Learning, doing and sticking with it: A qualitative study on achieving clinically significant reduction in cardiovascular disease risk in a healthy lifestyle intervention for people with serious mental illness

People with serious mental illness (SMI; e.g. schizophrenia) have mortality rates two to three times higher than the general population, largely due to a higher prevalence of cardiovascular disease (CVD). Healthy lifestyle interventions can improve the health of people with SMI, but information about why these interventions work for some and not others is scarce. Our study aims to qualitatively explore differences in these two groups' overall experiences and application of the intervention. Data were drawn from a randomised effectiveness trial of a peer-led healthy lifestyle intervention. Qualitative data from interviews and focus groups with 21 participants were linked to their 12-month outcome data. Grounded theory was used to compare the experiences of participants who achieved clinically significant CVD risk reduction (i.e. clinically significant weight loss or clinically significant improvements in cardiorespiratory fitness) versus those who did not. Three qualitative themes: learning, change, sticking with it - differentiated participants who achieved CVD risk reduction and those that did not. Participants achieving CVD risk reduction described learning and applying specific knowledge and skills related to a healthy lifestyle when making health decisions, made healthy concrete changes to diet and physical activity, and stuck with those changes. Participants not achieving clinically significant CVD risk reduction reported surface-level learning about healthy lifestyle practices, difficulty sticking with healthy changes, and were more likely to report ambiguous or no changes. Our findings suggest that healthy lifestyle interventions for people with SMI should provide experiential in-vivo learning experiences while periodically assessing participants' understanding and then tailoring the intervention to their needs. It is important to build self-efficacy for health behaviour changes by creating early perceptions of success, which was found to enhance motivation and sustain behaviour change. Helping people with SMI develop and strengthen their support systems will also be an important factor for building and sustaining health behaviour changes.

FtsZ-Ring Regulation and Cell Division Are Mediated by Essential EzrA and Accessory Proteins ZapA and ZapJ in Streptococcus pneumoniae

The bacterial FtsZ-ring initiates division by recruiting a large repertoire of proteins (the divisome; Z-ring) needed for septation and separation of cells. Although FtsZ is essential and its role as the main orchestrator of cell division is conserved in most eubacteria, the regulators of Z-ring presence and positioning are not universal. This study characterizes factors that regulate divisome presence and placement in the ovoid-shaped pathogen, Streptococcus pneumoniae (Spn), focusing on FtsZ, EzrA, SepF, ZapA, and ZapJ, which is reported here as a partner of ZapA. Epi-fluorescence microscopy (EFm) and high-resolution microscopy experiments showed that FtsZ and EzrA co-localize during the entire Spn cell cycle, whereas ZapA and ZapJ are late-arriving divisome proteins. Depletion and conditional mutants demonstrate that EzrA is essential in Spn and required for normal cell growth, size, shape homeostasis, and chromosome segregation. Moreover, EzrA(Spn) is required for midcell placement of FtsZ-rings and PG synthesis. Notably, overexpression of EzrA leads to the appearance of extra Z-rings in Spn. Together, these observations support a role for EzrA as a positive regulator of FtsZ-ring formation in Spn. Conversely, FtsZ is required for EzrA recruitment to equatorial rings and for the organization of PG synthesis. In contrast to EzrA depletion, which causes a bacteriostatic phenotype in Spn, depletion of FtsZ results in enlarged spherical cells that are subject to LytA-dependent autolysis. Co-immunoprecipitation and bacterial two-hybrid assays show that EzrA(Spn) is in complexes with FtsZ, Z-ring regulators (FtsA, SepF, ZapA, MapZ), division proteins (FtsK, StkP), and proteins that mediate peptidoglycan synthesis (GpsB, aPBP1a), consistent with a role for EzrA at the interface of cell division and PG synthesis. In contrast to the essentiality of FtsZ and EzrA, ZapA and SepF have accessory roles in regulating pneumococcal physiology. We further show that ZapA interacts with a non-ZapB homolog, named here as ZapJ, which is conserved in Streptococcus species. The absence of the accessory proteins, ZapA, ZapJ, and SepF, exacerbates growth defects when EzrA is depleted or MapZ is deleted. Taken together, these results provide new information about the spatially and temporally distinct proteins that regulate FtsZ-ring organization and cell division in Spn.