Effects of a Lifestyle Modification Program in Obese Adults
Effects of a Lifestyle Modification Program in Obese Adults
The study population included bariatric patients ≥18 years old with a BMI ≥40 kg m (or ≥35 with co-morbidity) who were willing to attend a community-based facility where the CLANN programme is delivered for 2 h per week for 8 weeks. Each patient was referred after careful assessment for suitability by the hospital-based, multidisciplinary bariatric team. Patients with poorly controlled diabetes or hypertension, symptoms suggestive of untreated ischaemic heart disease, an inability to walk 10 m or those deemed unlikely to attend for the full programme (e.g. frequent clinic non-attendance) were excluded from the programme.
The 8-week programme focused on weight management as part of a comprehensive cardiovascular risk reduction strategy. The main emphasis of the programme is on lifestyle modification, namely healthy food choices, weight reduction, physical activity and smoking cessation. We based our definition of "healthy food choices" on the European guidelines on healthy eating for cardiovascular disease prevention. Specifically, these stipulate saturated fatty acids <10 % of total daily energy intake, trans-unsaturated fatty acids <1 % of total daily energy intake, salt consumption <5 g/day, fibre intake 30–45 g/day, fruit >200 g/day (2–3 servings), vegetables >200 g/day (2–3 servings), fish at least twice per week, (one "oily") and alcohol consumption <20 g/day for men and <10 g/day for women. The Irish "Food Pyramid" (published by the Irish Government's Department of Health in 2012) was used as a visual tool to encourage the adoption of these dietary guidelines and to describe portion sizes to the participants. We sought to encourage a cardioprotective diet and to achieve an energy deficit of 600 kcal/day, in order to achieve a target weekly weight loss of 0.5 kg.
Initially, all patients received an individualised assessment by the multidisciplinary team (nurse, dietitian, physiotherapist, physical activity specialist). This included recording use of cardioprotective medications such as antihypertensive and antiplatelet agents and statins. The assessment also sought to identify individual priorities and needs and to explore beliefs, barriers and motivators to change. Following this assessment, patients attended the 8-week programme, consisting of a group-based exercise programme combined with educational workshops, lasting 2 h each week. Effective exercise and physical activity strategies which were specific, measurable, achievable, realistic and timed were also emphasised. These were initiated in the programme without specialist gym equipment with the objective of the patient maintaining these behaviours in the longer term after completion of the programme. While the exercise sessions were group-based for maximum efficiency, each patient had an individualised programme based on an assessment of their needs by the physiotherapist and exercise physiologist. The curriculum of eight theory-based health promotion workshops incorporated a module on "understanding cardiovascular disease", two modules on "eating for a healthy shape" (emphasising dietary modification techniques such as carbohydrate counting, food label interpretation and portion size calculation) and a module each on "exercising for life", "reading and understanding food labels", "stress management", "dealing with the psychological issues of obesity" (including mindfulness) and "maintaining a healthy lifestyle".
Individualised goal setting occurred at the initial assessment and then continued throughout the programme. Motivational interviewing was used to support patients in progressing through the stages of behaviour change, by enhancing intrinsic motivation, autonomy and self-efficacy. All patients were given a personal record card which they were encouraged to use on a weekly basis to record their goals and track their progress in relation to weight, BMI, blood pressure, lipid profile and for patients with diabetes, HbA1c and glucose levels.
At initial assessment, dietary habits, physical activity levels (7-day physical activity recall), functional capacity (Incremental Shuttle Walk Test, (ISWT) from which a Heart Rate Walking Speed Index (HRWSI) was derived) and psychosocial measures (questionnaire-based anxiety and depression scores) were recorded. Specifically, the Hospital Anxiety and Depression Scale (HADS), EQVAS (European Quality of Life Questionnaire, Visual Analogue Scale) and Dartmouth COOP questionnaires were administered. Weight was measured using a Seca® 877 scale and height with a Seca® Leicester stadiometer. Blood pressure was measured with an Omron® 705IT oscillometric device in both arms after the patient was sitting comfortably for five minutes. All of these measures were repeated following completion of the programme. The outcome targets were based on the 2012 European Society of Cardiology (ESC) prevention guidelines. Specifically, the blood pressure target was 140/90 mmHg (140/85 in patients with type 2 diabetes) while the lipid targets were total cholesterol <5 mmol/l, LDL cholesterol <3 mmol/l and triglycerides <1.7 mmol/l. The study was approved by the Galway Clinical Research Ethics Committee (the ethics committee for Galway University Hospitals). Patients signed written informed consent for their data to be used in the study.
All blood samples were analysed locally in the Galway University Hospitals' Department of Clinical Biochemistry (certified to ISO 15189 2007 accreditation standard). HbA1c was measured with HPLC (Menarini® HA8160 auto-analyzer). Total cholesterol was measured using the CHOP-PAP method. High density lipoprotein (HDL)-cholesterol and triglycerides were measured using the enzymatic and the GPO-PAP methods, respectively (Roche COBAS® 8000 modular analyzer). Low density lipoprotein (LDL)-Cholesterol was derived with the Friedewald equation.
Differences between outcomes at the start and the end of the programme for patients who completed the programme were assessed using the paired exact test for categorical variables, the paired t-test for normally distributed continuous variables and the Wilcoxon matched pairs test for non-normally distributed continuous variables. All analyses were performed using SPSS version 21.
Methods
The study population included bariatric patients ≥18 years old with a BMI ≥40 kg m (or ≥35 with co-morbidity) who were willing to attend a community-based facility where the CLANN programme is delivered for 2 h per week for 8 weeks. Each patient was referred after careful assessment for suitability by the hospital-based, multidisciplinary bariatric team. Patients with poorly controlled diabetes or hypertension, symptoms suggestive of untreated ischaemic heart disease, an inability to walk 10 m or those deemed unlikely to attend for the full programme (e.g. frequent clinic non-attendance) were excluded from the programme.
The 8-week programme focused on weight management as part of a comprehensive cardiovascular risk reduction strategy. The main emphasis of the programme is on lifestyle modification, namely healthy food choices, weight reduction, physical activity and smoking cessation. We based our definition of "healthy food choices" on the European guidelines on healthy eating for cardiovascular disease prevention. Specifically, these stipulate saturated fatty acids <10 % of total daily energy intake, trans-unsaturated fatty acids <1 % of total daily energy intake, salt consumption <5 g/day, fibre intake 30–45 g/day, fruit >200 g/day (2–3 servings), vegetables >200 g/day (2–3 servings), fish at least twice per week, (one "oily") and alcohol consumption <20 g/day for men and <10 g/day for women. The Irish "Food Pyramid" (published by the Irish Government's Department of Health in 2012) was used as a visual tool to encourage the adoption of these dietary guidelines and to describe portion sizes to the participants. We sought to encourage a cardioprotective diet and to achieve an energy deficit of 600 kcal/day, in order to achieve a target weekly weight loss of 0.5 kg.
Initially, all patients received an individualised assessment by the multidisciplinary team (nurse, dietitian, physiotherapist, physical activity specialist). This included recording use of cardioprotective medications such as antihypertensive and antiplatelet agents and statins. The assessment also sought to identify individual priorities and needs and to explore beliefs, barriers and motivators to change. Following this assessment, patients attended the 8-week programme, consisting of a group-based exercise programme combined with educational workshops, lasting 2 h each week. Effective exercise and physical activity strategies which were specific, measurable, achievable, realistic and timed were also emphasised. These were initiated in the programme without specialist gym equipment with the objective of the patient maintaining these behaviours in the longer term after completion of the programme. While the exercise sessions were group-based for maximum efficiency, each patient had an individualised programme based on an assessment of their needs by the physiotherapist and exercise physiologist. The curriculum of eight theory-based health promotion workshops incorporated a module on "understanding cardiovascular disease", two modules on "eating for a healthy shape" (emphasising dietary modification techniques such as carbohydrate counting, food label interpretation and portion size calculation) and a module each on "exercising for life", "reading and understanding food labels", "stress management", "dealing with the psychological issues of obesity" (including mindfulness) and "maintaining a healthy lifestyle".
Individualised goal setting occurred at the initial assessment and then continued throughout the programme. Motivational interviewing was used to support patients in progressing through the stages of behaviour change, by enhancing intrinsic motivation, autonomy and self-efficacy. All patients were given a personal record card which they were encouraged to use on a weekly basis to record their goals and track their progress in relation to weight, BMI, blood pressure, lipid profile and for patients with diabetes, HbA1c and glucose levels.
At initial assessment, dietary habits, physical activity levels (7-day physical activity recall), functional capacity (Incremental Shuttle Walk Test, (ISWT) from which a Heart Rate Walking Speed Index (HRWSI) was derived) and psychosocial measures (questionnaire-based anxiety and depression scores) were recorded. Specifically, the Hospital Anxiety and Depression Scale (HADS), EQVAS (European Quality of Life Questionnaire, Visual Analogue Scale) and Dartmouth COOP questionnaires were administered. Weight was measured using a Seca® 877 scale and height with a Seca® Leicester stadiometer. Blood pressure was measured with an Omron® 705IT oscillometric device in both arms after the patient was sitting comfortably for five minutes. All of these measures were repeated following completion of the programme. The outcome targets were based on the 2012 European Society of Cardiology (ESC) prevention guidelines. Specifically, the blood pressure target was 140/90 mmHg (140/85 in patients with type 2 diabetes) while the lipid targets were total cholesterol <5 mmol/l, LDL cholesterol <3 mmol/l and triglycerides <1.7 mmol/l. The study was approved by the Galway Clinical Research Ethics Committee (the ethics committee for Galway University Hospitals). Patients signed written informed consent for their data to be used in the study.
Laboratory Analysis
All blood samples were analysed locally in the Galway University Hospitals' Department of Clinical Biochemistry (certified to ISO 15189 2007 accreditation standard). HbA1c was measured with HPLC (Menarini® HA8160 auto-analyzer). Total cholesterol was measured using the CHOP-PAP method. High density lipoprotein (HDL)-cholesterol and triglycerides were measured using the enzymatic and the GPO-PAP methods, respectively (Roche COBAS® 8000 modular analyzer). Low density lipoprotein (LDL)-Cholesterol was derived with the Friedewald equation.
Statistical Analysis
Differences between outcomes at the start and the end of the programme for patients who completed the programme were assessed using the paired exact test for categorical variables, the paired t-test for normally distributed continuous variables and the Wilcoxon matched pairs test for non-normally distributed continuous variables. All analyses were performed using SPSS version 21.