"MOVE!" Outcomes of a weight loss program modified for veterans with serious mental illness

Lifestyle interventions improving health-related quality of life: A systematic review and meta-analysis of randomized control trials

Lifestyle interventions have garnered significant research interest for their potential to enhance health-related quality of life (HRQoL). Understanding the impact of these interventions on various dimensions of HRQoL is crucial for effective healthcare strategies. This study aims to systematically review and meta-analyze the effects of lifestyle interventions on HRQoL in randomized control trials. A systematic search was conducted across five scientific databases, including PubMed, Web of Science, Scopus, the Cochrane Library, and gray literature, with a filter applied to include only English language publications. Study selection was carried out by two independent reviewers in several steps, including duplicate removal and eligibility evaluation for meta-analysis. Information extracted from the studies included authors, countries, study designs, target populations, ages, genders, number of participants, interventions, outcomes, and results. A total of 61 randomized control trials were included in this meta-analysis. The meta-analysis revealed that lifestyle interventions significantly improved healthrelated quality of life compared to control groups, with Hedges' g of 0.38 (95% CI 0.25-0.50, Z = 5.94; P < 0.001; I2 = 84.59%). This positive effect was consistently observed in patients with heart-related diseases and metabolic disorders. Meta-regression analysis indicated that lifestyle interventions had the most substantial impact on health-related quality of life in the 1-month follow-up period. Considering the cost-effectiveness of lifestyle interventions compared to other intervention types, they can benefit various patient groups. This systematic review contributes to health policy goals by advocating focused preventive strategies in alignment with the observed benefits of lifestyle interventions.

Randomized Controlled Trials to Treat Obesity in Military Populations: A Systematic Review and Meta-Analysis

In recent years, overweight and obesity have reached an alarmingly high incidence and prevalence worldwide; they have also been steadily increasing in military populations. Military personnel, as an occupational group, are often exposed to stressful and harmful environments that represent a risk factor for disordered eating, with major repercussions on both physical and mental health. This study aims to explore the effectiveness of weight loss interventions and assess the significance of current obesity treatments for these populations. Three online databases (PubMed, PsycInfo, and Web of Science) were screened to identify randomized controlled trials (RCTs) aiming to treat obesity in active-duty military personnel and veterans. Random-effects meta-analyses were conducted for body weight (BW) and body mass index (BMI) values, both longitudinally comparing treatment groups from pre-to-post intervention and cross-sectionally comparing the treatment group to controls at the end of the intervention. A total of 21 studies were included: 16 cross-sectional (BW: n = 15; BMI: n = 12) and 16 longitudinal (BW: n = 15; BMI: n = 12) studies were meta-analyzed, and 5 studies were narratively synthesized. A significant small overall BW and BMI reduction from baseline to post-intervention was observed (BW: g = -0.10; p = 0.015; BMI: g = -0.32; p < 0.001), together with a decreased BMI (g = -0.16; p = 0.001) and nominally lower BW (g = -0.08; p = 0.178) in the intervention group compared to controls at the post-intervention time-point. Despite limitations, such as the heterogeneity across the included interventions and the follow-up duration, our findings highlight how current weight loss interventions are effective in terms of BW and BMI reductions in military populations and how a comprehensive approach with multiple therapeutic goals should be taken during the intervention.

Impacts of nutrition counseling on depression and obesity: A scoping review

This scoping review aims to evaluate the impact of nutrition counseling on mental health and wellbeing among people affected by obesity. Depression and obesity are major sources of morbidity and mortality worldwide. The prevalence of obesity is higher in patients with severe or suboptimally managed depression. Change in dietary quality prompted by nutrition counseling may pose a unique opportunity for intervention. Of the 1745 studies identified, 26 studies (total n = 6727) met inclusion criteria. Due to the heterogeneity of methods and outcome reporting, it was not possible to perform meta-analysis. Across all included studies, 34 different scales were used to quantify mental health/wellbeing. Eleven studies (42.3%) reported statistically significant findings between intervention and control groups. Only two of these studies assessed nutrition counseling independently rather than as part of a multidisciplinary intervention. Overall, many studies have examined the role of nutrition counseling on mental health/wellbeing in individuals affected by obesity. However, due to inconsistency in study methodologies and outcome measurement tools, it is challenging to draw robust or clinically meaningful conclusions about the effects of nutrition counseling on mental health in this population.

Personalized training as a promoter for physical activity in people with depressive disorder-a randomized controlled trial in Germany

Introduction

Adopting an active lifestyle is an important goal, but can be difficult to achieve for people with depressive disorders. Current guidelines recommend the integration of physical activity in the multimodal treatment of depressive disorders. However, the possibilities to provide individual support for physical activities are frequently limited. The aim of our study was to examine how physical activity can be increased in a real-world setting by combining physical training and psychological interventions.

Materials and methods

In this randomized-controlled interventional study, 31 outpatients diagnosed with moderate to severe depression were recruited from the region of Hannover. The intervention group (n = 16) was offered six weekly individual sessions lasting between 60 and 90  min with a sports scientist, including Motivational Interviewing and accompanied exercise activities. The control group (n = 15) received a written booklet with information on steps toward becoming more active. Moderate-to-vigorous physical activity (MVPA) as the primary outcome was analyzed using activity sensors before and after the 6-week intervention, and 3  months subsequently. Secondary outcomes included the Six-Minute Walk Test (6MWT), Sit-to-Stand test (STS), and mental health assessed with self-rating questionnaires.

Results

In the intervention group, MVPA increased significantly between baseline and the first follow-up and remained at an increased level at the second follow-up in comparison to decreased levels in the control group (difference of 15.5  min/day between groups over time, SE = 6.2  min/day, 95%-CI[2.7, 28.3], p = 0.020). The increased activity level was associated with markers of increased fitness (6MWT and STS) in the intervention group. Both groups showed comparable improvements in depressive symptoms, while the number of patients receiving antidepressants increased in the control group and decreased in the intervention group. Two patients dropped out of the intervention group during the trial.

Conclusion

The intervention proved to be a feasible and effective aid to promote a physically active lifestyle for patients diagnosed with depression. Furthermore, the higher level of physical activity was maintained for the follow-up period. Given the success of the approach evaluated in this project, individual support for physical activity should be investigated in larger sample sizes and potentially be considered in the multimodal treatment of depression.

Clinical trial registration

[https://clinicaltrials.gov/], identifier [DRKS00023257].

Improving physical activity and diet in patients with severe mental disorders: Results from the LIFESTYLE multicentric, real-world randomized controlled trial

Aims of the present study are to test the efficacy of a lifestyle group intervention, compared to a brief psychoeducational intervention, on levels of physical activity and dietary habits in a real-world sample of patients with severe mental disorders. The study, funded by the Italian Ministry of Education, has been carried out in six Italian University psychiatric outpatient units. All patients were randomly assigned to the experimental or control group and were assessed through standardized assessment instruments at baseline and six months after randomization. Of the 401 recruited patients, 43.3% had a diagnosis of bipolar disorder, 29.9% of psychosis and 26.9% of major depression. Patients were mainly female (57%), with a mean age of 45.6±11.8 years. Treated patients have almost 8 times the likelihood to show an increase of the total MET (OR: 8.02; p < .001) and of the walking MET (OR: 7.68; p < .001) and are more likely to increase the weekly consumption of vegetables (OR= 1.98, p < .05) and to reduce that of junk food (OR:0.23; p < .05). The present study support the notion that patients with severe mental disorders can improve their lifestyle behaviours and that, with appropriate support, they can achieve a healthy living.

Effectiveness of nutrition and dietary interventions for people with serious mental illness: systematic review and meta-analysis

OBJECTIVE

To review recent published trials of nutrition and dietary interventions for people with serious mental illness; to assess their effectiveness in improving metabolic syndrome risk factors.

STUDY DESIGN

Systematic review and meta-analysis of randomised and non-randomised controlled trials of interventions with a nutrition/diet-related component delivered to people with serious mental illness, published 1 January 2010 - 6 September 2021. Primary outcomes were weight, body mass index (BMI), and waist circumference. Secondary outcomes were total serum cholesterol, low-density lipoprotein (LDL) and high-density lipoprotein (HDL) cholesterol, triglyceride, and blood glucose levels.

DATA SOURCES

MEDLINE, EMBASE, PsycINFO, CINAHL, and CENTRAL databases. In addition, reference lists of relevant publications were examined for further additional studies.

DATA SYNTHESIS

Twenty-five studies encompassing 26 intervention arms were included in our analysis. Eight studies were at low or some risk of bias, seventeen were deemed to be at high risk. Eight of seventeen intervention arms found statistically significant intervention effects on weight, ten of 24 on BMI, and seven of seventeen on waist circumference. The pooled effects of nutrition interventions on metabolic syndrome risk factors were statistically non-significant. However, we identified small size effects on weight for interventions delivered by dietitians (five studies; 262 intervention, 258 control participants; standardised mean difference [SMD], -0.28; 95% CI, -0.51 to -0.04) and interventions consisting of individual sessions only (three studies; 141 intervention, 134 control participants; SMD, -0.30; 95% CI, -0.54 to -0.06).

CONCLUSIONS

We found only limited evidence for nutrition interventions improving metabolic syndrome risk factors in people with serious mental illness. However, they may be more effective when delivered on an individual basis or by dietitians.

PROSPERO REGISTRATION

CRD42021235979 (prospective).

Systematic review of lifestyle interventions to improve weight, physical activity and diet among people with a mental health condition

BACKGROUND

People with a mental health condition experience an elevated risk of chronic disease and greater prevalence of health and behaviours. Lifestyle interventions aim to reduce this risk by modifying health behaviours such as physical activity and diet. Previous reviews exploring the efficacy of such interventions for this group have typically limited inclusion to individuals with severe mental illness (SMI), with a focus of impact on weight. This review assessed the efficacy of lifestyle interventions delivered in community or outpatient settings to people with any mental health condition, on weight, physical activity and diet.

METHODS

Eligible studies were randomised or cluster-randomised controlled trials published between January 1999 and February 2019 aiming to improve weight, physical activity or diet, for people with any mental health condition. Two reviewers independently completed study screening, data extraction and assessment of methodological quality. Primary outcome measures were weight, physical activity and diet. Secondary outcome measures were body mass index (BMI), waist circumference, sedentary behaviour and mental health. Where possible, meta-analyses were conducted. Narrative synthesis using vote counting based on direction of effect was used where studies were not amenable to meta-analysis.

RESULTS

Fifty-seven studies were included (49 SMI only), with 46 contributing to meta-analyses. Meta-analyses revealed significant (< 0.05) effect of interventions on mean weight loss (-1.42 kg), achieving 5% weight loss (OR 2.48), weight maintenance (-2.05 kg), physical activity (IPAQ MET minutes: 226.82) and daily vegetable serves (0.51), but not on fruit serves (0.01). Significant effects were also seen for secondary outcomes of BMI (-0.48 units) and waist circumference (-0.87cm), but not mental health (depression: SMD -0.03; anxiety: SMD -0.49; severity of psychological symptoms: SMD 0.72). Studies reporting sedentary behaviour were not able to be meta-analysed. Most trials had high risk of bias, quality of evidence for weight and physical activity were moderate, while quality of evidence for diet was low.

CONCLUSION

Lifestyle interventions delivered to people with a mental health condition made statistically significant improvements to weight, BMI, waist circumference, vegetable serves and physical activity. Further high-quality trials with greater consistency in measurement and reporting of outcomes are needed to better understand the impact of lifestyle interventions on physical activity, diet, sedentary behaviour and mental health and to understand impact on subgroups.

SYSTEMATIC REVIEW REGISTRATION

PROSPERO CRD42019137197.

Using Innovation-Corps (I-Corps™) Methods to Adapt a Mobile Health (mHealth) Obesity Treatment for Community Mental Health Settings

Background

We employed Innovation Corps (I-Corps™) methods to adaptation of a mobile health (mHealth) short-message-system (SMS) -based interactive obesity treatment approach (iOTA) for adults with severe mentall illness receiving care in community settings.

Methods

We hypothesized "jobs to be done" in three broad stakeholder groups: "decision makers" (DM = state and community clinic administrators), "clinician consumers" (CC = case managers, peer supports, nurses, prescribers) and "service consumers" (SC = patients, peers and family members). Semistructured interviews (N = 29) were recorded and transcribed ver batim and coded based on pragmatic-variant grounded theory methods.

Results

Four themes emerged across groups: education, inertia, resources and ownership. Sub-themes in education and ownership differed between DM and CC groups on implementation ownership, intersecting with professional development, suggesting the importance of training and supervision in scalability. Sub-themes in resources and intertia differed between CC and SC groups, suggesting illness severity and access to healthy food as major barriers to engagement, whereas the SC group identified the need for enhanced emotional support, in addition to pragmatic skills like menu planning and cooking, to promote health behavior change. Although SMS was percieved as a viable education and support tool, CC and DM groups had limited familiarity with use in clinical care delivery.

Conclusions

Based on customer discovery, the characteristics of a minimum viable iOTA for implementation, scalability and sustainability include population- and context-specific adaptations to treatment content, interventionist training and delivery mechanism. Successful implementation of an SMS-based intervention will likely require micro-adaptations to fit specific clinical settings.

Scope of Use and Effectiveness of Dietary Interventions for Improving Health-Related Outcomes in Veterans: A Systematic Review

Military veterans often have numerous physical and mental health conditions and can face unique challenges to intervention and management. Dietary interventions can improve the outcomes in many health conditions. This study aimed to evaluate the scope of health conditions targeted with dietary interventions and the effectiveness of these interventions for improving health-related outcomes in veterans. A systematic literature review was performed following PRISMA guidelines to identify and evaluate studies related to veterans and dietary interventions. Five electronic databases were searched, identifying 2669 references. Following screening, 35 studies were evaluated, and 18 were related to a US national veteran weight-loss program. The included studies were critically appraised, and the findings were narratively synthesized. Study designs ranged from randomised controlled trials to cohort studies and were predominantly U.S. based. The intervention durations ranged from one to 24 months. The mean subject age ranged from 39.0 to 69.7 years, with often predominantly male participants, and the mean body mass index ranged from 26.4 to 42.9 kg/m². Most dietary interventions for veterans were implemented in populations with overweight/obesity or chronic disease and involved single dietary interventions or dietary components of holistic lifestyle interventions. The most common primary outcome of interest was weight loss. The success of dietary interventions was generally moderate, and barriers included poor compliance, mental health conditions and large drop-out rates. The findings from this review illustrate the need for further refinement of dietary and lifestyle interventions for the management of veterans with chronic health conditions.

Patient-reported outcomes of lifestyle interventions in patients with severe mental illness: a systematic review and meta-analysis

BACKGROUND

Lifestyle interventions for severe mental illness (SMI) are known to have small to modest effect on physical health outcomes. Little attention has been given to patient-reported outcomes (PROs).

AIM

To systematically review the use of PROs and their measures, and quantify the effects of lifestyle interventions in patients with SMI on these PROs.

METHODS

Five electronic databases were searched (PubMed/Medline, Embase, PsycINFO, CINAHL, and Web of Science) from inception until 12 November 2020 (PROSPERO: CRD42020212135). Randomised controlled trials (RCTs) evaluating the efficacy of lifestyle interventions focusing on healthy diet, physical activity, or both for patients with SMI were included. Outcomes of interest were PROs.

RESULTS

A total of 11.267 unique records were identified from the database search, 66 full-text articles were assessed, and 36 RCTs were included, of which 21 were suitable for meta-analyses. In total, 5.907 participants were included across studies. Lifestyle interventions had no significant effect on quality of life (g = 0.13; 95% CI = - 0.02 to 0.27), with high heterogeneity (I² = 68.7%). We found a small effect on depression severity (g = 0.30, 95% CI = 0.00 to 0.58, I² = 65.2%) and a moderate effect on anxiety severity (g = 0.56, 95% CI = 0.16 to 0.95, I² = 0%).

DISCUSSION

This meta-analysis quantifies the effects of lifestyle interventions on PROs. Lifestyle interventions have no significant effect on quality of life, yet they could improve mental health outcomes such as depression and anxiety symptoms. Further use of patient-reported outcome measures in lifestyle research is recommended to fully capture the impact of lifestyle interventions.

The effect of lifestyle intervention on cardiometabolic risk factors in mental health rehabilitation hostel residents at-risk: a cluster-randomized controlled 15-month trial

OBJECTIVE

Cardiometabolic disorders contribute to morbidity and mortality in people with severe mental illnesses (SMI), yet lifestyle-intervention efficacy in patients with SMI is unclear. Israel's unique mental-health rehabilitation hostels (MHRHs) provide housing to subjects with SMI. We tested how multi-component lifestyle intervention affects cardiometabolic risk-factors in at-risk SMI populations residing in MHRHs.

METHODS

In a prospective, cluster-randomized, controlled study, six MHRHs, paired by residents' functioning level, were randomized to lifestyle intervention (nutrition education, physical education), or usual care. Subjects recruited included those with ≥1 of: BMI > 25 kg/m²; plasma triglycerides ≥150 mg/dL; HbA1c ≥ 5.7%; fasting plasma glucose ≥ 100 mg/dL and plasma HDL < 40_(men)/ 50_(women) mg/dL. Primary outcome was BMI change after 15 months; other outcomes were plasma lipids levels and glycemic control. Low cooperation in one MHRH pair led to their exclusion, the others were assigned to intervention or control.

RESULTS

Eighty residents were enrolled to intervention groups and 74 to control. Compared to baseline, intervention-arm participants experienced improvements in BMI (-0.83 kg/m² [-1.36, -0.29] _95%CI), triglycerides (-30.60 mg/dL [-49.39, -11.82]_95%CI) and LDL (-15.51 mg/dL [-24.53, -6.50]_95%CI) (all P ≤ 0.003). BMI improvement correlated with number of dietitian consultations (r = -0.30; P = 0.001). No significant differences were found between treatment arms in BMI (-0.46 kg/m² [-1.11, 0.18]_95%CI;P = 0.189), triglycerides (-24.70 mg/dL [-57.66, 8.25]_95%CI), LDL (-9.24 mg/dL [-20.50, 2.03]_95%CI), HDL and glycemic control.

CONCLUSIONS

Lifestyle intervention significantly improved BMI, LDL and triglycerides compared to baseline in at-risk MHRHs residents with SMI, yet compared to usual care the differences did not reach statistical significance. The association between the number of dietitian's consultations and BMI improvement suggests that programs should highlight participants' adherence.

Identifying effective characteristics of behavioral weight management interventions for people with serious mental illness: A systematic review with a qualitative comparative analysis

People with serious mental illness (SMI) have identified barriers to engaging in behavioral weight management interventions (BWMIs). We assessed whether BWMIs that addressed these barriers were more effective. First, we systematically reviewed qualitative literature and used a thematic analysis to identify the characteristics of BWMIs that promote engagement for adults with SMI. Second, we systematically reviewed randomized controlled trials (RCTs) of BWMIs in adults with SMI. Data on the characteristics that promoted engagement and weight outcomes were extracted. We then used a crisp-set qualitative comparative analysis (CsQCA) to identify which characteristics were associated with weight loss. For the qualitative review, 20 studies in 515 people with SMI were analyzed and nine characteristics were reported to promote engagement in BWMIs. For the systematic review, 34 RCTs testing 36 interventions in 4305 participants were included. The active interventions resulted in more weight loss (mean = -4.37 to +1 kg at 6 weeks to 18 months follow-up) compared with controls (-1.64 to +3.08 kg). The CsQCA showed BWMIs that offered regular contact, tools to support enactment, and tailored materials were associated with effectiveness. As these are all supplementary strategies, it may be possible to augment BWMIs available for the general population to engage people with SMI.

Transdiagnostic efficacy of a group exercise intervention for outpatients with heterogenous psychiatric disorders: a randomized controlled trial

BACKGROUND

Exercise efficaciously reduces disorder-specific symptoms of psychiatric disorders. The current study aimed to examine the efficacy of a group exercise intervention on global symptom severity and disorder-specific symptoms among a mixed outpatient sample.

METHODS

Groups of inactive outpatients, waiting for psychotherapy, with depressive disorders, anxiety disorders, insomnia, and attention-deficit/hyperactivity disorders were randomized to a manualized 12-week exercise intervention, combining moderate to vigorous aerobic exercise with techniques for sustainable exercise behaviour change (n = 38, female = 71.1% (n = 27), M_age = 36.66), or a passive control group (n = 36, female = 75.0% (n = 27), M_age = 34.33). Primary outcomes were global symptom severity and disorder-specific symptoms, measured with the Symptom Checklist-90-Revised and Pittsburgh Sleep Quality Index pre- and post-treatment. Secondary outcome was the self-reported amount of exercise (Physical Activity, Exercise, and Sport Questionnaire), measured pre-treatment, intermediate-, and post-treatment. Intention-to-treat analyses were conducted using linear mixed models. Linear regressions were conducted to examine the effect of the change of exercise behaviour on the change of symptoms.

RESULTS

The intervention significantly improved global symptom severity (d = 0.77, p = .007), depression (d = 0.68, p = .015), anxiety (d = 0.87, p = .002), sleep quality (d = 0.88, p = .001), and increased the amount of exercise (d = 0.82, p < .001), compared to the control group. Post-treatment differences between groups were significant for depression (d = 0.63, p = .031), sleep quality (d = 0.61, p = .035) and the amount of exercise (d = 1.45, p < .001). Across both groups, the reduction of global symptom severity was significantly predicted by an increase of exercise (b = .35, p = .012).

CONCLUSIONS

The exercise intervention showed transdiagnostic efficacy among a heterogeneous clinical sample in a realistic outpatient setting and led to sustained exercise behaviour change. Exercise may serve as an efficacious and feasible transdiagnostic treatment option improving the existing treatment gap within outpatient mental health care settings.

TRIAL REGISTRATION

The study was registered on ClinicalTrials.gov (ID: NCT03542396 , 25/04/2018).

Stepped-down intervention programs to promote self-managed physical activity in military service veterans: A systematic review of randomised controlled trials

OBJECTIVES

A stepped-down program is one where clients transition from the care of a health professional to self-managed care. This study reviewed the effectiveness of stepped-down interventions to promote self-managed physical activity for health in military service veterans.

DESIGN

Systematic review.

METHODS

Literature searches of 11 electronic databases were performed (up to 28th April 2020) to identify randomised controlled trials that assessed self-managed physical activity interventions in military service veterans. Data were extracted on study characteristics, intervention programs (with strategies mapped against a taxonomy of behaviour change techniques), and physical activity outcomes; secondary outcomes were physical fitness/function, psychosocial health, and cost effectiveness. Study quality was assessed using a 15-item checklist adapted from the TESTEX scale.

RESULTS

Searches identified 26 studies (all from the United States; N = 45 to 531 participants) representing 17 intervention programs. Studies were of good quality (M = 10.7; SD = 2.3). More than half (54%) reported positive between-group intervention effects for physical activity outcomes (mean increase of 80 min/week in self-reported physical activity at 10-12 months). Physical fitness/function outcomes improved in 38% of studies, but no studies found significant intervention effects for psychosocial health or cost effectiveness outcomes. Behaviour change techniques most frequently used to elicit physical activity changes were education, goal setting, goal review and self-monitoring.

CONCLUSIONS

Stepped-down programs that include specific behaviour change techniques have the potential to promote self-management of physical activity in military service veterans. Multi-national randomised controlled trials that use objective physical activity measures are needed to further build the evidence base.

Computerized Conjoint Analysis of the Weight Treatment Preferences of Individuals With Schizophrenia

OBJECTIVE

Innovative approaches are needed for assessing treatment preferences of individuals with schizophrenia. Conjoint analysis methods may help to identify preferences, but the usability and validity of these methods for individuals with schizophrenia remain unclear. This study examined computerized conjoint analysis for persons with schizophrenia and whether preferences for weight management programs predict service use.

METHODS

A computerized, patient-facing conjoint analysis system was developed through iterative consultation with 35 individuals with schizophrenia enrolled at a community mental health clinic. An additional 35 overweight participants with schizophrenia then used the system to choose among psychosocial weight management programs varying in four attributes: location (community or clinic), delivery mode (Internet or in person), leader (clinician or layperson), and training mode (individual or group). A multilevel logit model with partial preference data determined contributions of each attribute to groupwide preferences. Associations were studied between preferences and use of a psychosocial weight management group.

RESULTS

Conjoint analysis system usability was rated highly. Groupwide preferences were significantly influenced by location (p<0.001; clinic was preferred), leader (p=0.02; clinician was preferred), and training mode (p<0.001; group was preferred) but not delivery mode (p=0.68). Preferences did not correlate with age, gender, body mass index, illness severity, or subsequent program use. Participants described barriers to program attendance, including transportation, scheduling, privacy, psychiatric illness, and lack of motivation.

CONCLUSIONS

Computerized conjoint analysis can produce valid assessments of treatment preferences of persons with schizophrenia and inform treatment development and implementation. Although preferences may affect treatment use, they are one of multiple factors.

Mental Health Diagnostic Patterns in Behavioral Weight Loss Program Attendees

INTRODUCTION

Individuals with obesity have higher rates of mental health disorders, both singly and in combination, than individuals of normal weight. Mental health disorders may negatively impact weight loss treatment outcomes; however, little is known about the mental health burden of individuals using weight loss programs. The current study identifies common mental health diagnostic profiles among participants of MOVE!-the Veterans Health Administration's behavioral weight loss program.

MATERIAL AND METHODS

We used national VHA administrative data from fiscal year 2014 to identify veteran primary care patients who participated in at least one MOVE! session the previous year (n = 110,830). Using latent class analysis, we identified patient types (classes) characterized by the presence or absence of mental health diagnoses, both overall and stratified by age and gender.

RESULTS

There were several patient types (classes), including psychologically healthy, predominantly depressed, depressed with co-occurring mental disorders, and co-occurring mental disorders with no predominant psychological condition. Additional patient types were found in men of different ages. The majority of patients had at least one psychiatric disorder, particularly younger patients.

CONCLUSIONS

Efforts to improve patients' engagement in the MOVE! program may need to address barriers to care associated with mental health disorders or incorporate care for both obesity and mental health diagnoses in MOVE! A holistic approach may be particularly important for younger patients who have a higher comorbidity burden and longer care horizons. Future work may address if patient types found in the current study extend to non-VHA obesity treatment seekers.

Lifestyle Interventions for Weight Management in People with Serious Mental Illness: A Systematic Review with Meta-Analysis, Trial Sequential Analysis, and Meta-Regression Analysis Exploring the Mediators and Moderators of Treatment Effects

BACKGROUND

Serious mental illness (SMI) reduces life expectancy, primarily due to somatic comorbidity linked to obesity. Meta-analyses have found beneficial effects of lifestyle interventions in people with SMI and recommended their implementation to manage obesity.

OBJECTIVE

The objective of this systematic review was to assess the benefits and harms of individualized lifestyle interventions for weight in people diagnosed with SMI and to explore potential mediators and moderators of the effect.

METHODS

The protocol was registered at PROSPERO (CRD42016049093). Randomized clinical trials (RCTs) assessing the effect of individualized lifestyle interventions on weight management in people with SMI were included. Primary outcomes were differences in endpoint body mass index (BMI) and the proportion achieving clinically relevant weight loss (≥5%). Secondary outcomes included quality of life, cardiometabolic risk factors, and adverse effects.

RESULTS

We included 41 RCTs (n = 4,267). All trials were at high risk of bias according to the Cochrane Handbook for Systematic Reviews of Interventions. The experimental interventions reduced the mean difference in BMI by -0.63 kg/m2 (95% confidence interval [CI] = -1.02 to -0.23; p = 0.002; I2 = 70.7%) compared to the control groups. At postintervention follow-up (17 RCTs), the effect size remained similar but was no longer significant (BMI = -0.63 kg/m2; 95% CI = -1.30 to 0.04; p = 0.07; I2 = 48.8%). The risk ratio for losing ≥5% of baseline weight was 1.51 (95% CI = 1.07-2.13; p = 0.02) compared to the control groups. GRADE showed very low or low quality of evidence.

CONCLUSION

There is a statistically significant, but clinically insignificant, mean effect of individualized lifestyle interventions for weight reduction in people with SMI.

Interventions for the management of obesity in people with bipolar disorder

BACKGROUND

Bipolar disorder is one of the most common serious mental illnesses, affecting approximately 60 million people worldwide. Characterised by extreme alterations in mood, cognition, and behaviour, bipolar disorder can have a significant negative impact on the functioning and quality of life of the affected individual. Compared with the general population, the prevalence of comorbid obesity is significantly higher in bipolar disorder. Approximately 68% of treatment seeking bipolar patients are overweight or obese. Clinicians are aware that obesity has the potential to contribute to other physical health conditions in people with bipolar disorder, including diabetes, hypertension, metabolic syndrome, cardiovascular disease, and coronary heart disease. Cardiovascular disease is the leading cause of premature death in bipolar disorder, happening a decade or more earlier than in the general population. Contributing factors include illness-related factors (mood-related factors, i.e. mania or depression), treatment-related factors (weight implications and other side effects of medications), and lifestyle factors (physical inactivity, poor diet, smoking, substance abuse). Approaches to the management of obesity in individuals with bipolar disorder are diverse and include non-pharmacological interventions (i.e. dietary, exercise, behavioural, or multi-component), pharmacological interventions (i.e. weight loss drugs or medication switching), and bariatric surgery.

OBJECTIVES

To assess the effectiveness of interventions for the management of obesity in people with bipolar disorder.

SEARCH METHODS

We searched the Cochrane Common Mental Disorders Controlled Trials Register (CCMDCTR) and the Cochrane Central Register for Controlled Trials (CENTRAL) to February 2019. We ran additional searches via Ovid databases including MEDLINE, Embase, and PsycInfo to May 2020. We searched the World Health Organization (WHO) trials portal (International Clinical Trials Registry Platform (ICTRP)) and ClinicalTrials.gov. We also checked the reference lists of all papers brought to full-text stage and all relevant systematic reviews.

SELECTION CRITERIA

Randomised controlled trials (RCTs), randomised at the level of the individual or cluster, and cross-over designs of interventions for management of obesity, in which at least 80% of study participants had a clinical diagnosis of bipolar disorder and comorbid obesity (body mass index (BMI) ≥ 30 kg/m²), were eligible for inclusion. No exclusions were based on type of bipolar disorder, stage of illness, age, or gender. We included non-pharmacological interventions comprising dietary, exercise, behavioural, and multi-component interventions; pharmacological interventions consisting of weight loss medications and medication switching interventions; and surgical interventions such as gastric bypass, gastric bands, biliopancreatic diversion, and vertical banded gastroplasty. Comparators included the following approaches: dietary intervention versus inactive comparator; exercise intervention versus inactive comparator; behavioural intervention versus inactive comparator; multi-component lifestyle intervention versus inactive comparator; medication switching intervention versus inactive comparator; weight loss medication intervention versus inactive comparator; and surgical intervention versus inactive comparator. Primary outcomes of interest were changes in body mass, patient-reported adverse events, and quality of life.

DATA COLLECTION AND ANALYSIS

Four review authors were involved in the process of selecting studies. Two review authors independently screened the titles and abstracts of studies identified in the search. Studies brought to the full-text stage were then screened by another two review authors working independently. However, none of the full-text studies met the inclusion criteria. Had we included studies, we would have assessed their methodological quality by using the criteria recommended in the Cochrane Handbook for Systematic Reviews of Interventions. We intended to combine dichotomous data using risk ratios (RRs), and continuous data using mean differences (MDs). For each outcome, we intended to calculate overall effect size with 95% confidence intervals (CIs).

MAIN RESULTS

None of the studies that were screened met the inclusion criteria.

AUTHORS' CONCLUSIONS

None of the studies that were assessed met the inclusion criteria of this review. Therefore we were unable to determine the effectiveness of interventions for the management of obesity in individuals with bipolar disorder. Given the extent and impact of the problem and the absence of evidence, this review highlights the need for research in this area. We suggest the need for RCTs that will focus only on populations with bipolar disorder and comorbid obesity. We identified several ongoing studies that may be included in the update of this review.

Quality of life outcomes of web-based and in-person weight management for adults with serious mental illness

Adults with serious mental illness have high rates of obesity, with associated negative impacts on health-related quality of life. The present study utilized data from a randomized controlled trial (N = 276) to examine the effectiveness of in-person and online-delivered weight management interventions, compared to usual care, for improving health-related quality of life in this population. Participants completed quality of life assessments at baseline, 3 months, and 6 months. Mixed effects models examined group by time interactions. Compared to usual care, in-person MOVE was associated with improvements in loneliness (t = - 2.76, p = .006) and mental health related quality of life (t = 1.99, p = 0.048) at 6 months, and webMOVE was associated with improvements in weight-related self-esteem at 6 months (t = 2.23, p = .026) and mental health-related quality of life at 3 months (t = 2.17, p = 0.031) and 6 months (t = 2.38, p = .018). Web-based and in-person weight management led to improvements in health-related quality of life for adults with serious mental illness.ClinicalTrials.gov Identifier: NCT00983476.

An appraisal of methodology reporting in lifestyle interventions among people with psychosis: A systematic review

ISSUE ADDRESSED

Lifestyle interventions use nutrition and physical activity behaviour modification techniques to decrease obesity and cardio-metabolic risk in people with psychosis. Evidence on the specific behaviour modification strategies applied to decrease obesity is weakened by inadequate methodology reporting of lifestyle interventions. A systematic review that we conducted earlier highlighted a possible deficiency in reporting; hence we aim to critically appraise lifestyle intervention studies that target weight outcomes for people with psychosis against the methods component of the CONSORT statement for randomised trials of nonpharmacologic treatments.

METHODS COMPONENT

We considered randomised controlled studies which delivered lifestyle interventions to community-dwelling adults with psychotic disorders, and included those with the following outcomes of interest: weight, body mass index, waist circumference and waist-to-hip ratio. The Cochrane Library, MEDLINE/PREMEDLINE, EMBASE, CINAHL, Scopus and PsycINFO were searched for English publications between 1985 and 2018. Methodology and reporting of studies were evaluated using the CONSORT statement for randomised trials of nonpharmacologic treatments.

RESULTS

Thirty-two studies met the inclusion criteria. Critical appraisals revealed that reporting of lifestyle intervention studies was generally incomplete. Fewer than 50% provided the recommended information on trial design, participant characteristics, detail of interventions, outcomes, sample size, randomisation, blinding and statistical methods.

CONCLUSIONS

Application of guidelines, like the CONSORT statement, in future publications of lifestyle interventions for people with psychosis will improve accuracy of reporting. SO WHAT?: Enhanced reporting in lifestyle intervention studies for people with psychosis will promote guideline creation and translation of research, which is likely to positively impact physical health outcomes.

Perspectives on diet and physical activity among urban African Americans with serious mental illness

African Americans are burdened by high rates of obesity that contribute to chronic disease and early mortality. To tailor a weight loss intervention to meet the needs of African Americans with serious mental illness, a community-based participatory research (CBPR) team comprised primarily of African Americans with serious mental illness guided qualitative research to understand factors that affect weight and interventions that may diminish obesity. Data from five focus groups (n = 55) were analyzed to better understand this group's needs. Participants voiced individual, social, and structural barriers to maintaining and achieving a healthy weight and provided perspectives on potential solutions.

Impact of lifestyle modification on some components of metabolic syndrome in persons with severe mental disorders: A meta-analysis

BACKGROUND

Metabolic syndrome (MS) is reportedly associated with high mortality from mostly cardiovascular causes in patients with severe mental disorders (SMD). Lifestyle interventions augment effective management of MS in patients with SMD. The present meta-analysis aims at updating the recent evidence on the effectiveness of lifestyle intervention for MS in patients with SMD.

METHOD

A literature search for English Language publications of randomized controlled trials (RCTs) from 2001 to 2016 comparing lifestyle modification (LM) with treatment as usual (TAU) in the management of MS were identified. Using PRISMA guidelines, 19 RCTs reporting data on 1688 SMD and MS patients and providing data on change in Body Weight, Body Mass Index (BMI) and waist circumference (WC) were included. Using random effects model, standardized mean difference between LM and TAU for the mean baseline-to-endpoint change in body weight, BMI and WC was calculated with a 95% confidence limit, on RevMan 5.3. The study was registered with PROSPERO (CRD42016046847).

RESULTS

LM had significantly superior efficacy in the reducing weight (-0.64, 95% CI -0.89, -0.39, Z = 5.03, overall effect p < 0.00001), BMI (-0.68, 95% CI -1.01, -0.35, Z = 4.05, overall effect p < 0.0001), and WC (-0.60, 95% CI -1.17, -0.03, Z = 2.06; overall effect p = 0.04), compared to TAU. LM was significantly more effective than TAU even in short duration (p = 0.0001) and irrespective of the treatment setting.

CONCLUSION

Interventions targeting LM in persons with SMD and MS are effective in reducing body weight, BMI and WC. It must be routinely recommended to all patients with SMD, ideally during commencement stage of second generation antipsychotic treatment.

Is it possible for people with severe mental illness to sit less and move more? A systematic review of interventions to increase physical activity or reduce sedentary behaviour

Individuals with severe mental illness (SMI) (schizophrenia-spectrum, bipolar disorder and major depressive disorder) die 10-20 years prematurely due to physical disorders such as cardiovascular disease. Physical activity (PA) is effective in preventing and managing these conditions in the general population, however individuals with SMI engage in substantially less PA and more sedentary behaviour (SB) compared to healthy counterparts. Furthermore, the effectiveness of intervening to increase PA or reduce SB in SMI populations is unknown. Therefore, we systematically reviewed studies measuring changes in PA or SB following behavioural interventions in people with SMI. A systematic search of major databases was conducted from inception until 1/3/2018 for behavioural interventions reporting changes in PA or SB in people with SMI. From 3018 initial hits, 32 articles were eligible, including 16 controlled trials (CT's; Treatment n = 1025, Control n = 1162) and 16 uncontrolled trials (n = 655). Of 16 CTs, seven (47%) reported significant improvements in PA, although only one found changes with an objective measure. Of 16 uncontrolled trials, 3 (20%) found improvements in PA (one with objective measurement). No intervention study had a primary aim of changing SB, nor did any note changes in SB using an objective measure. In conclusion, there is inconsistent and low quality evidence to show that interventions can be effective in changing PA or SB in this population. Future robust randomized controlled trials, using objectively-measured PA/SB as the primary outcome, are required to determine which behavioural interventions are effective in improving the sedentary lifestyles associated with SMI. Systematic review registration- PROSPERO registration number CRD42017069399.

Impact of Online Weight Management With Peer Coaching on Physical Activity Levels of Adults With Serious Mental Illness

OBJECTIVE

Many adults with serious mental illness are sedentary and experience significant medical illness burden. This study examined the effectiveness of online weight management with peer coaching (WebMOVE) for increasing general physical activity among adults with serious mental illness.

METHODS

Using quantitative and qualitative data from a randomized controlled trial (N=276), this study compared WebMOVE, in-person weight management for adults with serious mental illness (MOVE SMI), and usual care. Participants completed assessments of general physical activity (baseline, three months, and six months) and a qualitative assessment (six months). Mixed-effects models examined group × time interactions on general physical activity.

RESULTS

There were significant differences between MOVE SMI and usual care for total physical activity at three (t=3.06, p=.002) and six (t=3.12, p=.002) months, walking at six months (t=1.99, p=.048), and moderate (t=2.12, p=.035) and vigorous (t=2.34, p=.020) physical activity at six months. There was a significant difference between WebMOVE and usual care for total physical activity at six months (t=2.02, p=.044) and a trend for a group difference in walking at six months (t=1.78, p=.076). These findings reflected a decline in physical activity among participants in usual care and an increase in physical activity among participants in MOVE SMI or WebMOVE.

CONCLUSIONS

In-person weight management counseling increased total physical activity and led to initiation of moderate and vigorous physical activity among adults with serious mental illness. Computerized weight management counseling with peer support led to more gradual increases in total physical activity.

Effectiveness of Interventions for Weight Loss for People With Serious Mental Illness: A Systematic Review and Meta-Analysis

OBJECTIVE

We examined the effectiveness of weight loss interventions in community-based settings for people with serious mental illness (SMI).

METHOD

Four databases were searched for randomized controlled trials published in 2008 or later that met the criteria for the research question and used weight loss as an outcome measure. Data were extracted, and weight loss was analyzed using a meta-analysis. Similarities and differences in interventions were analyzed qualitatively.

RESULTS

Seventeen studies and a total of 1,874 participants with various diagnoses of SMI were included in the meta-analysis. The various lifestyle-focused interventions had a significant effect on weight loss with an overall effect size of -0.308 (p < .001).

CONCLUSION

Community-based interventions for people with SMI are effective for weight loss. Occupational therapists can be involved in the provision of weight loss interventions and in the development and study of intervention components that are most effective.

Does mental health influence weight loss in adults with prediabetes? Findings from the VA Diabetes Prevention Program

OBJECTIVES

Mental illness may impact outcomes from structured behavioral weight loss interventions. This secondary analysis investigated the influence of mental health on weight loss among Veterans with prediabetes enrolled in either an in-person diabetes prevention program (DPP) or the usual care weight management program (MOVE!) designed to help patients achieve weight loss through changes in physical activity and diet.

METHODS

Prediabetes was defined by Hemoglobin A1c between 5.7 and 6.4% or Fasting Plasma Glucose 100-125 mg/dL and no use of antiglycemic medications during the past six months. Veterans Health Administrative data were used to assign Veterans into one of three mental health diagnoses: severe mental illness (SMI), affective disorder (AD) without SMI, or No SMI/No AD. The influence of mental health on weight changes at 6 and 12 months was modeled using linear mixed-effects regression.

RESULTS

On average, Veterans with prediabetes (n = 386) were 59 years old (SD = 10.0 years), with a BMI of 34.8 kg/m² (SD = 5.3 kg/m²) and A1c of 6.0% (SD = 0.2%). The sample consisted of 12% (n = 47), 39% (n = 150), and 49% (n = 189) diagnosed with SMI, AD and No SMI/No AD, respectively. Across interventions, Veterans with SMI lost less weight than those with AD or No SMI/No AD. From baseline to 6 months, weight loss was significantly less for Veterans with SMI (1.53 kg) compared to Veterans with AD (3.85 kg) or No SMI/No AD (3.73 kg). This weight loss trend by mental health diagnosis continued from baseline to 12 months but was no longer statistically significant at 12 months.

CONCLUSION

Weight loss was not clinically or statistically different among Veterans with prediabetes diagnosed with AD or No SMI/No AD. However, Veterans diagnosed with SMI exhibited less weight loss over 6 months than Veterans with AD or No SMI/No AD and though not statistically significant, the trend continued to 12 months, suggesting that SMI may influence weight loss outcomes.

Systematic Review of Behavioral Weight Management Program MOVE! for Veterans

CONTEXT

Since 2006, the Veterans Health Administration has delivered a population-based behavioral weight management program (MOVE!) to Veterans, which numerous studies have examined. The purpose of this study was to systematically review these studies to understand MOVE! participation rates and the association between MOVE! participation and weight change.

EVIDENCE ACQUISITION

A December 2016 PubMed search identified 320 English-language abstracts published between January 1, 2005 and December 31, 2016, of which 42 underwent full-text review. Twenty-six articles were determined to be eligible for final inclusion and data elements extracted from these articles included study years, study design, content of MOVE! and control intervention (if any), inclusion/exclusion criteria, initial sample size and sample loss, intervention duration and follow-up, patient characteristics, and outcomes. Quality was assessed using the Newcastle-Ottawa Quality Scale.

EVIDENCE SYNTHESIS

Studies were judged to be of good quality. Twenty-one of the 26 studies were retrospective cohort studies, one was a prospective cohort study and four were randomized trials. Program participation varied substantially (2%-12%) across studies. Six-month weight loss ranged from -0.95 kg to -1.84 kg, whereas 12-month weight loss ranged from -0.13 kg to -3.3 kg. A maximum of 25% of MOVE! users engaged in intense and sustained participation (eight or more visits within 6 months), but higher participation levels were consistently associated with greater weight change (-1.18 kg to -5.3 kg at 6 months, -1.68 kg to -3.58 kg at 12 months).

CONCLUSIONS

MOVE! participation is associated with modest short-term weight loss, with greater weight loss as participation increases. More research is needed to understand the barriers and facilitators to participation and the effect of MOVE! participation on long-term health and economic outcomes.

Lifestyle interventions for weight loss among overweight and obese adults with serious mental illness: A systematic review and meta-analysis

OBJECTIVE

To conduct a systematic review and meta-analysis to estimate effects of lifestyle intervention participation on weight reduction among overweight and obese adults with serious mental illness.

METHOD

We systematically searched electronic databases for randomized controlled trials comparing lifestyle interventions with other interventions or usual care controls in overweight and obese adults with serious mental illness, including schizophrenia spectrum or mood disorders. Included studies reported change in weight [kg] or body mass index (BMI) [kg/m2] from baseline to follow-up. Standardized mean differences (SMD) were calculated for change in weight from baseline between intervention and control groups.

RESULTS

Seventeen studies met inclusion criteria (1968 participants; 50% male; 66% schizophrenia spectrum disorders). Studies were grouped by intervention duration (≤6-months or ≥12-months). Lifestyle interventions of ≤6-months duration showed greater weight reduction compared with controls as indicated by effect size for weight change from baseline (SMD=-0.20; 95% CI=-0.34, -0.05; 10 studies), but high statistical heterogeneity (I2=90%). Lifestyle interventions of ≥12-months duration also showed greater weight reduction compared with controls (SMD=-0.24; 95% CI=-0.36, -0.12; 6 studies) with low statistical heterogeneity (I2=0%).

CONCLUSION

Lifestyle interventions appear effective for treating overweight and obesity among people with serious mental illness. Interventions of ≥12-months duration compared to ≤6-months duration appear to achieve more consistent outcomes, though effect sizes are similar for both shorter and longer duration interventions.

Improving physical health of patients with severe mental disorders: a critical review of lifestyle psychosocial interventions

INTRODUCTION

People with severe mental disorders have a mortality rate that is more than two times higher than the general population, with at least a decade of potential years of life lost. People with mental disorders have a significantly higher risk of obesity, hyperglycemia and metabolic syndrome, which are related to modifiable risk factors, such as heavy smoking, poor physical activities, and inappropriate unhealthy diet, which can be improved through lifestyle changes. Areas covered: Lifestyle behaviours are amenable to change through the adoption of specific psychosocial interventions, and several approaches have been promoted. In the present review, the authors aim to: 1) critically analyze studies involving multimodal lifestyle interventions; 2) discuss the way forward to integrate these interventions in clinical routine care. Expert commentary: The psychoeducational approaches developed for the improvement of healthy lifestyle behaviours differ for several aspects: 1) the format (individual vs. group); 2) the setting (outpatient vs. inpatient vs. home-based); 3) the professional characteristics of the staff running the intervention (psychiatrists or nurses or dietitians or psychologists); 4) the active ingredients of the intervention (education only or inclusion of motivational interview or of problem solving); 5) the duration of treatment (ranging from 3 months to 2 years).

Examining the Dose-Response Relationship in the Veterans Health Administration's MOVE!® Weight Management Program: A Nationwide Observational Study

BACKGROUND

For more than a decade, the Veterans Health Administration (VHA) has offered MOVE!, a comprehensive lifestyle intervention for weight management. However, there is limited knowledge to inform resource allocation decisions at the health system level-for example, the choice between reaching new veterans with weight management treatment, re-engaging veterans who have stopped attending, and/or increasing contact with current MOVE!

OBJECTIVE

To inform VHA policy and planning, this VHA-wide study examines the relationship between MOVE! participation and weight outcomes.

DESIGN

A longitudinal observational study of veterans across VHA who participated in MOVE!.

PARTICIPANTS

Veterans who initiated their most recent episode of MOVE! care between 2004 and 2014.

MAIN MEASURES

Weight measurements were abstracted from VHA electronic health records. The primary outcome was the proportion of veterans with clinically relevant weight loss. The predictor of interest was number of MOVE! contacts during the 12 months following MOVE! initiation.

KEY RESULTS

The cohort consisted of 237,577 veterans (87.4% male; mean age 54.4 years), who had 5.3 contacts on average in the 12 months following initiation. Veterans with 2-5 contacts had the same odds of achieving clinically relevant weight loss as veterans with only one contact (adjusted OR: 1.00, 95% CI: 0.98-1.03). Veterans with 6-9, 10-13, 14-17, and 18 or more contacts had significantly higher odds of clinically relevant weight loss (adjusted OR: 1.17, 95% CI: 1.13-1.20; adjusted OR: 1.53, 95% CI: 1.47-1.59; adjusted OR: 1.84, 95% CI: 1.74-1.94; adjusted OR: 2.21, 95% CI: 2.12-2.31, respectively).

CONCLUSIONS

Veterans with ≥6 MOVE! contacts in the year following treatment initiation were significantly more likely to achieve clinically relevant weight loss than those with one contact, with greater participation further increasing the odds of clinically relevant weight loss. While further characterization of weight loss predictors is needed, the VHA should provide policy guidance that supports increasing participation among veterans who have initiated MOVE!.

Improving Weight in People with Serious Mental Illness: The Effectiveness of Computerized Services with Peer Coaches

BACKGROUND

People with serious mental illness have high rates of obesity and related medical problems, and die years prematurely, most commonly from cardiovascular disease. Specialized, in-person weight management interventions result in weight loss in efficacy trials with highly motivated patients. In usual care, patient enrollment and retention are low with these interventions, and effectiveness has been inconsistent.

OBJECTIVE

To determine whether computerized provision of weight management with peer coaching is feasible to deliver, is acceptable to patients, and is more effective than in-person delivery or usual care.

DESIGN

Mixed-methods randomized controlled trial.

PARTICIPANTS

Two hundred seventy-six overweight patients with serious mental illness receiving care at a Veterans Administration medical center.

INTERVENTIONS

Patients were randomized to 1) computerized weight management with peer coaching (WebMOVE), 2) in-person clinician-led weight services, or 3) usual care. Both active interventions offered the same educational content.

MAIN MEASURES

Body mass index; and feasibility and acceptability of the intervention.

KEY RESULTS

At 6 months, in obese patients (n = 200), there was a significant condition by visit effect (F = 4.02, p = 0.02). The WebMOVE group had an average estimated BMI change from baseline to 6 months of 34.9 ± 0.4 to 34.1 ± 0.4. This corresponds to 2.8 kg (6.2 lbs) weight loss (t = 3.2, p = 0.001). No significant change in BMI was seen with either in-person services (t = 0.10, p = 0.92), or usual care (t = -0.25, p = 0.80). The average percentage of modules completed in the WebMOVE group was 49% and in the in-person group was 41% (t = 1.4, p = 0.17). When non-obese patients were included in the analyses, there was a trend towards a condition by visit effect (F = 2.8, p = 0.06). WebMOVE was well received, while the acceptability of in-person services was mixed.

CONCLUSIONS

Computerized weight management with peer support results in lower weight, and can have greater effectiveness than clinician-led in-person services. This intervention is well received, and could be feasible to disseminate.

The Obesity Epidemic in the Veterans Health Administration: Prevalence Among Key Populations of Women and Men Veterans

BACKGROUND

Most US adults are overweight or obese. Understanding differences in obesity prevalence across subpopulations could facilitate the development and dissemination of weight management services.

OBJECTIVES

To inform Veterans Health Administration (VHA) weight management initiatives, we describe obesity prevalence among subpopulations of VHA patients.

DESIGN

Cross-sectional descriptive analyses of fiscal year 2014 (FY2014) national VHA administrative and clinical data, stratified by gender. Differences ≥5% higher than the population mean were considered clinically significant.

PARTICIPANTS

Veteran VHA primary care patients with a valid weight within ±365 days of their first FY2014 primary care visit, and a valid height (98% of primary care patients).

MAIN MEASURES

We used VHA vital signs data to ascertain height and weight and calculate body mass index, and VHA outpatient, inpatient, and fee basis data to identify sociodemographic- and comorbidity-based subpopulations.

KEY RESULTS

Among nearly five million primary care patients (347,112 women, 4,567,096 men), obesity prevalence was 41% (women 44%, men 41%), and overweight prevalence was 37% (women 31%, men 38%). Across the VHA's 140 facilities, obesity prevalence ranged from 28% to 49%. Among gender-stratified subpopulations, obesity prevalence was high among veterans under age 65 (age 18-44: women 40%, men 46%; age 45-64: women 49%, men 48%). Obesity prevalence varied across racial/ethnic and comorbidity subpopulations, with high obesity prevalence among black women (51%), women with schizophrenia (56%), and women and men with diabetes (68%, 56%).

CONCLUSIONS

Overweight and obesity are common among veterans served by the VHA. VHA's weight management initiatives have the potential to avert long-term morbidity arising from obesity-related conditions. High-risk groups-such as black women veterans, women veterans with schizophrenia, younger veterans, and Native Hawaiian/Other Pacific Islander and American Indian/Alaska Native veterans-may require particular attention to ensure that systems improvement efforts at the population level do not inadvertently increase health disparities.

Solving a weighty problem: systematic review and meta-analysis of nutrition interventions in severe mental illness

BACKGROUND

Nutrition interventions would appear fundamental for weight management and cardiometabolic risk reduction in people experiencing severe mental illness (SMI). Comprehensive evaluation of nutrition interventions is lacking.

AIMS

To subject randomised controlled trials of nutrition interventions in people with SMI to systematic review and meta-analysis, and to measure anthropometric and biochemical parameters and nutritional intake.

METHOD

An electronic database search identified trials with nutrition intervention components. Trials were pooled for meta-analysis. Meta-regression analyses were performed on anthropometric moderators.

RESULTS

Interventions led to significant weight loss (19 studies), reduced body mass index (17 studies), decreased waist circumference (10 studies) and lower blood glucose levels (5 studies). Dietitian-led interventions (6 studies) and studies delivered at antipsychotic initiation (4 studies) had larger effect sizes.

CONCLUSIONS

Evidence supports nutrition interventions as standard care in preventing and treating weight gain among people experiencing SMI.

The Effectiveness of Pharmacological and Non-Pharmacological Interventions for Improving Glycaemic Control in Adults with Severe Mental Illness: A Systematic Review and Meta-Analysis

People with severe mental illness (SMI) have reduced life expectancy compared with the general population, which can be explained partly by their increased risk of diabetes. We conducted a meta-analysis to determine the clinical effectiveness of pharmacological and non-pharmacological interventions for improving glycaemic control in people with SMI (PROSPERO registration: CRD42015015558). A systematic literature search was performed on 30/10/2015 to identify randomised controlled trials (RCTs) in adults with SMI, with or without a diagnosis of diabetes that measured fasting blood glucose or glycated haemoglobin (HbA_1c). Screening and data extraction were carried out independently by two reviewers. We used random effects meta-analysis to estimate effectiveness, and subgroup analysis and univariate meta-regression to explore heterogeneity. The Cochrane Collaboration’s tool was used to assess risk of bias. We found 54 eligible RCTs in 4,392 adults (40 pharmacological, 13 behavioural, one mixed intervention). Data for meta-analysis were available from 48 RCTs (n = 4052). Both pharmacological (mean difference (MD), -0.11mmol/L; 95% confidence interval (CI), [-0.19, -0.02], p = 0.02, n = 2536) and behavioural interventions (MD, -0.28mmol//L; 95% CI, [-0.43, -0.12], p<0.001, n = 956) were effective in lowering fasting glucose, but not HbA_1c (pharmacological MD, -0.03%; 95% CI, [-0.12, 0.06], p = 0.52, n = 1515; behavioural MD, 0.18%; 95% CI, [-0.07, 0.42], p = 0.16, n = 140) compared with usual care or placebo. In subgroup analysis of pharmacological interventions, metformin and antipsychotic switching strategies improved HbA_1c. Behavioural interventions of longer duration and those including repeated physical activity had greater effects on fasting glucose than those without these characteristics. Baseline levels of fasting glucose explained some of the heterogeneity in behavioural interventions but not in pharmacological interventions. Although the strength of the evidence is limited by inadequate trial design and reporting and significant heterogeneity, there is some evidence that behavioural interventions, antipsychotic switching, and metformin can lead to clinically important improvements in glycaemic measurements in adults with SMI.

Leveraging Spousal Support to Improve Health Promotion in Serious Mental Illness

Although the majority of Veterans are overweight or obese, and many have comorbid mental health disorders, little is known about the most effective way to intervene in this complex population. This case describes a telephone-based cognitive-behavioral treatment for depression and weight management with an obese Veteran with bipolar disorder. His wife joined sessions to leverage spousal support. The Veteran evidenced variable levels of physical activity and mood fluctuations during treatment; although he reported some degree of positive behavior change and improved social support, he did not lose weight. He continued to endorse moderate levels of depressive symptomatology at the end of the nine-session intervention. This case illustrates the complexity of treating those with chronic serious mental illness and multimorbidities. Further research is needed to inform interventions that concurrently improve mental health symptomatology and weight-related outcomes in chronic, complex cases.

Sex Differences in Weight Loss among Veterans with Serious Mental Illness: Observational Study of a National Weight Management Program

PURPOSE

Obesity disproportionately burdens individuals with serious mental illness (SMI), especially women. This observational study investigated whether there were sex differences in weight loss and program participation among veterans with SMI enrolled in the Veterans Health Administration's (VHA) MOVE! weight management program.

PROCEDURES

Participants were identified from a national cohort of 148,254 veterans enrolled in MOVE! during fiscal years 2008 through 2012 who attended two or more sessions within 12 months of enrollment. The cohort included those with International Classification of Disease, 9th Edition, Clinical Modification (ICD-9-CM) diagnoses for SMI, age less than 70 years, and weight data at baseline and one or more follow-up timepoints within approximately 1 year of enrollment (n = 8,943 men; n = 2,245 women). Linear mixed models assessed associations of sex with 6- and 12-month weight change from baseline, adjusting for demographic- and site-level variables.

FINDINGS

Both sexes averaged 6.4 (standard deviation, 4.6) sessions within 12 months; however, women with and without SMI participated at rates double their respective proportion rates among all VHA users. Participants averaged statistically significant weight loss at 6 months (men, -2.5 lb [95% CI, -2.8 to -2.1]; women, -2.4 lb [95% CI, -3.1 to -1.7]) and 12 months (men, -2.5 lb [95% CI, -2.8 to -2.2]; women, -2.9 lb [95% CI, -3.6 to -2.2]), but no sex-based difference in absolute weight loss at either timepoint. Slightly more women achieved 5% or greater (clinically significant) weight loss at the 12-month follow-up than did men (25.7% vs. 23.0%; p < .05).

CONCLUSIONS

Women with SMI participated in MOVE! at rates equivalent to or greater than men with SMI, with comparable weight loss. More women were Black, single, had bipolar and posttraumatic stress disorder, and higher service-connected disability, suggesting areas for program customization.

Women Veterans' Treatment Preferences for Disordered Eating

OBJECTIVE

Disordered eating, which includes subclinical and clinical maladaptive eating behaviors, is common among women, including those served by the Veterans Health Administration (VA). We used qualitative methods to determine whether and how women veterans want to receive treatment for disordered eating.

METHOD

Women veterans participated in one of seven focus groups/interviews and completed in-person demographic and psychological questionnaires. We used thematic analysis of focus groups/interviews to understand preferences for disordered eating treatment.

RESULTS

Participants (n = 20) were mostly women of color (55%); mean age was 48 (SD = 15) and 65% had significant psychological symptoms. Few participants described being assessed for disordered eating, but all thought VA should provide treatment for disordered eating. Through thematic analysis, we identified six preferences: 1) treatment for disordered eating should be provided in groups, 2) treatment for disordered eating should provide concrete skills to facilitate the transition out of structured military environments, 3) treatment for disordered eating should address the relationship between eating and mental health, 4) disordered eating can be treated with mindfulness and cognitive-behavioral therapy, 5) disordered eating treatment providers should be experienced and take an interactive approach to care, but can come from diverse disciplines, and 6) referrals to treatment for disordered eating should be open ended, occur early, and allow for ongoing, flexible access to treatment.

CONCLUSIONS

Women veterans are interested in treatment for disordered eating. Preferred treatments align with existing treatments, could be offered in conjunction with weight loss or primary care services, and should provide social support and interactive learning.

Physical activity counseling in overweight and obese primary care patients: Outcomes of the VA-STRIDE randomized controlled trial

The purpose of this 2-arm randomized clinical trial was to evaluate the effectiveness of a 12-month, expert system-based, print-delivered physical activity intervention in a primary care Veteran population in Pittsburgh, Pennsylvania. Participants were not excluded for many health conditions that typically are exclusionary criteria in physical activity trials. The primary outcome measures were physical activity reported using the Community Healthy Activities Model Program for Seniors (CHAMPS) questionnaire and an accelerometer-based activity assessment at baseline, 6, and 12 months. Of the 232 Veterans enrolled in the study, 208 (89.7%) were retained at the 6-month follow-up and 203 (87.5%) were retained at 12 months. Compared to the attention control, intervention participants had significantly increased odds of meeting the U.S. recommended guideline of ≥ 150 min/week of at least moderate-intensity physical activity at 12 months for the modified CHAMPS (odds ratio [OR] = 2.86; 95% CI: 1.03-7.96; p = 0.04) but not at 6 months (OR = 1.54; 95% CI: 0.56-4.23; p = 0.40). Based on accelerometer data, intervention participants had significantly increased odds of meeting ≥ 150 min/week of moderate-equivalent physical activity at 6 months (OR = 6.26; 95% CI: 1.26-31.22; p = 0.03) and borderline significantly increased odds at 12 months (OR = 4.73; 95% CI: 0.98-22.76; p = 0.053). An expert system physical activity counseling intervention can increase or sustain the proportion of Veterans in primary care meeting current recommendations for moderate-intensity physical activity. Trial Registration Clinical trials.gov identifier: NCT00731094 URL: http://www.clinicaltrials.gov/ct2/show/NCT00731094.

Motivation for physical activity and exercise in severe mental illness: A systematic review of intervention studies

There has been increasing interest for research on motivation for physical activity (PA) and exercise among individuals with severe mental illness (SMI). The aim of this systematic review is to summarize findings from all intervention studies on PA or exercise that either include empirical data on motivational constructs or apply motivational techniques/theories in their intervention. Systematic searches of seven databases were conducted from database inception to February 2015. Studies were eligible if they: (i) included participants with SMI, (ii) had PA as part of the intervention, and (iii) reported empirical data on motivational constructs related to PA or incorporated motivational techniques/theory in their intervention. Of the 79 studies that met the inclusion criteria only one had motivation for PA as its main outcome. Nine additional interventions reported empirical data on motivational constructs. Altogether these studies yielded mixed results with respect to change in motivational constructs. Only one of those examined the association between motivation and PA, but found none. Sixty-four studies reported using motivational techniques/theory in their intervention. Motivational interviewing and goal-setting were the most popular techniques. Due to the exploratory nature of most of these studies, findings from intervention studies do not so far give very clear directions for motivational work with the patients. There is an urgent need for a more systematic theory based approach when developing strategies that target to increase engagement in PA among people with SMI.

Interventions to Address Medical Conditions and Health-Risk Behaviors Among Persons With Serious Mental Illness: A Comprehensive Review

People with serious mental illness (SMI) have mortality rates 2 to 3 times higher than the overall US population, largely due to cardiovascular disease. The prevalence of cardiovascular risk factors such as obesity and diabetes mellitus and other conditions, such as HIV/AIDS, is heightened in this group. Based on the recommendations of a National Institute of Mental Health stakeholder meeting, we conducted a comprehensive review examining the strength of the evidence surrounding interventions to address major medical conditions and health-risk behaviors among persons with SMI. Peer-reviewed studies were identified using 4 major research databases. Randomized controlled trials and observational studies testing interventions to address medical conditions and risk behaviors among persons with schizophrenia and bipolar disorder between January 2000 and June 2014 were included. Information was abstracted from each study by 2 trained reviewers, who also rated study quality using a standard tool. Following individual study review, the quality of the evidence (high, medium, low) and the effectiveness of various interventions were synthesized. 108 studies were included. The majority of studies examined interventions to address overweight/obesity (n = 80). The strength of the evidence was high for 4 interventions: metformin and behavioral interventions had beneficial effects on weight loss; and bupropion and varenicline reduced tobacco smoking. The strength of the evidence was low for most other interventions reviewed. Future studies should test long-term interventions to cardiovascular risk factors and health-risk behaviors. In addition, future research should study implementation strategies to effectively translate efficacious interventions into real-world settings.

Using Smartphone Apps to Promote Psychiatric and Physical Well-Being

This pilot study tested the acceptability and usability of a prototype app designed to promote the physical well-being of adults with psychiatric disorders. The application under evaluation, WellWave, promoted walking as a physical exercise, and offered a variety of supportive non-physical activities, including confidential text-messaging with peer staff, and a digital library of readings and videos on recovery from psychiatric illness. Study participants engaged strongly in the app throughout the 4-week study, showing a 94 % mean daily usage rate, and a 73 % mean response rate across all electronic messages and prompts, which approximates the gold standard of 75 % for momentary ecological assessment studies. Seven of the ten study participants averaged two or more walks per week, beginning with 5-min walks and ending with walks lasting 20 min or longer. This responsiveness to the walking prompts, and the overall high rate of engagement in other app features, suggest that adults with psychiatric conditions would welcome and benefit from similar smartphone interventions that promote healthy behaviours in life domains other than exercise. Pilot study results also suggest that smartphone applications can be useful as research tools in the development and testing of theories and practical strategies for encouraging healthy lifestyles. Participants were prompted periodically to rate their own health quality, perceived control over their health, and stage-of-change in adopting a walking routine, and these electronic self-ratings showed acceptable concurrent and discriminant validity, with all participants reporting moderate to high motivation to exercise by the end of the study.

Pragmatic replication trial of health promotion coaching for obesity in serious mental illness and maintenance of outcomes

OBJECTIVE

Few studies targeting obesity in serious mental illness have reported clinically significant risk reduction, and none have been replicated in community settings or demonstrated sustained outcomes after intervention withdrawal. The authors sought to replicate positive health outcomes demonstrated in a previous randomized effectiveness study of the In SHAPE program across urban community mental health organizations serving an ethnically diverse population.

METHOD

Persons with serious mental illness and a body mass index (BMI) >25 receiving services in three community mental health organizations were recruited and randomly assigned either to the 12-month In SHAPE program, which included membership in a public fitness club and weekly meetings with a health promotion coach, or to fitness club membership alone. The primary outcome measures were weight and cardiorespiratory fitness (as measured with the 6-minute walk test), assessed at baseline and at 3, 6, 9, 12, and 18 months.

RESULTS

Participants (N=210) were ethnically diverse (46% were nonwhite), with a mean baseline BMI of 36.8 (SD=8.2). At 12 months, the In SHAPE group (N=104) had greater reduction in weight and improved fitness compared with the fitness club membership only group (N=106). Primary outcomes were maintained at 18 months. Approximately half of the In SHAPE group (51% at 12 months and 46% at 18 months) achieved clinically significant cardiovascular risk reduction (a weight loss ≥5% or an increase of >50 meters on the 6-minute walk test).

CONCLUSIONS

This is the first replication study confirming the effectiveness of a health coaching intervention in achieving and sustaining clinically significant reductions in cardiovascular risk for overweight and obese persons with serious mental illness.

National evaluation of obesity screening and treatment among veterans with and without mental health disorders

OBJECTIVE

The objective was to determine whether obesity screening and weight management program participation and outcomes are equitable for individuals with serious mental illness (SMI) and depressive disorder (DD) compared to those without SMI/DD in Veterans Health Administration (VHA), the largest integrated US health system, which requires obesity screening and offers weight management to all in need.

METHODS

We used chart-reviewed, clinical and administrative VHA data from fiscal years 2010-2012 to estimate obesity screening and participation in the VHA's weight management program (MOVE!) across groups. Six- and 12-month weight changes in MOVE! participants were estimated using linear mixed models adjusted for confounders.

RESULTS

Compared to individuals without SMI/DD, individuals with SMI or DD were less frequently screened for obesity (94%-94.7% vs. 95.7%) but had greater participation in MOVE! (10.1%-10.4% vs. 7.4%). MOVE! participants with SMI or DD lost approximately 1 lb less at 6 months. At 12 months, average weight loss for individuals with SMI or neither SMI/DD was comparable (-3.5 and -3.3 lb, respectively), but individuals with DD lost less weight (mean=-2.7 lb).

CONCLUSIONS

Disparities in obesity screening and treatment outcomes across mental health diagnosis groups were modest. However, participation in MOVE! was low for every group, which limits population impact.

Telephone-delivered physical activity intervention for individuals with serious mental illness: a feasibility study

BACKGROUND

Obesity is prevalent in individuals with serious mental illness (SMI).

OBJECTIVE

The purpose of this study is to examine the feasibility of a telephone-delivered physical activity (PA) intervention for outpatients with serious mental illness to maintain PA and to explore the preliminary efficacy of the intervention on health status.

DESIGN

This study used a randomized experimental design. The treatment group received pedometers and eight weekly phone calls; the control group received written information regarding PA. Descriptive statistics were used to analyze data collected at baseline and 8 weeks.

RESULTS

Twenty-two subjects with SMI (mean age = 44.09 ± 7.6 years; 54.5% were male) were recruited and 16 subjects completed the study in 8 weeks. PA (z = -2.37, p = .02) increased in the treatment group (n = 8) whereas the control group (n = 8) maintained baseline PA level (z = -1.61, p = .11). Health outcomes were not changed (ps > .05).

CONCLUSION

Telephone-delivered intervention is feasible and has the potential to improve PA in individuals with SMI.