Adherence to lifestyle modification advices in Non alcoholic fatty liver

disease

Introduction

NAFLD is the most common cause of abnormal liver function tests and it is the leading cause
of cryptogenic cirrhosis. Spectrum ranges from simple steatosis to steatohepatitis,
steatohepatitis with fibrosis (NASH) and cirrhosis. Therapeutic options for NAFLD are
limited. Weight loss is the only therapy that has shown evidence of being beneficial and safe.
Options to lose weight include lifestyle modifications like physical activity and diet
restriction. Adherence to lifestyle modification advices in patients receiving treatment to
chronic conditions is very low. Poor adherence to lifestyle modification advices leads to
substantial worsening of disease and increase health care costs.

It is quite difficult to find out the quantum of adherence in patients of NAFLD because of non
availability of tools. Non adherence to medication and lifestyle modification advices increases
the morbidity, mortality and economic burden on the health care system (19,20). There is no
data from our country depicting the extent of adherence to medical advices and associated
factors for non adherence. So we need tools (questionnaire) for assessing the extent of
Adherence to lifestyle modification advices in NAFLD.

Protocol
Study design: observational study
Primary objective:
1.To develop questionnaire based tools for assessment of extent of adherence to lifestyle
modification advices
Secondary objective:
1.To find out the extent of adherence to lifestyle modification advices in patients with NAFLD
2.To assess associated factors for non adherence

Our study design encompasses the following broad steps:

a. Literature review
b. Focused group discussion
c. Selection of variables
d. Expert evaluation
e. Pilot study
f. Statistical analysis
g. Using the Developed validated questionnaire in the population to assess the
extent of Adherence

Ethical clearance obtained on 27/04/2016

Work progress:
Literature review was done using keywords such as “NAFLD questionnaire”, “adherence”,
“non adherence”, “lifestyle style modification advices”, “hypertension questionnaire”,
“diabetes questionnaire”, in PubMed, Google scholar, Medline, Google and more than 750
articles were found ranging from 2000 to 2016 of which around 71 articles were found to be
relevant to our study and was selected.
After going through these 71 articles some items were generated which would be relevant to
our study.

Focused group discussion:

A semi-structured interview via focused group discussion was done which was stratified into
3 groups consisting of 4 members in each group.
After extensive literature review and focused group discussion items are generated which has
been submitted for internal review.
Questionnaire generated are subdivided under the headings Questions to check adherence to
lifestyle modification advices in NAFLD and questions to check reasons for non adherence to
lifestyle modification advices in NAFLD.
Under questions to check adherence to lifestyle modification advices in NAFLD we have
generated 30 questions, under questions to check reasons for non adherence to lifestyle
modification advices in NAFLD we have generated 31 questions.

Questions to check adherence to lifestyle modification advices in NAFLD

1) Do you have breakfast daily?

Always/Very often/Sometimes/Rarely/Never
2) Do you have breakfast heavily?
Always/Very often/Sometimes/Rarely/Never
3) Do you eat more than three times in a day?
Always/Very often/Sometimes/Rarely/Never
4) Do you have large meals?
Always/Very often/Sometimes/Rarely/Never
5) Do you follow your diet chart?
Always/Very often/Sometimes/Rarely/Never
6) Do you want to follow your diet chart?
Always/Very often/Sometimes/Rarely/Never
7) Do you eat fried foods daily?
Always/Very often/Sometimes/Rarely/Never
8) Do you eat pizzas/burgers daily?
Always/Very often/Sometimes/Rarely/Never
9) Do you have snacks in between the meals?
Always/Very often/Sometimes/Rarely/Never
10) Do you eat Non-veg daily?
Always/Very often/Sometimes/Rarely/Never
11) Do you eat eggs daily?
Always/Very often/Sometimes/Rarely/Never
12) Do you eat green salad daily?
Always/Very often/Sometimes/Rarely/Never
13) Do you have vegetable curries in your food?
Always/Very often/Sometimes/Rarely/Never
14) Do you drink fruit juices daily?
Always/Very often/Sometimes/Rarely/Never
15) Do you drink soft drinks daily?
Always/Very often/Sometimes/Rarely/Never
16) Do you drink milk daily?
Always/Very often/Sometimes/Rarely/Never
17) Do you eat food outside the home daily?
Always/Very often/Sometimes/Rarely/Never
18)Do you eat cheese, butter, curd and yoghurt so often?
Always/Very often/Sometimes/Rarely/Never
19) Do you have tea/coffee daily?
Always/Very often/Sometimes/Rarely/Never
20)Do you eat sea foods daily?
Always/Very often/Sometimes/Rarely/Never
21) Do you eat pulses daily?
Always/Very often/Sometimes/Rarely/Never
22) Do you lead a sedentary lifestyle?
Strongly agree/Agree/Undecided/Disagree/Strongly disagree
23) Do you sit for more than 5 hours per day?
Always/Very often/Sometimes/Rarely/Never
24) Do you watch TV more than 2 hours per day?
Always/Very often/Sometimes/Rarely/Never
25) Do you do exercise daily?
Always/Very often/Sometimes/Rarely/Never
26) Do you exercise more than for each session?
Always/Very often/Sometimes/Rarely/Never
27) Do you exercise more than 4 hours in a week?
Always/Very often/Sometimes/Rarely/Never
28) Do you do low intensity physical activity?
Always/Very often/Sometimes/Rarely/Never
29) Do you do moderate intensity physical activity?
Always/Very often/Sometimes/Rarely/Never
30) Do you do vigorous physical activity?
Always/Very often/Sometimes/Rarely/Never
Questions to check reasons for non-adherence to lifestyle modification advices in NAFLD

Patient related factors:

1)Do you know what is NAFLD? Yes/No
2)Do you know the natural history of NAFLD? Yes/No
3)Do you know the risk factors of NAFLD? Yes/No
4)Do you know the complications of NAFLD? Yes/No
5)Do you consider NAFLD is harmful to your health? Yes/No
6)Do you know that western diet is one of the reasons for NAFLD? Yes/No
7) Do you know that NAFLD causes future health problems? Yes/No
8) Are you motivated to follow lifestyle modification advices? Yes/No
9) Have you ever tried to follow lifestyle modification advices? Yes/No
10) Do you have love for food? Yes/No
11) Do you have helpers for household work? Yes/No
12) Is depression due to NAFLD is the reason for not following lifestyle modification
advices? Yes/No
13) Are there any comorbidities that are making you not to follow lifestyle modification
advices? Yes/No
14) Is long-term follow up is the reason that is making you not to follow lifestyle
modification advices? Yes/No
15) Is lack of knowledge making you not to follow the advices given by doctor? Yes/No
16) Is your occupation is responsible for not doing physical activity? Yes/No
17) Is your occupation is responsible for not following the dietary chart? Yes/No
18) Are your family members cooperative in following the lifestyle modification advices?
Yes/No
19) U don’t follow lifestyle modification advices because you are not symptomatic?
Yes/No
Physician and Hospital related factors:
1) Did Doctor explained you the importance of diet? Yes/No
2) Did doctor spend adequate time with you explaining about NAFLD? Yes/No
3) Do u follow up with the doctor? Yes/No
4) Do you follow the advices which are given by the doctor? Yes/No
5) Is it difficult to follow the advices given by the doctor? Yes/No
6) Is it difficult to follow your diet chart advised by the doctor? Yes/No
7) Are the lifestyle modification advices prescribed to you are complex? Yes/No
8) Did you understand the lifestyle modifications prescribed by the doctor? Yes/No
9) Did doctor spend adequate time with you explaining about lifestyle modification
advices? Yes/No
10) Is it difficult to do the physical activity advised by the doctor? Yes/No
11) Educated? Yes/No
12) Men/Women?