Evaluating a community lifestyle intervention: adherence and the role of perceived support

Background Interventions that increase participation in physical activity and positive dietary changes may improve the health of the community through modifying the lifestyle contribution to preventable disease. However, previous evaluations have identified concerns about inequitable and unsustainable uptake, adherence and retention within healthy lifestyle schemes.

Intervention study The intervention evaluated here was designed to be a 12-week intervention for participants, offering free testing of physiological indicators of health, one-to-one health advice and a range of exercise, activity and cookery classes, at no or reduced cost, at local venues throughout the community. This paper reports the findings from a small qualitative study undertaken to explore the experiences and reflections of those who took part in the intervention to different extents, including those who fully and partially participated as well as those who dropped out or declined to take part.

Method Sixteen respondents took part in semi-structured interviews (5 male, 11 female; 8 black, 8 white; age range 25–85).

Findings The findings suggest that participants assessed the healthy lifestyle intervention in terms of how well it met their pre-existing needs and opportunities for change, and that they selected the aspects of the scheme that suited them, interested them and were perceived as delivering salient results. There is also evidence for a stronger role of perceived support in influencing uptake and maintenance of lifestyle changes, and that support was conceptualised by participants as one of the services offered by the scheme. Perceived support and related perceptions of reliance on the scheme to sustain lifestyle changes also suggested that in some cases full adherence to a scheme is not as likely to produce long-term adherence to lifestyle changes as compared to partial, but more realistic adherence and smaller lifestyle changes. Implications for delivering and evaluating healthy lifestyle interventions are also discussed.

Prevention of type 2 diabetes by lifestyle intervention in an Australian primary health care setting : Greater Green Triangle (GGT) Diabetes Prevention Project

Background
Randomised controlled trials demonstrate a 60% reduction in type 2 diabetes incidence through lifestyle modification programmes. The aim of this study is to determine whether such programmes are feasible in primary health care.

Methods
An intervention study including 237 individuals 40–75 years of age with moderate or high risk of developing type 2 diabetes. A structured group programme with six 90 minute sessions delivered during an eight month period by trained nurses in Australian primary health care in 2004–2006. Main outcome measures taken at baseline, three, and 12 months included weight, height, waist circumference, fasting plasma glucose and lipids, plasma glucose two hours after oral glucose challenge, blood pressure, measures of psychological distress and general health outcomes. To test differences between baseline and follow-up, paired t-tests and Wilcoxon rank sum tests were performed.

Results
At twelve months participants' mean weight reduced by 2.52 kg (95% confidence interval 1.85 to 3.19) and waist circumference by 4.17 cm (3.48 to 4.87). Mean fasting glucose reduced by 0.14 mmol/l (0.07 to 0.20), plasma glucose two hours after oral glucose challenge by 0.58 mmol/l (0.36 to 0.79), total cholesterol by 0.29 mmol/l (0.18 to 0.40), low density lipoprotein cholesterol by 0.25 mmol/l (0.16 to 0.34), triglycerides by 0.15 mmol/l (0.05 to 0.24) and diastolic blood pressure by 2.14 mmHg (0.94 to 3.33). Significant improvements were also found in most psychological measures.

Conclusion
This study provides evidence that a type 2 diabetes prevention programme using lifestyle intervention is feasible in primary health care settings, with reductions in risk factors approaching those observed in clinical trials.

Trial Number
Current Controlled Trials ISRCTN38031372

A culturally appropriate diet and lifestyle intervention can successfully treat the components of metabolic syndrome in female Pakistani immigrants residing in Melbourne, Australia

This study was designed to test the effectiveness of a culturally appropriate diet and lifestyle intervention to treat metabolic syndrome in female Pakistani immigrants residing in Melbourne, Australia. Forty Pakistani women with metabolic syndrome (aged 20-50 years) completed a 12-week culturally appropriate diet and exercise program. Results indicate that, before intervention, participants were sedentary, taking 4000 ± 22.6 steps per day, and had an obese-classified body mass index (BMI) of 29.2 ± 0.46 kg/m2 (BMI was categorized in accordance with guidelines specifically designed for Asians) and high waist circumference of 132 ± 25.95 cm. Participants were hypertensive (systolic, 135 ± 1.3 mm Hg; diastolic, 86 ± 0.68 mm Hg), were dyslipidemic (total cholesterol, 6.8 ± 0.15 mmol/L; triglycerides, 2.9 ± 0.09 mmol/L), and had elevated blood glucose (6.4 ± 0.33 mmol/L) and fasting blood insulin (45 ± 6.3 μU/mL) levels. After the 12-week culturally appropriate intervention, activity increased (8600 ± 596.7 steps per day, P < .05); and BMI (27.8 ± 0.45 kg/m2), blood pressure (systolic, 125 ± 1.4 mm Hg; diastolic, 80 ± 0.6 mm Hg), cholesterol (5.5 ± 0.1 mmol/L), blood glucose (5.9 ± 0.33 mmol/L), and blood insulin (24.14 ± 1.8 μU/mL) levels were all significantly reduced (P < .05). This study revealed that the Pakistani female migrants who had metabolic syndrome and its components can successfully be treated via a culturally appropriate diet and lifestyle intervention. The success of the current program raises the possibility that other high-risk ethnic groups can also be treated with a culturally appropriate program.

Treatment acceptability and psychosocial outcomes of a randomised controlled trial of a cognitive behavioural lifestyle intervention for overweight and obese adolescents

This study explores the impact of a cognitive behavioural lifestyle program, the CHOOSE HEALTH Program, on psychosocial wellbeing in overweight and obese adolescents. The sample comprised 29 male and 34 female adolescents aged 11.5 to 18.9 years (M = 14.3, SD = 1.9) and classified as overweight (n = 15) or obese (n=48). Participantswere randomly allocated to treatment or wait-list control conditions; participants allocated the wait-list condition were offered treatment after 6 months. Adolescents and parents completed self-report measures of psychopathology, psychosocial and family functioning. Treatment did not have detrimental effects on the psychosocial factors assessed. It resulted in significant improvements in weight control behaviour, impulse regulation, social support from family and parent–adolescent problem communication (p<.05). Similar results were obtained with completer and intention-to-treat analyses. Treatment acceptability was high, with all respondents indicating that they made progress. Combined, results indicate that treatment did not have detrimental effects on psychopathology, psychosocial functioning, or family functioning. Treatment resulted in significant improvements in impulse regulation, social support from family and parent–adolescent communication. Thus, parents and professionals can be assured that a comprehensive, multifaceted, parent-supported, cognitive behavioural intervention for overweight and obese adolescents does not cause psychological harm.

The impact of a brief lifestyle intervention delivered by generalist community nurses (CN SNap trial)

Background
The risk factors for chronic disease, smoking, poor nutrition, hazardous alcohol consumption, physical inactivity and weight (SNAPW) are common in primary health care (PHC) affording opportunity for preventive interventions. Community nurses are an important component of PHC in Australia. However there has been little research evaluating the effectiveness of lifestyle interventions in routine community nursing practice. This study aimed to address this gap in our knowledge.

Methods
The study was a quasi-experimental trial involving four generalist community nursing (CN) services in New South Wales, Australia. Two services were randomly allocated to an ‘early intervention’ and two to a ‘late intervention’ group. Nurses in the early intervention group received training and support in identifying risk factors and offering brief lifestyle intervention for clients. Those in the late intervention group provided usual care for the first 6 months and then received training. Clients aged 30–80 years who were referred to the services between September 2009 and September 2010 were recruited prior to being seen by the nurse and baseline self-reported data collected. Data on their SNAPW risk factors, readiness to change these behaviours and advice and referral received about their risk factors in the previous 3 months were collected at baseline, 3 and 6 months. Analysis compared changes using univariate and multilevel regression techniques.

Results
804 participants were recruited from 2361 (34.1%) eligible clients. The proportion of clients who recalled receiving dietary or physical activity advice increased between baseline and 3 months in the early intervention group (from 12.9 to 23.3% and 12.3 to 19.1% respectively) as did the proportion who recalled being referred for dietary or physical activity interventions (from 9.5 to 15.6% and 5.8 to 21.0% respectively). There was no change in the late intervention group. There a shift towards greater readiness to change in those who were physically inactive in the early but not the comparison group. Clients in both groups reported being more physically active and eating more fruit and vegetables but there were no significant differences between groups at 6 months.

Conclusion
The study demonstrated that although the intervention was associated with increases in advice and referral for diet or physical activity and readiness for change in physical activity, this did not translate into significant changes in lifestyle behaviours or weight. This suggests a need to facilitate referral to more intensive long-term interventions for clients with risk factors identified by primary health care nurses.

A randomised controlled trial investigating the effects of Mediterranean diet and aerobic exercise on cognition in cognitively healthy older people living independently within aged care facilities: The Lifestyle Intervention in Independent Living Aged Car

Background: The rapid ageing of the population is becoming an area of great concern, both globally and in Australia. On a societal level, the cost of supporting an ageing demographic, particularly with their associated medical requirements, is becoming an ever increasing burden that is only predicted to rise in the foreseeable future. The progressive decline in individuals' cognitive ability as they age, particularly with respect to the ever increasing incidence of Alzheimer's Disease (AD) and other cognitive complications, is in many respects one of the foundation stones of these concerns. There have been numerous observational studies reporting on the positive effects that aerobic exercise and the Mediterranean diet appear to have on improving cognitive ability. However, the ability of such interventions to improve cognitive ability, or even reduce the rate of cognitive ageing, has not been fully examined by substantial interventional studies within an ageing population. Methods: The LIILAC trial will investigate the potential for cognitive change in a cohort of cognitively healthy individuals, between the ages of 60 and 90 years, living in independent accommodation within Australian aged care facilities. This four-arm trial will investigate the cognitive changes which may occur as a result of the introduction of aerobic exercise and/or Mediterranean diet into individuals' lifestyles, as well as the mechanisms by which these changes may be occurring. Participants will be tested at baseline and 6 months on a battery of computer based cognitive assessments, together with cardiovascular and blood biomarker assessments. The cardiovascular measures will assess changes in arterial stiffness and central pulse pressures, while the blood measures will examine changes in metabolic profiles, including brain derived neurotrophic factor (BDNF), inflammatory factors and insulin sensitivity. Conclusion: It is hypothesised that exercise and Mediterranean diet interventions, both individually and in combination, will result in improvements in cognitive performance compared with controls. Positive findings in this research will have potential implications for the management of aged care, particularly in respect to reducing the rate of cognitive decline and the associated impacts both on the individual and the broader community.

An efficacy trial of brief lifestyle intervention delivered by generalist community nurses (CN SNAP trial)

Background
Lifestyle risk factors, in particular smoking, nutrition, alcohol consumption and physical inactivity (SNAP) are the main behavioural risk factors for chronic disease. Primary health care (PHC) has been shown to be an effective setting to address lifestyle risk factors at the individual level. However much of the focus of research to date has been in general practice. Relatively little attention has been paid to the role of nurses working in the PHC setting. Community health nurses are well placed to provide lifestyle intervention as they often see clients in their own homes over an extended period of time, providing the opportunity to offer intervention and enhance motivation through repeated contacts. The overall aim of this study is to evaluate the impact of a brief lifestyle intervention delivered by community nurses in routine practice on changes in clients' SNAP risk factors.

Methods/Design
The trial uses a quasi-experimental design involving four generalist community nursing services in NSW Australia. Services have been randomly allocated to an 'early intervention' group or 'late intervention' (comparison) group. 'Early intervention' sites are provided with training and support for nurses in identifying and offering brief lifestyle intervention for clients during routine consultations. 'Late intervention site' provide usual care and will be offered the study intervention following the final data collection point. A total of 720 generalist community nursing clients will be recruited at the time of referral from participating sites. Data collection consists of 1) telephone surveys with clients at baseline, three months and six months to examine change in SNAP risk factors and readiness to change 2) nurse survey at baseline, six and 12 months to examine changes in nurse confidence, attitudes and practices in the assessment and management of SNAP risk factors 3) semi-structured interviews/focus with nurses, managers and clients in 'early intervention' sites to explore the feasibility, acceptability and sustainability of the intervention.

Discussion
The study will provide evidence about the effectiveness and feasibility of brief lifestyle interventions delivered by generalist community nurses as part of routine practice. This will inform future community nursing practice and PHC policy.

Client experience of brief lifestyle intervention by community nurses

Lifestyle modification interventions in primary health care settings are an important means of addressing lifestyle risk factors. An essential factor for the success of lifestyle advice is the client’s acceptance. Lifestyle interventions offered in general practice are well accepted by clients. However, little is known about how lifestyle interventions are accepted if offered by community nurses in the client’s home. This study investigates the experience and perspectives of clients who were offered brief lifestyle interventions from community nurses, based on the 5As model. Semi-structured interviews were conducted with 20 clients who had received brief lifestyle interventions from community nurses as part of a larger intervention trial. All clients perceived the provision of lifestyle interventions to be an appropriate part of the community nurses’ role. The advice and support offered was useful only to some, depending on personal preferences, experiences, perceived lifestyle risk and self-rated health. Offering brief lifestyle interventions did not affect the rapport between client and nurse and this puts community nurses in an ideal place to address lifestyle issues that can sometimes be sensitive. However, client-centredness must be emphasised to improve clients’ uptake of lifestyle advice and support.

Weight loss and attrition in overweight and obese young women during a 36- week internet-based lifestyle intervention

Background: Young women are at high risk of weight gain yet few studies have examined the long-term effectiveness of weight loss programs in this group. This study aimed to investigate the effects of a self-directed internet-based lifestyle program on body weight in young women.

Methods: Overweight or obese young women (BMI 33.4 ± 0.3 kg/m2, age 27.8 ± 0.3 years) were initially randomized to General lifestyle advice (G) or Structured lifestyle advice (S) via in-person and website support for 12 weeks (Phase I). After Phase I, all participants were supported through a self-directed internet-based program for 36 weeks (Phase II). The internet-based program included a structured hypocaloric diet, physical activity program, self-monitoring tools, peer group forum and monthly emails. Body weight, energy intake and physical activity were measured at week 0, week 12, week 24 and week 48. Adherence to self-regulatory behaviors was measured at week 48. Mixed model analyses were conducted to determine changes in body weight, energy intake and physical activity.

Results: A total of 203 overweight or obese young women commenced Phase I and 130 commenced Phase II. In Phase I, S group had significantly greater weight loss than G group (4.2 ± 0.6 kg vs 0.6 ± 0.3 kg, P<0.001). In Phase II, both groups had significant weight loss over time without significant group differences (-0.8 ± 1.1kg vs -0.8 ± 0.6, P>0.05). Forty-one percent (53/130) of the participants who commenced Phase II completed the internet-based intervention. Dropouts had a higher baseline BMI, were more likely to be married or in a de facto relationship, and more likely to have at least one child.

Conclusions: A self-directed internet-based program could be effective in providing support in maintaining weight loss on a structured lifestyle program in young women over 36 weeks. Further research is required to maintain engagement in young women who were married/in a de facto relationship or have children.

Randomised controlled trial evaluating lifestyle interventions in people with impaired glucose tolerance

Aim

To evaluate the effectiveness of lifestyle interventions in people with impaired glucose tolerance (IGT).
Methods

Participants with IGT (n = 78), diagnosed on two consecutive oral glucose tolerance tests (OGTTs), were randomly assigned to a 2-year lifestyle intervention or to a control group. Main outcome measures were changes from baseline in: nutrient intake; physical activity; anthropometry, glucose tolerance and insulin sensitivity. Measurements were repeated at 6, 12 and 24 months follow-up.
Results

After 24 months follow-up, there was a significant fall in total fat consumption (difference in change between groups (Δ intervention − Δ control) = −17.9, 95% confidence interval (CI) −33.6 to −2.1 g/day) as a result of the intervention. Body mass was significantly lower in the intervention group compared with controls after 6 months (−1.6, 95% CI −2.9 to −0.4 kg) and 24 months (−3.3, 95% CI −5.7 to −0.89 kg). Whole body insulin sensitivity, assessed by the short insulin tolerance test (ITT), improved after 12 months in the intervention group (0.52, 95% CI 0.15–0.89%/min).
Conclusions

These findings complement the findings of the Finnish Diabetes Prevention Study and the American Diabetes Prevention Study, both of which tested intensive interventions, by showing that pragmatic lifestyle interventions result in improvements in obesity and whole body insulin sensitivity in individuals with IGT, without change in other cardiovascular risk factors.

Life! in Australia : translating prevention research into a large-scale intervention

The increasing prevalence of type 2 diabetes is of great public health concern. In the state of Victoria, Australia, a group-based lifestyle intervention programme, Life! – Taking Action on Diabetes, was developed for people over the age of 50 years who are at high risk of diabetes. It aims to reduce the risk of diabetes by providing practical skills, including goal setting and problem solving, to encourage participants to adopt a healthy diet and active lifestyle. The programme is delivered by specially trained facilitators who have undergone an accredited three-stage training programme. A quality assurance process is also in place to ensure that it is delivered to a consistently high standard. The Life! program
is a direct progression from the Finnish randomised controlled trial and the Greater Green Triangle Diabetes Prevention Project implementation trial. This paper describes how a diabetes prevention programme was implemented at a state-wide level and the training of facilitators to conduct the group sessions. Future studies are needed to examine the cost effectiveness and development of specific programmes for diverse population groups.

A cognitive behavioural intervention for overweight and obese adolescents illustrated by four case studies

This article reports four case studies illustrating the implementation of the CHOOSE HEALTH Program, a cognitive behavioural lifestyle intervention for overweight and obese adolescents. Participants were an overweight (12 years) and obese (15 years) female, and an overweight (14 years) and obese (12 years) male. The program was delivered by provisional psychologists with program specific training and supervision. All participants demonstrated improvements in body composition, and maintained or improved dietary quality and psychosocial wellbeing. The program had variable effects on physical activity and minimal effect on cardiovascular fitness for three of the four participants. While parents and adolescents required considerable assistance to develop and monitor long term program goals, these goals were a useful clinical tool to support the adolescent and parent to recognise the improvements they had made. Identification and monitoring of specific, measurable, and realistic behaviour change strategies was particularly important in assisting adolescents and their parents to translate session information into improved health behaviours. Results indicate that an adolescent overweight and obesity treatment program that promotes adolescent responsibility and autonomy, and emphasises the importance of parent support and family change is both effective and highly acceptable to both adolescents and parents.

Mothers after gestational diabetes in Australia Diabetes Prevention Program (MAGDA-DPP) post-natal intervention: study protocol for a randomized controlled trial

Background:
Gestational diabetes mellitus (GDM) is defined as glucose intolerance with its onset or first recognition during pregnancy. Post-GDM women have a life-time risk exceeding 70% of developing type 2 diabetes mellitus (T2DM). Lifestyle modifications reduce the incidence of T2DM by up to 58% for high-risk individuals.

Methods/Design:
The Mothers After Gestational Diabetes in Australia Diabetes Prevention Program (MAGDA-DPP) is a randomized controlled trial aiming to assess the effectiveness of a structured diabetes prevention intervention for post-GDM women. This trial has an intervention group participating in a diabetes prevention program (DPP), and a control group receiving usual care from their general practitioners during the same time period. The 12-month intervention comprises an individual session followed by five group sessions at two-week intervals, and two follow-up telephone calls. A total of 574 women will be recruited, with 287 in each arm. The women will undergo blood tests, anthropometric measurements, and self-reported health status, diet, physical activity, quality of life, depression, risk perception and healthcare service usage, at baseline and 12 months. At completion, primary outcome (changes in diabetes risk) and secondary outcome (changes in psychosocial and quality of life measurements and in cardiovascular disease risk factors) will be assessed in both groups.

Discussion:
This study aims to show whether MAGDA-DPP leads to a reduction in diabetes risk for post-GDM women. The characteristics that predict intervention completion and improvement in clinical and behavioral measures will be useful for further development of DPPs for this population.