A Behavioral Weight-Loss Intervention in Persons with Serious Mental Illness

ALIEF AL AMIN NIM: 01.208.5590

INTRODUCTION

BACKGROUND
Overweight and obesity are epidemic among persons with serious mental illness, yet weight-loss trials systematically exclude this vulnerable population.

TUJUAN
to determine the effectiveness of an 18-month tailored behavioral weight-loss intervention in adults with serious mental illness.

METHODS
STUDY OVERSIGHT
Institutional review boards at Johns Hopkins Uni-versity and Sheppard Pratt Health System and an independent data and safety monitoring board approved the protocol for the Randomized Trial of Achieving Healthy Lifestyles in Psychiatric Rehabilitation (ACHIEVE )

SETTING AND STUDY POPULATION

We placed the trial in outpatient psychiatric rehabilitation programs, settings that provide poten-tially unrealized opportunities to deliver lifestyle interventions overweight or obese adults (18 years of age) who attended 1 of 10 community psychiatric rehabilitation pro-grams in central Maryland or their affiliated out-patient mental health clinics

Kriteria eksklusi
We excluded persons with: a medical contraindication to weight loss, a cardiovascular event within the previous 6 months, an inability to walk, or an active alcohol-use or substance-use disorder

 STUDY PERIODS
January 2009 to February2011

Group studi
Intervention
The conceptual framework of the intervention incorporated social cognitive and behavioral self-management theories and was congruent with psychiatric rehabilitation principles of skill building and environmental supports

Control
Participants in the control group received standard nutrition and physical activity information at base-line. Health classes were offered quarterly, with content unrelated to weight (e.g., cancer screening).

 Data Collection
Data collectors visited the rehabilitation programs to determine study eligibility, to collect baseline data, and to perform follow-up assessments at 6, 12, and 18 months. Height was measured at study entry. At each visit, weight was measured. Measurements of blood pressure, waist circumference, and fasting blood chemical levels were obtained at baseline and at 6 and 18 months. Information on sociodemographic characteristics and medications were obtained from participant self-reports and program records; psychiatric diagnoses were abstracted from program records.

Statistical Analysis
Done with intention-to-treat
Primary Outcome :
BMI changes Persentage of weight change

chi-square test Sensitivity analysis

RESULTS
STUDY PARTICIPANTS
A total of 417 persons provided written informed consent for screening in the trial; of these, 291 underwent randomization

BASELINE CHARACTERISTIC
The mean age was 45.3 years; 49.8% of the participants were men, and 38.1% were black (Table 1). More than half the participants lived in supported housing, and almost 80% were unable to work. A total of 58.1% of the participants had schizophrenia or a schizoaffective disorder, 22.0% had bipolar disorder, and 12.0% had major depression. The mean number of psychotropic medications was 3.1. On average, there were 29 participants per study site (range, 18 to 45). Follow-up weights were ob-tained from 279 participants, out of 280 for whom data were not censored at 18 months. At follow-up visits, 93.3% of the participants had their weight measured within the data-collection windows.

Figure 2.Mean Weight Change, According to Study Group.

As compared with the control group, the mean net weight loss in the intervention group increased progressively over the 18-month study period.

Table 2. Weight-Loss Outcomes at 6, 12, and 18 Months.

Among participants in the intervention group, 63.9% had a weight at 18 months that was at or lower than their baseline weight, as compared with 49.2% of those in the control group. The percentage of participants who lost at least 5% of their baseline weight was 37.8% in the intervention group, as compared with 22.7% in the control group. At 18 months, the net difference in change in BMI for participants in the intervention group, as compared with those in the control group, was 1.1 (95% CI, 1.8 to 0.5)

INTERVENTION PARTICIPATION
The median number of total attended sessions was 46 in the first 6 months and 31 in months 7 through 18. Attendance at the group exercise sessions contributed most to the total number of contacts.

ADVERSE EFFECT

DISCUSSION
In overweight and obese adults with serious mental illness who were participating in psychiatric rehabilitation programs, a behavioral weight-loss intervention incorporating weightmanagement counseling and group exercise significantly reduced participant weight over a period of 18 months. despite sub-stantial challenges, persons with serious mental illness are able to lose weight with a tailored in-tervention.
Incorporating lifestyle interventions into rehabilitation programs or placing such programs in other mental health settings would require financial and organizational resources

STUDY STRENGTHS
enrolled a diverse population of patients with serious mental illnesses from multiple community-based programs
throughout the trial, we attained high follow-up rates for outcome data the interven-tion was offered over a period of 18 months, in contrast to the short-term interventions in previous randomized trials of behavioral weight-loss interventions in this population

STUDY WEAKNESS
attendance at the intervention sessions and rehabilitation programs decreased
the trial was not deSigned or powered to determine the effects of weight reduction on cardiovascular risk factors in this population the trial was not designed to influence the prescribing of medication efforts to provide healthy meal options were available to all participants in the rehabilitation programs

 Conclusion
over-weight and obese adults with serious mental illness can make substantial lifestyle changes despite the myriad challenges they face.

Suggestion
Given the epidemic of obesity and weight-related disease among persons with serious mental illness, our findings support implementation of targeted behavioral weight-loss interventions in this high-risk population

CRITICAL APPRAISAL

Journal identity
Positive:
Penulis come from Welch Center for Prevention, Epidemiology, and Clinical Research, Johns Hopkins University Published by n engl j med 368;17 nejm.org april 25, 2013

CRITICAL APPRAISAL
Titles

A Behavioral Weight-Loss Intervention in Persons with Serious Mental Illness

Positive:
Clearly shows that variables that were investigated Bold written with a capital letter at the beginning of the word There is no abbreviation Less than 12 words

Negative: -

 Methods
Positive:
Participant of study is clear, followed by the inclusion and exclusion criteria inter-group interventions are clear Analysis tools mentionedclearly measurable outcomes are clear

Negative:
-

 Results
Positive
Tables are presented in accordance with the international journal writing format (without the vertical and horizontal lines in a) with no serial number and table title and description of the contents of the table The values of the statistics written

Negative : -

 Discussion
Positive
There is a comparison test of previous research and theory There are disadvantages and advantages of the mentioned research results that have been achieved There is an emphasis if the results of the research will be applied There are suggestions for future research -

Negative

PICO ANALYSIS
PATIENT
Adult patients with serious mental disorders excess body weight or obesity from 10 community rehabilitation program of outpatient psychiatry at central Maryland and affiliates

INTERVENTION
Behavioral weight loss through lifestyle in adult patients with serious mental disorders excess body weight or obesity

ANALISIS PICO
COMPARATION
Persentase penurunan berat badan pada 6, 12, dan 24 bulan antara kelompok kontrol dan kelompok intervensi

OUTCOME
Intervensi perilaku penurunan berat badan secara signifikan mengurangi berat badan selama periode 18 bulan pada orang dewasa dengan kelebihan berat badan dan obesitas dengan penyakit mental serius

Validitas Uji

VALID EVIDENCE
QUESTIONS Is the allocation of patients in the study randomized? Is patient observation done quite long and complete? Are all patients in the randomized, analyzed? Whether patients and physicians remain blind in doing therapy, apart from the therapy being tested? Is the treatment and control groups equally? ya ya. ya NO

NO. BUT ALMOST SIMILAR. 144 in intervention group and 147 in control group

APPLICABILITY OF TEST
APPLICABILITY APLIKASI Is there a difference in our patients when compared with that found in previous studies so that the results can not be applied to our patients? Whether such therapy may be applied to our patients? Does the patient have a potential beneficial or detrimental treatment or when the program implemented? NO

ya Profitable. Behavioral weight loss interventions can significantly reduce body weight over a period of 18 months in adults with overweight and obesity with serious mental DISORDER

THE IMPORTANCE OF STUDY

WEIGHT LOSS FROM BASELINE AT 18 MONTHS FOLLOW UP

WEIGHT LOSS (+) (-) Total

Intervention
Control Total

88
70 158

49
72 121

137
142 279

EBM for RCT

RRR = -0.303 (95% CI: -0.605 to -0.058) Weight loss from baseline in the intervention group was 30.3% higher than the control group ARR = -0.149 (95% CI: -0.26 to -0.033) ARR = -0.149 means absolute advantage derived from behavioral interventions for weight loss is a 14.9% increase in the weight loss from baseline. NNT = -7 (-4 to -30) The number of patients who must be treated (for the duration of the study) in order to increase the weight loss from baseline in obese adult patients with mental disorders are 7 people All 95%CI does not include the number 1, indicating that the RRR, ARR, and NNT meaningful.

THE IMPORTANCE OF STUDY

WEIGHT LOSS 5% FROM BASELINE AT 18 MONTHS FOLLOW UP

WEIGHT LOSS (+) (-) Total

Intervention
Control Total

52
32 52

85
110 85

137
142 137

EBM for RCT

RRR = -0.684 (95% CI: -1.445 to -0.16)

Weight loss in the intervention group by 5% from baseline was 68.4% higher than the control group
ARR = -0.154 (95% CI: -0.258 to -0.046) ARR = -0.154 means absolute advantage derived from behavioral interventions for weight loss is a 15.4% increase in the weight loss of 5% from the baseline. NNT = -7 (-4 to -22) The number of patients who must be treated (for the duration of the study) in order to increase the 5% weight loss from baseline in obese adult patients with mental disorders are 7 people

All 95% CI does not include the number 1, indicating that the RRR, ARR, and NNT meaningful

CONCLUSIONS
1 2 3

Clinical study is valid

Clinical study is applicable

Clinical study is important