequently across both. Findings do not contribute additional evidence for MI use in this context, however methodological limitations were identified which must be resolved to better identify the intervention effects on obesity-related outcomes.

Are interventions to improve cardiovascular disease risk factors in premenopausal women effective? A systematic review and meta-analysis

OBJECTIVES

Non-traditional risk factors place young women at increased risk of cardiovascular disease (CVD) over their lifetime. The current study undertakes a systematic review and meta-analysis of randomised controlled trials (RCTs) that examined the effectiveness of primary prevention interventions for CVD in premenopausal women.

METHODS

An electronic literature search was performed in key databases in July 2018 and updated in May 2020. RCTs that recruited predominately female participants with a proportion aged under 55 years and that compared primary prevention interventions of CVD with usual practice were included. Two reviewers undertook the selection process for study inclusion. Meta-analysis was conducted for studies based on the same intervention in order to synthesise the results.

RESULTS

14 RCTs with sample size ranging from 49 to 39 876 were included. Interventions included diet (2), vitamin E/antioxidants (3), lifestyle modification programme (7) and aspirin (2). The meta-analysis results indicated that diet nor vitamin E/antioxidant did not significantly lower the CVD risk profiles, while lifestyle modification programme involving components of lifestyle education, counselling and multiple follow-ups showed great potential to improve risk profiles. The lifestyle modification intervention improved blood pressure (-2.11 mm Hg, 95% CI -4.32 to 0.11, for systolic and -3.31 mm Hg (95% CI -4.72 to -1.91, for diastolic), physical activity (30.72 MET-min/week, 95% CI 23.57 to 37.87, for moderate physical activity 12.70 MET-min/week, 95% CI 8.27 to 17.14, for vigorous physical activity) and fasting blood glucose (-0.37 mmol/L, 95% CI -0.58 to -0.15). Subgroup meta-analysis in studies with a mean age under 51 years old suggested that lifestyle modification intervention remained to be effective in improving physical activity and fasting blood glucose.

CONCLUSION

The effective interventions identified in this review although with a small sample size and short duration could potentially inform future design of primary prevention of CVD in premenopausal women.

Effects of a lifestyle-related risk factor modification intervention on lifestyle changes among patients with coronary artery disease in Nepal

OBJECTIVE

To investigate the effect of a lifestyle-related risk factor modification intervention on coronary artery disease (CAD) patients' lifestyle changes.

METHOD

A randomized controlled study was conducted in Nepal. A total of 224 CAD patients (112 in each study group) were included at baseline, and 196 patients (98 in each group) completed the one-month follow-up. Patients in the intervention group (IG) received nurse-led intervention in addition to the usual care. Face-to face and telephone interview was conducted using standard questionnaires to collect data on lifestyle-related risk factors; smoking, alcohol consumption, diet, body mass index, stress, adherence to medical therapy, and physical activity. General linear model repeated measure analysis was used to analyse the effects of the intervention.

RESULTS

Based on self-reported data we found significant improvement in lifestyle-related risk factor habits in the IG compared with the usual care group with respect to diet (p < 0.001), physical activity (p < 0.001), medication adherence (p < 0.001) and stress (p < 0.001) at one-month follow-up.

CONCLUSION

Lifestyle-related risk factor modification intervention can positively influence health risk habits, even when it is less intensive but supplemented with information leaflets.

PRACTICAL IMPLICATIONS

Nurse-led one-time intervention may successfully deliver counselling to improve healthy lifestyle among underserved CAD patients.

Primary care-based interventions for treatment of obesity: a systematic review

OBJECTIVE

The objective of this study was to synthesise evidence from primary care-based interventions for the treatment of obesity in adults and the elderly.

STUDY DESIGN

Systematic review.

METHODS

Eight electronic databases (MEDLINE, Lilacs, Embase, Psycinfo, Cochrane, WHOLIS, Open Gray and Scholar Google) were searched. There was no limitation on publication period; articles published in English, Portuguese or Spanish were included. The selection, data extraction and quality analyses were performed by three reviewers.

RESULTS

A literature search retrieved 6464 publications, of which 5120 publications were excluded after reading the title/abstract and 293 after reading the full text. In total, 56 publications, representing 72 interventions were included. All studies were published between 2000 and 2020. Most studies were conducted in high-income countries. The mean duration of interventions was 11.5 months (SD: 7.5), ranging from 3 to 44 months. Most interventions were effective for body mass index reduction, weight loss and waist circumference change.

CONCLUSION

Our study showed that most interventions were effective for outcomes analysed in adults and the elderly. We also found some literature gaps, such as the need to implement and evaluate obesity after intervention and the requirement to carry out more studies in low- and middle-income countries.

Nutrition and physical activity interventions for the general population with and without cardiometabolic risk: a scoping review

OBJECTIVE

The objective of this scoping review was to examine the research question: In the adults with or without cardiometabolic risk, what is the availability of literature examining interventions to improve or maintain nutrition and physical activity-related outcomes? Sub-topics included: (1) behaviour counseling or coaching from a dietitian/nutritionist or exercise practitioner, (2) mobile applications to improve nutrition and physical activity and (3) nutritional ergogenic aids.

DESIGN

The current study is a scoping review. A literature search of the Medline Complete, CINAHL Complete, Cochrane Database of Systematic Reviews and other databases was conducted to identify articles published in the English language from January 2005 until May 2020. Data were synthesised using bubble charts and heat maps.

SETTING

Out-patient, community and workplace.

PARTICIPANTS

Adults with or without cardiometabolic risk factors living in economically developed countries.

RESULTS

Searches resulted in 19 474 unique articles and 170 articles were included in this scoping review, including one guideline, thirty systematic reviews (SR), 134 randomised controlled trials and five non-randomised trials. Mobile applications (n 37) as well as ergogenic aids (n 87) have been addressed in several recent studies, including SR. While primary research has examined the effect of individual-level nutrition and physical activity counseling or coaching from a dietitian/nutritionist and/or exercise practitioner (n 48), interventions provided by these practitioners have not been recently synthesised in SR.

CONCLUSION

SR of behaviour counseling or coaching provided by a dietitian/nutritionist and/or exercise practitioner are needed and can inform practice for practitioners working with individuals who are healthy or have cardiometabolic risk.

A scoping review of exercise referral schemes involving qualified exercise professionals in primary health care

Qualified exercise professionals (QEPs) have the training, knowledge, and scope of practice to effectively provide physical activity counselling, prescribe exercise, and deliver exercise programming to patients with or without chronic diseases. Healthcare providers identify an interest in referring patients to QEPs; however, the impact of exercise referral schemes (ERS) involving QEPs on patients' physical health is unclear. A scoping review regarding the available evidence of ERS involving healthcare provider referrals to QEPs was performed. A literature search was conducted in 6 databases (initially: n = 6011 articles), yielding n = 23 articles examining QEP delivered physical activity counselling (n = 7), QEP supervised exercise training (n = 4), or some combination (n = 12). Although studies were heterogeneous in methods, procedures, and populations, ERSs increased patients' subjective physical activity levels. Few studies incorporated objective physical activity measures (n = 5/23), and almost half measured aerobic fitness (n = 11/23). ERS involving a QEP that includes activity counselling and/or exercise programming/training report favourable impacts on patients' subjectively measured physical activity and objectively measured aerobic fitness. Based on the existing literature on the topic, this scoping review provides recommendations for designing and evaluating ERS with QEPs that include: objective measures, long-term follow-up, QEP qualifications, and the cost-effectiveness of ERS. Novelty: ERS involving QEPs report increased patients' perceived physical activity level and may improve patients' cardiorespiratory fitness. Promoting the collaboration of QEPs with other healthcare providers can enhance patients' physical fitness and health. This scoping review provides recommendations for the design and evaluation of ERS involving QEPs.

Behavioral Counseling to Promote a Healthy Diet and Physical Activity for Cardiovascular Disease Prevention in Adults With Cardiovascular Risk Factors: Updated Evidence Report and Systematic Review for the US Preventive Services Task Force

IMPORTANCE

Cardiovascular disease is the leading cause of death in the US, and poor diet and lack of physical activity are major factors contributing to cardiovascular morbidity and mortality.

OBJECTIVE

To review the benefits and harms of behavioral counseling interventions to improve diet and physical activity in adults with cardiovascular risk factors.

DATA SOURCES

MEDLINE, PubMed, PsycINFO, and the Cochrane Central Register of Controlled Trials through September 2019; literature surveillance through July 24, 2020.

STUDY SELECTION

English-language randomized clinical trials (RCTs) of behavioral counseling interventions to help people with elevated blood pressure or lipid levels improve their diet and increase physical activity.

DATA EXTRACTION AND SYNTHESIS

Data were extracted from studies by one reviewer and checked by a second. Random-effects meta-analysis and qualitative synthesis were used.

MAIN OUTCOMES AND MEASURES

Cardiovascular events, mortality, subjective well-being, cardiovascular risk factors, diet and physical activity measures (eg, minutes of physical activity, meeting physical activity recommendations), and harms. Interventions were categorized according to estimated contact time as low (≤30 minutes), medium (31-360 minutes), and high (>360 minutes).

RESULTS

Ninety-four RCTs were included (N = 52 174). Behavioral counseling interventions involved a median of 6 contact hours and 12 sessions over the course of 12 months and varied in format and dietary recommendations; only 5% addressed physical activity alone. Interventions were associated with a lower risk of cardiovascular events (pooled relative risk, 0.80 [95% CI, 0.73-0.87]; 9 RCTs [n = 12 551]; I2 = 0%). Event rates were variable; in the largest trial (Prevención con Dieta Mediterránea [PREDIMED]), 3.6% in the intervention groups experienced a cardiovascular event, compared with 4.4% in the control group. Behavioral counseling interventions were associated with small, statistically significant reductions in continuous measures of blood pressure, low-density lipoprotein cholesterol levels, fasting glucose levels, and adiposity at 12 to 24 months' follow-up. Measurement of diet and physical activity was heterogeneous, and evidence suggested small improvements in diet consistent with the intervention recommendation targets but mixed findings and a more limited evidence base for physical activity. Adverse events were rare, with generally no group differences in serious adverse events, any adverse events, hospitalizations, musculoskeletal injuries, or withdrawals due to adverse events.

CONCLUSIONS AND RELEVANCE

Medium- and high-contact multisession behavioral counseling interventions to improve diet and increase physical activity for people with elevated blood pressure and lipid levels were effective in reducing cardiovascular events, blood pressure, low-density lipoproteins, and adiposity-related outcomes, with little to no risk of serious harm.

Recruitment of Men Into a Pragmatic Rural Primary Care Weight Loss Trial

Men remain underrepresented in behavioral weight loss trials and are more difficult to recruit compared to women. We describe recruitment response of men and women into a mixed-gender behavioral weight loss trial conducted within 36 rural primary care clinics. Participants were recruited through primary care clinics via direct mailings (n = 15,076) and in-clinic referrals by their primary care provider (PCP). Gender differences were examined in response rate to direct mailings, study referral source, and rates of proceeding to study screening, being eligible, and enrolling. Men had a lower response rate to direct mailings than women (7.8% vs. 17.7%, p < .001). Men (vs. women) responding to the mailing were more likely to respond by opt-in postcard (64.6% vs. 56.8%) and less likely to respond by phone (33.9% vs. 39.6%), p = .002. Among potential participants contacting the study (n = 2413), men were less likely to report being referred by PCPs (15.2% vs. 21.6%; p < .001), but were just as likely to proceed to screening, be eligible, and enroll. Men and women were more likely to proceed to screening when referred by PCPs (93.3% vs. 95.4%) compared to direct mailings (74.2% vs. 73.9%). Enrolled men were older (p < .001), more likely to be married (p = .04), and had higher levels of education (p = .01). Men were less likely than women to respond to direct mailings and to be referred by their PCP, but after contacting the study, had similar screening, eligibility, and enrollment rates. Encouraging and training providers to refer men during clinic visits may help recruit more men into primary care-based weight loss trials.

Motivational interviewing to support modifiable risk factor change in individuals at increased risk of cardiovascular disease: A systematic review and meta-analysis

BACKGROUND

Programmes using motivational interviewing show potential in facilitating lifestyle change, however this has not been well established and explored in individuals at risk of, yet without symptomatic pre-existent cardiovascular disease. The objective of this systematic review and meta-analysis was to determine the effectiveness of motivational interviewing in supporting modifiable risk factor change in individuals at an increased risk of cardiovascular disease.

METHODS

Systematic review and meta-analysis with results were reported using the Preferred Reporting Items for Systematic Reviews and Meta-Analyses statement. Health-related databases were searched for randomised controlled trials from 1980 to March 2020. Criteria for inclusion included; preventive programmes, motivational interviewing principles, modification of cardiovascular risk factors in adults of both genders, different ethnicities and employment status, and having at least 1 or more modifiable cardiovascular risk factor/s. Two reviewers independently extracted data and conducted a quality appraisal of eligible studies using an adapted Cochrane framework. The Cochrane framework supports to systematically identify, appraise and synthesize all the empirical evidence that meets the pre-specified eligibility criteria to answer a specific question.

FINDINGS

A total of 12 studies met the inclusion criteria. While completeness of intervention reporting was found to be adequate, the application of motivational interviewing was found to be insufficiently reported across all studies (mean overall reporting rate; 68%, 26% respectively). No statistical difference between groups in smoking status and physical activity was reported. A random effects analysis from 4 studies was conducted, this determined a synthesized estimate for standardised mean difference in weight of -2.00kg (95% CI -3.31 to -0.69 kg; p = 0.003), with high statistical heterogeneity. Pooled results from 4 studies determined a mean difference in LDL-c of -0.14mmol/l (5.414mg/dl), which was non-significant. The characteristics of interventions more likely to be effective were identified as: use of a blended approach delivered by a nurse expert in motivational interviewing from an outpatient-clinic. The application of affirmation, compassion and evocation, use of open questions, summarising, listening, supporting and raising ambivalence, combining education and barrier change identification with goal setting are also important intervention characteristics.

CONCLUSIONS

While motivational interviewing may support individuals to modify their cardiovascular risk through lifestyle change, the effectiveness of this approach remains uncertain. The strengths and limitations of motivational interviewing need to be further explored through robust studies.

Weight Management Interventions for Adults With Overweight or Obesity: An Evidence Analysis Center Scoping Review

The objectives of this evidence scoping review were to identify and characterize studies investigating weight management interventions provided by a registered dietitian nutritionist or international equivalent (RDN) among adults with overweight or obesity. A medical librarian conducted an electronic literature search in 6 databases-MEDLINE (Ovid), Embase (Ovid), PyscINFO (Ovid), Cochrane CENTRAL (Ovid), Cochrane Database of Systematic Reviews (Ovid), and CINAHL (Ebsco). Except for narrative review, gray literature, and case study or report, all types of peer-reviewed articles published between January 2008 and April 26, 2019 were eligible. Two content advisors, who are experts in adult weight management, guided the process and reviewed the search plan and findings. The literature search resulted in 30,551 records with 16 additional records identified through other sources. A total of 29,756 records were excluded during the first round of screening due to duplication or irrelevancy. Of the 811 full-text articles that were screened, 139 met the criteria and were included. Approximately 51% and 43% of the studies were conducted in the community setting and in the United States or Canada, respectively. Over 97% of the studies were clinical or quasi-experimental trials. A total of 6 different intervention delivery modes were reported, which resulted in 22 combinations of the modes of delivery. RDNs delivered the weight management intervention (especially the nutrition component) in all studies, but some (61%) also involved an interdisciplinary team to deliver other components of the intervention. The average length of the intervention was about 10 months with a follow-up that ranged from 0 to 9 years. The commonly reported outcomes were anthropometrics, endocrine, and cardiovascular measures; dietary intake; and physical activity. Based on the scoping review, there were systematic reviews and evidence-based practice guidelines on weight management interventions but none of them met the a priori inclusion or exclusion criteria. Therefore, it would be beneficial to conduct a systematic review and develop an evidence-based practice guideline on adult weight management interventions provided by an RDN to guide practitioners and to evaluate their effects on health and nutrition-related outcomes.

The added value of frequent physical activity group sessions in a combined lifestyle intervention: A cluster randomised trial in primary care

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A combined lifestyle intervention improves lifestyle in overweight and obese subjects.

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Real-world setting study shows that changed lifestyle after a combined lifestyle intervention can be sustained.

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Adding group sessions with a physiotherapist had no added value.

Combined lifestyle interventions (CLIs) that target both physical activity (PA) and diet have been shown to improve PA and health of adults who are overweight; however, optimal amount of guidance remains unclear. This study evaluated the effects of adding PA group sessions to a standard CLI in primary care in the Netherlands. 411 participants (BMI 34.5 ± 4.4 kg/m²) in thirty locations were randomised into a one year CLI or CLI+. CLI comprised individual meetings with lifestyle coach (LSC) and physiotherapist, and group meetings with dietician. PA group sessions were added in CLI+. Primary outcome was minutes of moderate to vigorous PA per week. Secondary outcomes of PA, diet and cardiovascular risk factors (i.e. waist circumference, HbA1c and blood pressure) were evaluated after 12 and 24 months with multilevel analyses. Data were collected from 2010 to 2015. Significant between-group effects were only found for waist circumference, which was significantly lower at twelve months in the CLI+ group (p = 0.011), no other between-group differences were found. Several within-group changes were significant. After participating in the intervention, walking time increased with 83 ± 35 min/week and 100 ± 38 min/week, and BMI decreased with 0.7 ± 0.3 kg/m² and 1.5 ± 0.3 kg/m² in CLI and CLI+ respectively (p < 0.001). Diet, HbA1c and systolic blood pressure changed favourably in both groups. Adding PA group sessions did not elicit added, sustained benefits. A programme with individual meetings with LSC and physiotherapist, and group meetings with dietician can be sufficient to facilitate a healthy lifestyle and reduce cardiovascular risk factors in a population with overweight.

Effects of a short health education intervention on physical activity, arterial stiffness and cardiac autonomic function in individuals with moderate-to-high cardiovascular risk

OBJECTIVE

This study evaluated the effects of a short health education and counseling intervention program, in a primary healthcare setting, on daily physical activity (PA), arterial stiffness, and cardiac autonomic function in individuals with moderate-to-high risk of cardiovascular disease.

METHODS

This was a parallel-group study with a 4-month-long intervention, plus 8 months of follow-up. 164 individuals with moderate-to-high cardiovascular risk were allocated to either an intervention (n = 87) or a control group (n = 77). The intervention consisted of 3 walking and face-to-face group sessions plus text messages. Primary outcome was daily PA (sedentary time, light and moderate-to-vigorous PA, all in min/day); secondary outcomes were arterial stiffness i.e., carotid-femoral pulse wave velocity (cfPWV, m/s)] and cardiac autonomic function [(i.e., standard deviation of all N-N intervals (SDNN, ms) and absolute high frequency (HF, ms²)].

RESULTS

There were not significant group*time interactions for sedentary time [-7.4 (7.6); p = 0.331)], light PA [4.4 (6.4); p = 0.491] or moderate-to-vigorous PA [0.1 (2.6); p = 0.938]. Considering secondary outcomes, there were not significant group*time interactions for cfPWV [0.09 (0.18); p = 0.592], Ln_SDNN [0.09 (0.06); p = 0.148], or Ln_HF [0.16 (0.14); p = 0.263].

CONCLUSION

The program did not improve daily PA, arterial stiffness, or the autonomic cardiac function.

PRACTICE IMPLICATIONS

Primary care staff should consider longer or other types of intervention to improve daily PA.

Reduction in saturated fat intake for cardiovascular disease

BACKGROUND

Reducing saturated fat reduces serum cholesterol, but effects on other intermediate outcomes may be less clear. Additionally, it is unclear whether the energy from saturated fats eliminated from the diet are more helpfully replaced by polyunsaturated fats, monounsaturated fats, carbohydrate or protein.

OBJECTIVES

To assess the effect of reducing saturated fat intake and replacing it with carbohydrate (CHO), polyunsaturated (PUFA), monounsaturated fat (MUFA) and/or protein on mortality and cardiovascular morbidity, using all available randomised clinical trials.

SEARCH METHODS

We updated our searches of the Cochrane Central Register of Controlled Trials (CENTRAL), MEDLINE (Ovid) and Embase (Ovid) on 15 October 2019, and searched Clinicaltrials.gov and WHO International Clinical Trials Registry Platform (ICTRP) on 17 October 2019.

SELECTION CRITERIA

Included trials fulfilled the following criteria: 1) randomised; 2) intention to reduce saturated fat intake OR intention to alter dietary fats and achieving a reduction in saturated fat; 3) compared with higher saturated fat intake or usual diet; 4) not multifactorial; 5) in adult humans with or without cardiovascular disease (but not acutely ill, pregnant or breastfeeding); 6) intervention duration at least 24 months; 7) mortality or cardiovascular morbidity data available.

DATA COLLECTION AND ANALYSIS

Two review authors independently assessed inclusion, extracted study data and assessed risk of bias. We performed random-effects meta-analyses, meta-regression, subgrouping, sensitivity analyses, funnel plots and GRADE assessment.

MAIN RESULTS

We included 15 randomised controlled trials (RCTs) (16 comparisons, 56,675 participants), that used a variety of interventions from providing all food to advice on reducing saturated fat. The included long-term trials suggested that reducing dietary saturated fat reduced the risk of combined cardiovascular events by 17% (risk ratio (RR) 0.83; 95% confidence interval (CI) 0.70 to 0.98, 12 trials, 53,758 participants of whom 8% had a cardiovascular event, I² = 67%, GRADE moderate-quality evidence). Meta-regression suggested that greater reductions in saturated fat (reflected in greater reductions in serum cholesterol) resulted in greater reductions in risk of CVD events, explaining most heterogeneity between trials. The number needed to treat for an additional beneficial outcome (NNTB) was 56 in primary prevention trials, so 56 people need to reduce their saturated fat intake for ~four years for one person to avoid experiencing a CVD event. In secondary prevention trials, the NNTB was 53. Subgrouping did not suggest significant differences between replacement of saturated fat calories with polyunsaturated fat or carbohydrate, and data on replacement with monounsaturated fat and protein was very limited. We found little or no effect of reducing saturated fat on all-cause mortality (RR 0.96; 95% CI 0.90 to 1.03; 11 trials, 55,858 participants) or cardiovascular mortality (RR 0.95; 95% CI 0.80 to 1.12, 10 trials, 53,421 participants), both with GRADE moderate-quality evidence. There was little or no effect of reducing saturated fats on non-fatal myocardial infarction (RR 0.97, 95% CI 0.87 to 1.07) or CHD mortality (RR 0.97, 95% CI 0.82 to 1.16, both low-quality evidence), but effects on total (fatal or non-fatal) myocardial infarction, stroke and CHD events (fatal or non-fatal) were all unclear as the evidence was of very low quality. There was little or no effect on cancer mortality, cancer diagnoses, diabetes diagnosis, HDL cholesterol, serum triglycerides or blood pressure, and small reductions in weight, serum total cholesterol, LDL cholesterol and BMI. There was no evidence of harmful effects of reducing saturated fat intakes.

AUTHORS' CONCLUSIONS

The findings of this updated review suggest that reducing saturated fat intake for at least two years causes a potentially important reduction in combined cardiovascular events. Replacing the energy from saturated fat with polyunsaturated fat or carbohydrate appear to be useful strategies, while effects of replacement with monounsaturated fat are unclear. The reduction in combined cardiovascular events resulting from reducing saturated fat did not alter by study duration, sex or baseline level of cardiovascular risk, but greater reduction in saturated fat caused greater reductions in cardiovascular events.

Physical Activity Component Should be Included when Designing National Child-Obesity Program: The Rapid Review of Multi-Component Child Obesity Intervention Programs

OBJECTIVES The prevalence of child obesity is steadily increasing in Korea, thus government needs to seek for effective intervention programs to counteract current epidemics. This study sought to find proven effective child obesity programs implemented in other countries in order to provide policy recommendation. We report the results of rapid review of child obesity programs which were implemented outside of Korea.METHODS A search of multiple databases (NICE Evidence Search, Open Grey, Grey Literature Report, National Cancer institute: research-tested intervention programs) was conducted to identify relevant research articles published after January 2010.RESULTS 11 studies met the inclusion criteria after systematic screening. Most of the included studies used physical activity & diet/nutrition at the same time, while school was the most common location for the intervention. 5 studies showed improvement in obesity related outcomes. Interventions contained physical activity & diet/nutrition or physical activity & psychological coaching, and intervention implemented in school, healthcare facility, summer camp, and after-school class were shown effective.CONCLUSIONS Considering the results of current review, multi-component intervention which includes physical activity is recommended when designing child obesity program. The location of the intervention should be school to maximize its effectiveness.

Effects of total fat intake on body fatness in adults

BACKGROUND

The ideal proportion of energy from fat in our food and its relation to body weight is not clear. In order to prevent overweight and obesity in the general population, we need to understand the relationship between the proportion of energy from fat and resulting weight and body fatness in the general population.

OBJECTIVES

To assess the effects of proportion of energy intake from fat on measures of body fatness (including body weight, waist circumference, percentage body fat and body mass index) in people not aiming to lose weight, using all appropriate randomised controlled trials (RCTs) of at least six months duration.

SEARCH METHODS

We searched CENTRAL, MEDLINE, Embase, Clinicaltrials.gov and the WHO International Clinical Trials Registry Platform (ICTRP) to October 2019. We did not limit the search by language.

SELECTION CRITERIA

Trials fulfilled the following criteria: 1) randomised intervention trial, 2) included adults aged at least 18 years, 3) randomised to a lower fat versus higher fat diet, without the intention to reduce weight in any participants, 4) not multifactorial and 5) assessed a measure of weight or body fatness after at least six months. We duplicated inclusion decisions and resolved disagreement by discussion or referral to a third party.

DATA COLLECTION AND ANALYSIS

We extracted data on the population, intervention, control and outcome measures in duplicate. We extracted measures of body fatness (body weight, BMI, percentage body fat and waist circumference) independently in duplicate at all available time points. We performed random-effects meta-analyses, meta-regression, subgrouping, sensitivity, funnel plot analyses and GRADE assessment.

MAIN RESULTS

We included 37 RCTs (57,079 participants). There is consistent high-quality evidence from RCTs that reducing total fat intake results in small reductions in body fatness; this was seen in almost all included studies and was highly resistant to sensitivity analyses (GRADE high-consistency evidence, not downgraded). The effect of eating less fat (compared with higher fat intake) is a mean body weight reduction of 1.4 kg (95% confidence interval (CI) -1.7 to -1.1 kg, in 53,875 participants from 26 RCTs, I² = 75%). The heterogeneity was explained in subgrouping and meta-regression. These suggested that greater weight loss results from greater fat reductions in people with lower fat intake at baseline, and people with higher body mass index (BMI) at baseline. The size of the effect on weight does not alter over time and is mirrored by reductions in BMI (MD -0.5 kg/m², 95% CI -0.6 to -0.3, 46,539 participants in 14 trials, I² = 21%), waist circumference (MD -0.5 cm, 95% CI -0.7 to -0.2, 16,620 participants in 3 trials; I² = 21%), and percentage body fat (MD -0.3% body fat, 95% CI -0.6 to 0.00, P = 0.05, in 2350 participants in 2 trials; I² = 0%). There was no suggestion of harms associated with low fat diets that might mitigate any benefits on body fatness. The reduction in body weight was reflected in small reductions in LDL (-0.13 mmol/L, 95% CI -0.21 to -0.05), and total cholesterol (-0.23 mmol/L, 95% CI -0.32 to -0.14), with little or no effect on HDL cholesterol (-0.02 mmol/L, 95% CI -0.03 to 0.00), triglycerides (0.01 mmol/L, 95% CI -0.05 to 0.07), systolic (-0.75 mmHg, 95% CI -1.42 to -0.07) or diastolic blood pressure(-0.52 mmHg, 95% CI -0.95 to -0.09), all GRADE high-consistency evidence or quality of life (0.04, 95% CI 0.01 to 0.07, on a scale of 0 to 10, GRADE low-consistency evidence).

AUTHORS' CONCLUSIONS

Trials where participants were randomised to a lower fat intake versus a higher fat intake, but with no intention to reduce weight, showed a consistent, stable but small effect of low fat intake on body fatness: slightly lower weight, BMI, waist circumference and percentage body fat compared with higher fat arms. Greater fat reduction, lower baseline fat intake and higher baseline BMI were all associated with greater reductions in weight. There was no evidence of harm to serum lipids, blood pressure or quality of life, but rather of small benefits or no effect.

Reduction in saturated fat intake for cardiovascular disease

BACKGROUND

Reducing saturated fat reduces serum cholesterol, but effects on other intermediate outcomes may be less clear. Additionally, it is unclear whether the energy from saturated fats eliminated from the diet are more helpfully replaced by polyunsaturated fats, monounsaturated fats, carbohydrate or protein.

OBJECTIVES

To assess the effect of reducing saturated fat intake and replacing it with carbohydrate (CHO), polyunsaturated (PUFA), monounsaturated fat (MUFA) and/or protein on mortality and cardiovascular morbidity, using all available randomised clinical trials.

SEARCH METHODS

We updated our searches of the Cochrane Central Register of Controlled Trials (CENTRAL), MEDLINE (Ovid) and Embase (Ovid) on 15 October 2019, and searched Clinicaltrials.gov and WHO International Clinical Trials Registry Platform (ICTRP) on 17 October 2019.

SELECTION CRITERIA

Included trials fulfilled the following criteria: 1) randomised; 2) intention to reduce saturated fat intake OR intention to alter dietary fats and achieving a reduction in saturated fat; 3) compared with higher saturated fat intake or usual diet; 4) not multifactorial; 5) in adult humans with or without cardiovascular disease (but not acutely ill, pregnant or breastfeeding); 6) intervention duration at least 24 months; 7) mortality or cardiovascular morbidity data available.

DATA COLLECTION AND ANALYSIS

Two review authors independently assessed inclusion, extracted study data and assessed risk of bias. We performed random-effects meta-analyses, meta-regression, subgrouping, sensitivity analyses, funnel plots and GRADE assessment.

MAIN RESULTS

We included 15 randomised controlled trials (RCTs) (16 comparisons, ~59,000 participants), that used a variety of interventions from providing all food to advice on reducing saturated fat. The included long-term trials suggested that reducing dietary saturated fat reduced the risk of combined cardiovascular events by 21% (risk ratio (RR) 0.79; 95% confidence interval (CI) 0.66 to 0.93, 11 trials, 53,300 participants of whom 8% had a cardiovascular event, I² = 65%, GRADE moderate-quality evidence). Meta-regression suggested that greater reductions in saturated fat (reflected in greater reductions in serum cholesterol) resulted in greater reductions in risk of CVD events, explaining most heterogeneity between trials. The number needed to treat for an additional beneficial outcome (NNTB) was 56 in primary prevention trials, so 56 people need to reduce their saturated fat intake for ~four years for one person to avoid experiencing a CVD event. In secondary prevention trials, the NNTB was 32. Subgrouping did not suggest significant differences between replacement of saturated fat calories with polyunsaturated fat or carbohydrate, and data on replacement with monounsaturated fat and protein was very limited. We found little or no effect of reducing saturated fat on all-cause mortality (RR 0.96; 95% CI 0.90 to 1.03; 11 trials, 55,858 participants) or cardiovascular mortality (RR 0.95; 95% CI 0.80 to 1.12, 10 trials, 53,421 participants), both with GRADE moderate-quality evidence. There was little or no effect of reducing saturated fats on non-fatal myocardial infarction (RR 0.97, 95% CI 0.87 to 1.07) or CHD mortality (RR 0.97, 95% CI 0.82 to 1.16, both low-quality evidence), but effects on total (fatal or non-fatal) myocardial infarction, stroke and CHD events (fatal or non-fatal) were all unclear as the evidence was of very low quality. There was little or no effect on cancer mortality, cancer diagnoses, diabetes diagnosis, HDL cholesterol, serum triglycerides or blood pressure, and small reductions in weight, serum total cholesterol, LDL cholesterol and BMI. There was no evidence of harmful effects of reducing saturated fat intakes.

AUTHORS' CONCLUSIONS

The findings of this updated review suggest that reducing saturated fat intake for at least two years causes a potentially important reduction in combined cardiovascular events. Replacing the energy from saturated fat with polyunsaturated fat or carbohydrate appear to be useful strategies, while effects of replacement with monounsaturated fat are unclear. The reduction in combined cardiovascular events resulting from reducing saturated fat did not alter by study duration, sex or baseline level of cardiovascular risk, but greater reduction in saturated fat caused greater reductions in cardiovascular events.

'If I Had Someone Looking Over My Shoulder…': Exploration of Advice Received and Factors Influencing Physical Activity Among Non-metropolitan Cancer Survivors

BACKGROUND

There are significant geographic inequalities in cancer survival with poorer survival rates in non-metropolitan areas compared to major cities. Physical activity (PA) can reduce cancer recurrence and prevent cardiovascular disease. However, few survivors participate in sufficient PA and the prevalence of inactivity is significantly higher in non-metropolitan survivors. The study investigated non-metropolitan survivors' recollections regarding PA advice received following cessation of active treatment, their knowledge of PA guidelines, and the factors that impact on PA behaviour change.

METHOD

Sixteen individuals (14 women and 2 men) with breast (n = 8), endometrial (n = 4) or colorectal cancer (n = 4), with a mean age of 60 years (SD = 12) completed semi-structured interviews as part of a larger study to examine the acceptability and utility of wearable trackers to increase PA. Interviews explored survivors' recollections regarding the advice they received concerning PA following active treatment, knowledge of PA guidelines for cancer survivors and the influences on PA behaviour change. Interview transcripts were analysed using thematic analysis.

RESULTS

Four main themes emerged: (i) insufficient knowledge of guidelines, (ii) support from the treating oncology team, (iii) external accountability, and (iv) barriers to PA.

CONCLUSIONS

Survivors' knowledge of PA guidelines was limited and they did not often recall their oncologists making specific recommendations concerning PA. Survivors' referred to the desire for accountability and monitoring in order to successfully change PA. Lack of motivation was the main barrier to PA participation. Other barriers included age, health status, and lack of facilities or exercise programs.

Randomized Controlled Trial of Primary Health Care Strategies for the Promotion of Leisure-Time Physical Activity Among Older Brazilians

BACKGROUND

Physical activity promotion within primary health care is in the spotlight. However, few studies have evaluated the long-term effectiveness of possible interventions. This study aimed to compare the effectiveness of 3 primary health care interventions in increasing leisure-time physical activity among older Brazilians.

METHODS

Experimental study with 142 older residents of an ongoing urban cohort in São Paulo (Brazil). Participants were randomized into 3 groups: minimal intervention group, physician-based counseling group, and individual counseling and referral for physical activity programs group (CRG). We used the long version of the International Physical Activity Questionnaire to assess leisure-time physical activity at baseline, 4 years after baseline without any intervention, 3 months after intervention, and 6 months after intervention. Statistical analysis included repeated analysis of variance.

RESULTS

At baseline, 31% of the individuals were active, and this figure remained stable for a period of 4 years. Three months after the interventions, there was a significant increase in leisure-time physical activity for CRG compared with the minimal intervention (P < .001) and physician-based counseling (P < .02) groups, and these differences persisted after 6 months (P < .001 and P < .05, respectively).

CONCLUSION

Results indicate that interventions with CRG are effective in producing sustained changes in physical activity among older Brazilians.

Nutrition Counseling for Hypertension Within a Grocery Store: An Example of the Patient-Centered Medical Neighborhood Model

OBJECTIVE

To evaluate the effectiveness of nutrition counseling for patients with hypertension, provided in a grocery store setting.

DESIGN

Single-arm pretest-posttest design implementing a 12-week dietary intervention.

SETTING

Grocery store.

PARTICIPANTS

Thirty adults with hypertension recruited from a primary care practice.

INTERVENTION

Registered dietitian nutritionists provided counseling based on the Dietary Approaches to Stop Hypertension diet.

MAIN OUTCOME MEASURES

Dietary intake patterns and Healthy Eating Index-2010 (HEI-2010) scores measured via food-frequency questionnaire. Change in systolic blood pressure (SBP) was a secondary outcome.

ANALYSIS

Paired t tests were used to test for differences between HEI-2010 scores, intake of key food pattern components, and SBP at baseline compared with follow-up. Statistical significance was established at P ≤ .05.

RESULTS

Eight HEI-2010 component scores increased significantly from baseline to follow-up (a change toward a more desirable eating pattern): total fruit, whole fruit, greens and beans, whole grains, fatty acids, refined grains, and empty calories. Sodium (P < .001), saturated fat (P < .001), discretionary solid fat (P < .001), added sugars (P = .01), and total fat (P < .001) all decreased significantly. The change in SBP was not significant.

CONCLUSIONS AND IMPLICATIONS

Grocery store-based counseling for patients with hypertension may be an effective strategy to provide lifestyle counseling that is not typically available within primary care.

The Effect of Counseling on Stigma in Psychiatric Patients Receiving Electroconvulsive Therapy: A Clinical Trial Study

PURPOSE

Despite its efficacy and safety, electroconvulsive therapy (ECT) is underutilized, in part, due to the stigma associated with the treatment. This study aimed to evaluate the effect of counseling on stigma in patients with psychiatric disorders receiving ECT.

PATIENTS AND METHODS

A total of 114 patients with psychiatric disorders undergoing ECT were randomly divided into two groups. Both the groups received routine care and treatment, but the intervention group (n=57) received four counseling sessions. At the beginning and end of the study (6 weeks, post-treatment), patients completed the Internalized Stigma of Mental Illness scale. The data were analyzed using independent and paired sample t-tests.

RESULTS

There was no significant difference in the mean stigma scores of participants in the control and intervention groups before counseling (P>0.08). However, post-intervention, there was a significant difference in the mean stigma scores between both the groups (P<0.001).

CONCLUSION

The findings demonstrate that the counseling intervention is effective in decreasing stigma in patients undergoing ECT. Therefore, it is recommended to use this therapeutic method in such patients.

Randomized Trial of Motivational Interviewing to Prevent Early Childhood Caries in Public Housing

INTRODUCTION

Caries experience among preschool-age children has remained relatively unchanged for the past 2 decades, despite recently documented decreases in untreated decay.

OBJECTIVES

In a community-based cluster-randomized controlled trial, a motivational interviewing (MI) intervention administered to primary caregivers was hypothesized to reduce caries increment over 2 y as compared with controls, among children aged 0 to 5 y at baseline living in public housing.

METHODS

Public housing residents, who served as interventionists, were trained in MI with a focus on early childhood caries prevention. All 26 eligible public housing developments were randomized to either control (quarterly clinical examinations, fluoride varnish applications, toothbrush/toothpaste, and educational brochures) or intervention (same procedures as control plus MI counseling). Quarterly MI sessions were delivered in English or Spanish over 2 y, audio recorded, and assessed for treatment fidelity. The primary outcome was the increment in dmfs (decayed, missing, and filled tooth surfaces) as assessed by clinical examination at baseline, 12 mo, and 24 mo. Secondary outcomes included caregiver oral health knowledge and child oral health behaviors (child toothbrushing and sugar-sweetened beverage intake). Baseline characteristics were compared between groups and adjusted for housing-site clusters. Longitudinal outcomes were analyzed with mixed models.

RESULTS

A total of 1,065 children (49% female, 55% non-White, 61% Hispanic, 89% below poverty level, n = 686 control) and their caregivers were enrolled. During 2 y of follow-up, the mean dmfs increment increased in both groups; however, there were no statistically significant group differences at 24 mo or group × time interactions. The mean increase in intervention caregivers' knowledge was significantly greater than that of control, F(2, 1,593) = 3.48, P = 0.0310, but there were no significant intervention effects on caregiver-reported child sugar-sweetened beverage intake or child toothbrushing.

CONCLUSION

MI counseling plus intensive caries prevention activities resulted in knowledge increases but did not improve oral health behaviors or caries increment (ClinicalTrials.gov NCT01205971).

KNOWLEDGE TRANSFER STATEMENT

When viewed in light of the findings from the companion Pine Ridge study and other recent MI studies, the results of this study suggest that when the complex disease of early childhood caries is addressed in high-risk populations, MI is not effective, and alternative approaches are warranted.

Toward an Emerging Role for Motivational Interviewing in Primary Care

PURPOSE OF REVIEW

Implementing Motivational Interviewing (MI) in primary care settings has been problematic due in part to persistent gaps in knowledge. Examples include poor understanding of how to effectively train persons to conduct MI, or of which aspects of MI-related communication are associated with better outcomes for patients. This review describes how recent research findings addressing the knowledge gaps support a growing role for MI in primary care.

RECENT FINDINGS

Two trials of MI training combined classroom time with ongoing coaching and feedback, resulting in enhanced MI ability relative to a control arm where PCPs received minimal or no MI training. A third MI training trial excluded coaching and feedback, failing to increase use of MI. Adding to a growing list of behavioral health-related problems for which MI training has shown some effectiveness, a trial of training PCPs to use MI with depressed patients was associated with significantly improved depressive symptoms. Moreover, aspects of the PCPs' MI-related language and patients' arguments for positive behavior changes, "change talk," appeared to explain the positive effects of MI training on depression outcome. MI-training approaches have improved such that PCPs and possibly other clinic staff may want to consider MI training as a way to more effectively support their patients as they address behavioral health-related problems (e.g., tobacco use). MI training should focus on eliciting "change talk" from patients. Researchers and funding agencies might collaborate to continue closing knowledge gaps in the MI literature.

Experiences of a Motivational Interview Delivered by a Robot: Qualitative Study

BACKGROUND

Motivational interviewing is an effective intervention for supporting behavior change but traditionally depends on face-to-face dialogue with a human counselor. This study addressed a key challenge for the goal of developing social robotic motivational interviewers: creating an interview protocol, within the constraints of current artificial intelligence, which participants will find engaging and helpful.

OBJECTIVE

The aim of this study was to explore participants' qualitative experiences of a motivational interview delivered by a social robot, including their evaluation of usability of the robot during the interaction and its impact on their motivation.

METHODS

NAO robots are humanoid, child-sized social robots. We programmed a NAO robot with Choregraphe software to deliver a scripted motivational interview focused on increasing physical activity. The interview was designed to be comprehensible even without an empathetic response from the robot. Robot breathing and face-tracking functions were used to give an impression of attentiveness. A total of 20 participants took part in the robot-delivered motivational interview and evaluated it after 1 week by responding to a series of written open-ended questions. Each participant was left alone to speak aloud with the robot, advancing through a series of questions by tapping the robot's head sensor. Evaluations were content-analyzed utilizing Boyatzis' steps: (1) sampling and design, (2) developing themes and codes, and (3) validating and applying the codes.

RESULTS

Themes focused on interaction with the robot, motivation, change in physical activity, and overall evaluation of the intervention. Participants found the instructions clear and the navigation easy to use. Most enjoyed the interaction but also found it was restricted by the lack of individualized response from the robot. Many positively appraised the nonjudgmental aspect of the interview and how it gave space to articulate their motivation for change. Some participants felt that the intervention increased their physical activity levels.

CONCLUSIONS

Social robots can achieve a fundamental objective of motivational interviewing, encouraging participants to articulate their goals and dilemmas aloud. Because they are perceived as nonjudgmental, robots may have advantages over more humanoid avatars for delivering virtual support for behavioral change.

An Exercise Counseling Intervention in Minority Adults With Heart Failure

PURPOSE

The primary aim of this study was to assess the feasibility of an exercise counseling intervention for adults of diverse race/ethnicity with heart failure (HF) and to assess its potential for improving overall physical activity, functional capacity, and HF self-care.

DESIGN

This study was a quasi-experimental, prospective, longitudinal cohort design.

METHODS

Twenty adults were enrolled and completed the 6-minute walk and standardized instruments, followed by exercise counseling using motivational interviewing. Each received an accelerometer, hand weights, and a diary to record self-care behaviors. Participants were followed via phone for 12 weeks to collect step-counts, review symptoms, and plan the following week's step goal.

FINDINGS

Results indicate that this intervention was feasible for most participants and resulted in improvements in physical activity, functional capacity, and self-care behaviors.

CONCLUSION/CLINICAL RELEVANCE

Brief exercise counseling may be an appropriate option to improve outcomes for stable patients with HF and may be tailored to fit different settings.

Practical Strategies for Engaging Individuals With Obesity in Primary Care

Although widely recognized as a chronic disease that requires long-term, structured, and multidisciplinary management, obesity remains largely underdiagnosed and undertreated. The prevalence of obesity continues to increase dramatically, with the highest rates seen in the United States. Despite the availability of several clinical practice guidelines, published studies suggest that health care professionals (HCPs) infrequently and inconsistently follow guideline recommendations. Barriers to HCP participation in obesity management are likely to inhibit obesity counseling in primary care. Improving HCP obesity-related practices and counseling is important. This article discusses current practices, barriers to effective obesity management, and recommendations to improve HCP obesity management and counseling, based on findings from a PubMed search and clinical experience. The aim of the article is to share best-practice strategies for engaging patients.

Reducing Commercial Truck Driver BMI Through Motivational Interviewing and Self-Efficacy

Obesity is recognized as a national and global health epidemic. Commercial truck drivers (CTDs) have a higher obesity rate and lower life expectancy compared with the general population. CTDs work sedentary jobs with long hours that pose barriers to healthy eating and regular exercise. An evidenced-based practice (EBP) change project that used motivational interviewing (MI) and education regarding diet and exercise over a 4-week period was found to have a positive impact on CTDs behavior. Results revealed an increase in aggregated self-efficacy for weight loss (14.8%, exceeding the benchmark of 11%). For aggregated body mass index (BMI), CTDs lost a mean of 0.65 kg/m2, over a 4-week period which was statistically significant at p = .0001. The results suggest a short-term MI intervention can be effective when implemented as a clinical standard for CTDs.

Moderating Nutritious Habits in Psychiatric Patients Using Transtheoretical Model of Change and Counseling

Motivational Interviewing provides the opportunity to health professionals to have an effective strategy to increase the level of readiness to change health behaviors. Along with the Transtheoretical Model (Stages of Change Model) compose the theoretical base of intervention in psychiatry settings.

OBJECTIVE

This study was aimed to change nutritious behavior of psychiatric patients using a specific Model of Change and Counseling implementing a health education program.

METHODOLOGY

A quasi-experimental design was adopted on a random sample of 60 psychiatric patients at Military Hospital of Athens. Patients were divided into two groups as follows; (a) Intervention Group (four sessions of counseling and encouraging motivation for modification of their nutritious habits), and (b) Control Group (simple information sessions about the principles of healthy alimentation).

RESULTS

The mean age of Intervention Group (IG) was 43.9 ± 9.5 and Control Group (CG) 46.1 ± 9.1, ranging from 40 to 55 years old. Also, 26.7% of the participants were female, 23.3% were married and, 10% divorced. Our analyses showed that IG patients were significantly loss weight post-intervention compared to CG patients. Specifically, IG patients were significantly moderated the intake of starchy foods in every meal (p < 0.001) and the intake of fruits and vegetables (p < 0.001). Similarly, IG patients were moderated the intake of low fat dairy foods while they changed the full fat dairy foods with low fat (p < 0.001). Also important, IG patients showed significant enhance (80%) regarding drugs compliance, suggesting that 34% of the CG patients often forgot to take their medication. Finally, IG patients reported a positive attitude towards moderating unhealthy nutritious behaviors (p = 0.032).

CONCLUSIONS

Our results confirms that health educational and promotional Interventions may change behavior of psychiatric patients and thus may positively influence their nutritious habits.

Impact of educational interventions on primary prevention of cardiovascular disease: A systematic review with a focus on physical activity

Background: Evidence from epidemiological and experimental studies illustrates the beneficial impact of healthy lifestyle behaviours on cardiovascular risk.

Objectives: To assess the effectiveness of primary care health education interventions designed to promote healthy lifestyles on physical activity levels and cardiovascular risk.

Methods: A computer-aided search on PubMed and Scopus was performed to identify relevant studies published from January 2000 to October 2016. Two authors independently selected studies for inclusion and extracted data, including intervention characteristics and outcome measures, namely physical activity and cardiovascular risk or risk factors.

Results: Of the 212 identified studies, 15 met the inclusion criteria. The 15 studies enrolled 6727 participants; the sample size varied between 74 and 878 adults. Fourteen studies assessed physical activity by questionnaire and only one study used accelerometry. Eight of the 15 studies showed improvements in the physical activity levels after the intervention, ranging from 5% to 26% in those where significant changes between groups were detected. Most studies reported significant positive effects of the health education interventions on cardiovascular risk factors, mainly on lipid profile, blood pressure and cardiovascular risk score.

Conclusion: The health education interventions, in primary care, seem to improve daily physical activity, cardiovascular risk factors and risk score.

Preliminary examination of metabolic syndrome response to motivational interviewing for weight loss as compared to an attentional control and usual care in primary care for individuals with and without binge-eating disorder

Motivational interviewing (MI) treatment for weight loss is being studied in primary care. The effect of such interventions on metabolic syndrome or binge eating disorder (BED), both highly related to excess weight, has not been examined in primary care. This study conducted secondary analyses from a randomized controlled trial to test the impact of MI for weight loss in primary care on metabolic syndrome. 74 adult participants with overweight/obesity recruited through primary care were randomized to 12weeks of either MI, an attentional control, or usual care. Participants completed measurements for metabolic syndrome at pre- and post-treatment. There were no statistically significant differences in metabolic syndrome rates at pre-, X²(2)=0.16, p=0.921, or post-, X²(2)=0.852, p=0.653 treatment. The rates in metabolic syndrome, however, decreased for MI (10.2%) and attentional control (13.8%) participants, but not for usual care. At baseline, metabolic syndrome rates did not differ significantly between participants with BED or without BED across treatments. At post-treatment, participants with BED were significantly more likely to meet criteria for metabolic syndrome than participants without BED, X²(1)=5.145, p=0.023, phi=0.273. Across treatments, metabolic syndrome remitted for almost a quarter of participants without BED (23.1%) but for 0% of those with BED. These preliminary results are based on a small sample and should be interpreted with caution, but they are the first to suggest that relatively low intensity MI weight loss interventions in primary care may decrease metabolic syndrome rates but not for individuals with BED.

Psychological interventions for coronary heart disease

BACKGROUND

Coronary heart disease (CHD) is the most common cause of death globally, although mortality rates are falling. Psychological symptoms are prevalent for people with CHD, and many psychological treatments are offered following cardiac events or procedures with the aim of improving health and outcomes. This is an update of a Cochrane systematic review previously published in 2011.

OBJECTIVES

To assess the effectiveness of psychological interventions (alone or with cardiac rehabilitation) compared with usual care (including cardiac rehabilitation where available) for people with CHD on total mortality and cardiac mortality; cardiac morbidity; and participant-reported psychological outcomes of levels of depression, anxiety, and stress; and to explore potential study-level predictors of the effectiveness of psychological interventions in this population.

SEARCH METHODS

We updated the previous Cochrane Review searches by searching the following databases on 27 April 2016: CENTRAL in the Cochrane Library, MEDLINE (Ovid), Embase (Ovid), PsycINFO (Ovid), and CINAHL (EBSCO).

SELECTION CRITERIA

We included randomised controlled trials (RCTs) of psychological interventions compared to usual care, administered by trained staff, and delivered to adults with a specific diagnosis of CHD. We selected only studies estimating the independent effect of the psychological component, and with a minimum follow-up of six months. The study population comprised of adults after: a myocardial infarction (MI), a revascularisation procedure (coronary artery bypass graft (CABG) or percutaneous coronary intervention (PCI)), and adults with angina or angiographically defined coronary artery disease (CAD). RCTs had to report at least one of the following outcomes: mortality (total- or cardiac-related); cardiac morbidity (MI, revascularisation procedures); or participant-reported levels of depression, anxiety, or stress.

DATA COLLECTION AND ANALYSIS

Two review authors independently screened titles and abstracts of all references for eligibility. A lead review author extracted study data, which a second review author checked. We contacted study authors to obtain missing information.

MAIN RESULTS

This review included 35 studies which randomised 10,703 people with CHD (14 trials and 2577 participants added to this update). The population included mainly men (median 77.0%) and people post-MI (mean 65.7%) or after undergoing a revascularisation procedure (mean 27.4%). The mean age of participants within trials ranged from 53 to 67 years. Overall trial reporting was poor, with around a half omitting descriptions of randomisation sequence generation, allocation concealment procedures, or the blinding of outcome assessments. The length of follow-up ranged from six months to 10.7 years (median 12 months). Most studies (23/35) evaluated multifactorial interventions, which included therapies with multiple therapeutic components. Ten studies examined psychological interventions targeted at people with a confirmed psychopathology at baseline and two trials recruited people with a psychopathology or another selecting criterion (or both). Of the remaining 23 trials, nine studies recruited unselected participants from cardiac populations reporting some level of psychopathology (3.8% to 53% with depressive symptoms, 32% to 53% with anxiety), 10 studies did not report these characteristics, and only three studies excluded people with psychopathology.Moderate quality evidence showed no risk reduction for total mortality (risk ratio (RR) 0.90, 95% confidence interval (CI) 0.77 to 1.05; participants = 7776; studies = 23) or revascularisation procedures (RR 0.94, 95% CI 0.81 to 1.11) with psychological therapies compared to usual care. Low quality evidence found no risk reduction for non-fatal MI (RR 0.82, 95% CI 0.64 to 1.05), although there was a 21% reduction in cardiac mortality (RR 0.79, 95% CI 0.63 to 0.98). There was also low or very low quality evidence that psychological interventions improved participant-reported levels of depressive symptoms (standardised mean difference (SMD) -0.27, 95% CI -0.39 to -0.15; GRADE = low), anxiety (SMD -0.24, 95% CI -0.38 to -0.09; GRADE = low), and stress (SMD -0.56, 95% CI -0.88 to -0.24; GRADE = very low).There was substantial statistical heterogeneity for all psychological outcomes but not clinical outcomes, and there was evidence of small-study bias for one clinical outcome (cardiac mortality: Egger test P = 0.04) and one psychological outcome (anxiety: Egger test P = 0.012). Meta-regression exploring a limited number of intervention characteristics found no significant predictors of intervention effects for total mortality and cardiac mortality. For depression, psychological interventions combined with adjunct pharmacology (where deemed appropriate) for an underlying psychological disorder appeared to be more effective than interventions that did not (β = -0.51, P = 0.003). For anxiety, interventions recruiting participants with an underlying psychological disorder appeared more effective than those delivered to unselected populations (β = -0.28, P = 0.03).

AUTHORS' CONCLUSIONS

This updated Cochrane Review found that for people with CHD, there was no evidence that psychological treatments had an effect on total mortality, the risk of revascularisation procedures, or on the rate of non-fatal MI, although the rate of cardiac mortality was reduced and psychological symptoms (depression, anxiety, or stress) were alleviated; however, the GRADE assessments suggest considerable uncertainty surrounding these effects. Considerable uncertainty also remains regarding the people who would benefit most from treatment (i.e. people with or without psychological disorders at baseline) and the specific components of successful interventions. Future large-scale trials testing the effectiveness of psychological therapies are required due to the uncertainty within the evidence. Future trials would benefit from testing the impact of specific (rather than multifactorial) psychological interventions for participants with CHD, and testing the targeting of interventions on different populations (i.e. people with CHD, with or without psychopathologies).

Effective behaviour change techniques for physical activity and healthy eating in overweight and obese adults; systematic review and meta-regression analyses

PURPOSE

This systematic review aims to explain the heterogeneity in results of interventions to promote physical activity and healthy eating for overweight and obese adults, by exploring the differential effects of behaviour change techniques (BCTs) and other intervention characteristics.

METHODS

The inclusion criteria specified RCTs with ≥ 12 weeks' duration, from January 2007 to October 2014, for adults (mean age ≥ 40 years, mean BMI ≥ 30). Primary outcomes were measures of healthy diet or physical activity. Two reviewers rated study quality, coded the BCTs, and collected outcome results at short (≤6 months) and long term (≥12 months). Meta-analyses and meta-regressions were used to estimate effect sizes (ES), heterogeneity indices (I²) and regression coefficients.

RESULTS

We included 48 studies containing a total of 82 outcome reports. The 32 long term reports had an overall ES = 0.24 with 95% confidence interval (CI): 0.15 to 0.33 and I² = 59.4%. The 50 short term reports had an ES = 0.37 with 95% CI: 0.26 to 0.48, and I² = 71.3%. The number of BCTs unique to the intervention group, and the BCTs goal setting and self-monitoring of behaviour predicted the effect at short and long term. The total number of BCTs in both intervention arms and using the BCTs goal setting of outcome, feedback on outcome of behaviour, implementing graded tasks, and adding objects to the environment, e.g. using a step counter, significantly predicted the effect at long term. Setting a goal for change; and the presence of reporting bias independently explained 58.8% of inter-study variation at short term. Autonomy supportive and person-centred methods as in Motivational Interviewing, the BCTs goal setting of behaviour, and receiving feedback on the outcome of behaviour, explained all of the between study variations in effects at long term.

CONCLUSION

There are similarities, but also differences in effective BCTs promoting change in healthy eating and physical activity and BCTs supporting maintenance of change. The results support the use of goal setting and self-monitoring of behaviour when counselling overweight and obese adults. Several other BCTs as well as the use of a person-centred and autonomy supportive counselling approach seem important in order to maintain behaviour over time.

TRIAL REGISTRATION

PROSPERO CRD42015020624.

Effective behaviour change techniques for physical activity and healthy eating in overweight and obese adults; systematic review and meta-regression analyses

Purpose

This systematic review aims to explain the heterogeneity in results of interventions to promote physical activity and healthy eating for overweight and obese adults, by exploring the differential effects of behaviour change techniques (BCTs) and other intervention characteristics.

Methods

The inclusion criteria specified RCTs with ≥ 12 weeks’ duration, from January 2007 to October 2014, for adults (mean age ≥ 40 years, mean BMI ≥ 30). Primary outcomes were measures of healthy diet or physical activity. Two reviewers rated study quality, coded the BCTs, and collected outcome results at short (≤6 months) and long term (≥12 months). Meta-analyses and meta-regressions were used to estimate effect sizes (ES), heterogeneity indices (I²) and regression coefficients.

Results

We included 48 studies containing a total of 82 outcome reports. The 32 long term reports had an overall ES = 0.24 with 95% confidence interval (CI): 0.15 to 0.33 and I² = 59.4%. The 50 short term reports had an ES = 0.37 with 95% CI: 0.26 to 0.48, and I² = 71.3%. The number of BCTs unique to the intervention group, and the BCTs goal setting and self-monitoring of behaviour predicted the effect at short and long term. The total number of BCTs in both intervention arms and using the BCTs goal setting of outcome, feedback on outcome of behaviour, implementing graded tasks, and adding objects to the environment, e.g. using a step counter, significantly predicted the effect at long term. Setting a goal for change; and the presence of reporting bias independently explained 58.8% of inter-study variation at short term. Autonomy supportive and person-centred methods as in Motivational Interviewing, the BCTs goal setting of behaviour, and receiving feedback on the outcome of behaviour, explained all of the between study variations in effects at long term.

Conclusion

There are similarities, but also differences in effective BCTs promoting change in healthy eating and physical activity and BCTs supporting maintenance of change. The results support the use of goal setting and self-monitoring of behaviour when counselling overweight and obese adults. Several other BCTs as well as the use of a person-centred and autonomy supportive counselling approach seem important in order to maintain behaviour over time.

Trial Registration

PROSPERO CRD42015020624

Electronic supplementary material

The online version of this article (doi:10.1186/s12966-017-0494-y) contains supplementary material, which is available to authorized users.

The effects of the Norwegian Coordination Reform on the use of rehabilitation services: panel data analyses of service use, 2010 to 2013

BACKGROUND

In 2012 the Norwegian Coordination Reform was implemented. The main motivation was to encourage municipalities to expand local, primary health care services. From 2012 to 2014, under the Municipal Co-Financing regime, municipalities were obliged to cover 20 % of the costs of health services provided at the specialist (hospital) level. Importantly, use of rehabilitation services in private institutions was not part of the cost-sharing mechanism of Municipal Co-Financing. Rehabilitation services may be seen as quite similar in nature whether they be provided by municipalities, hospitals or private institutions. Thus, with rehabilitation patients readily "transferrable" between levels, the question is whether the reform brought with it a sought after shift towards more municipal rehabilitation and less specialist rehabilitation.

METHODS

Data from the Norwegian Patient Register and from Statistics Norway/KOSTRA were utilized to gauge annual expenditures and inputs in specialist, municipal and private institution rehabilitation services respectively. Fixed effects and first difference regression analyses for the period 2010-2013 were carried out to account for certain time-invariant traits of municipalities and/or hospital regions, and results were adjusted for contemporaneous trends in local needs.

RESULTS

Expenditures in specialist rehabilitation services declined sharply (typically by 8-10 %) from 2011 (pre-reform) to 2012 (post-reform), while expenditures in private rehabilitation services rose markedly in the same period (typically by 42-44 %). The results do not suggest any general expansion of municipal rehabilitation services.

CONCLUSIONS

The results of the analyses suggest that municipalities shift away from the use of specialist rehabilitation services and towards the use of rehabilitation services in private institutions since the latter becomes relatively cheaper (free-of charge) than both municipal and specialist services in post-reform periods (as specialist services come at a cost to municipalities post-reform). While the main goal of the reform has not materialized the results nevertheless suggest that incentives (of cost-shifting) do play a significant role in rehabilitation service use.