A psycho-educational intervention for the prevention of foot lesions in people with diabetes: Report of a clinical audit.

BACKGROUND AND AIMS: Motivational approaches may help target the psychological aspects of self-care, improving adherence to good practices in individuals with diabetes. The present study was designed to test the feasibility and effectiveness of a psychoeducational program for diabetic foot prevention or disease progression. METHODS AND RESULTS: Eighty-one subjects with or at high risk of foot ulcer development entered a program consisting of six 120-min group sessions, conducted by a podiatrist and an expert in psycho-education. Occurrence/recurrence of lesions in a 3-year follow-up was compared with 172 cases with similar risk score (IWGDF score 2019), receiving education at any 6-month podiatric visit (standard-of-care). Motivation to self-care and competence were assessed by specific questionnaires. The experimental program increased adherence to follow-up. The prevalence of foot lesions was higher at baseline and was remarkably reduced at any time-point in patients attending the psychoeducational program, whereas it remained relatively stable in standard care (around 10% of cases). The cumulative incidence was lower in the psychoeducational program (13.2, 95% CI 9.2-18.0 per 100 patient-year vs. 26.1; 95% CI 22.1-30.2); time to new lesions was increased (P = 0.022). Cox proportional hazard analysis confirmed an overall reduction of lesions in the psychoeducational program (HR 0.34; 95% CI 0.18-0.66; P < 0.001), after adjustment for confounders. The program was associated with significant changes in competence and motivation to self-care. CONCLUSION: A psychoeducational approach is both feasible and effective to support patients with diabetes at high risk of first or recurrent foot lesions, increasing their adherence to self-care practices.

Motivational Interviewing Adapted to Group Setting for the Treatment of Relapse in the Behavioral Therapy of Obesity. A Clinical Audit.

Motivational interviewing (MI) is devised to change unhealthy behaviors by increasing motivation. We adapted MI to a group format for the treatment of relapse during the behavioral treatment of obesity and performed a clinical audit to evaluate its effectiveness in stopping weight regain. The program was structured in seven weekly sessions, plus a 6-month follow-up. Patients (n = 86) completed a questionnaire on motivation to change in both healthy diet and physical activity, and a self-reported measurement of calorie intake and physical activity at baseline, at program end and at 6-month follow-up. The attendance to the program was high, with only 13 patients (15%) not completing the program and 24% not attending the 6-month follow-up. By the end of follow up, the prevalence of patients in either precontemplation or contemplation was reduced from over 60% at enrollment to approximately 20%, whereas the sum of patients in action or maintenance stages was increased from 9.5% in healthy diet and 14% in physical activity to 39.7% and 41.3%, respectively. These changes translated into significant behavioral changes (mean calorie intake, -13%; total physical activity, +125%; sedentary time, -8%) and finally into reduced body weight ( -3%). We conclude that MI programs adapted for groups may be used to stop relapse in individuals following a behavioral intervention for obesity.

Physical activity support or weight loss counseling for nonalcoholic fatty liver disease?

AIM: To determine the clinical effectiveness of intense psychological support to physical activity (PA) in nonalcoholic fatty liver disease (NAFLD), compared with cognitive-behavioral treatment (CBT). METHODS: Twenty-two NAFLD cases received support to exercise, tailored to their motivational needs (PA group). The effects on body weight, physical fitness [6-min walk test, VO2max and the PA-rating (PA-R) questionnaire] and body fat (fatty liver indices and visceral adiposity index) were compared with data obtained in 44 NAFLD subjects enrolled in a CBT program for weight loss, after adjustment for propensity score, calculated on baseline data. Measurements were performed at baseline, at 4-mo and one-year follow-up. Changes in anthropometric, biochemical and PA parameters were tested by repeated measurement ANOVA. Outcome results were tested by logistic regression analysis. RESULTS: At the end of the intensive program, BMI was less significantly reduced in the PA group (-1.09 ± 1.68 kg/m(2) vs -2.04 ± 1.42 kg/m(2) in the CBT group, P = 0.019) and the difference was maintained at 1-year follow-up (-0.73 ± 1.63 vs -1.95 ± 1.88, P = 0.012) (ANOVA, P = 0.005). PA-R was similar at baseline, when only 14% of cases in PA and 36% in CBT (P = 0.120) recorded values ≥ 3. At 4 mo, a PA-R ≥ 3 was registered in 91% of PA and 46% of CBT, respectively (P < 0.001) and PA-R ≥ 5 (up to 3 h/wk of moderate-to-heavy intensity physical activity) was registered in 41% of PA and only 9% of CBT group (P < 0.007). The 6-min walk test increased by 139 ± 26 m in PA and by only 43 ± 38 m in CBT (P < 0.001) and VO2max by 8.2 ± 3.8 mL/kg per minute and 3.3 ± 2.7 mL/kg per minute, respectively (P < 0.002). After adjustment for propensity, weight loss > 7% was significantly associated with CBT group at one year (OR = 6.21; 95%CI: 1.23-31.30), whereas PA-R > 3 was associated with PA group (10.31; 2.02-52.63). Liver enzymes decreased to values within normal limits in 36% of PA cases and 61% of CBT (P < 0.070). Estimated liver fat (Kotronen index) fell below the fatty liver threshold in 36% of PA and 34% and CBT cases at one-year (not different). Also the fatty liver index and the visceral adiposity index improved to a similar extent. CONCLUSION: Intensive psychological counseling for PA produces hepatic effects not different from standard CBT, improving physical fitness and liver fat independent of weight loss. Strategies promoting exercise are worth and effective in motivated patients, particularly in lean NAFLD patients where large weight loss cannot be systematically pursued.

Major factors for facilitating change in behavioral strategies to reduce obesity.

It is very unlikely that our obesity-promoting environment will change in the near future. It is therefore mandatory to improve our knowledge of the main factors associated with successful adoption of obesity-reducing behaviors. This may help design more powerful procedures and strategies to facilitate the adoption of healthy lifestyles in a "toxic" environment favoring the development of a positive energy balance. The aim of this review is to describe the main factors associated with successful adoption of obesity-reducing behaviors and to describe the most recent development, limits, and outcomes of lifestyle modification programs. The evidence regarding predictors of weight loss and weight loss maintenance remains largely incomplete. It is necessary to develop strategies matching treatments to patients' needs to improve successful weight loss and its maintenance. How to detect and how to address these needs is a continuous, challenging, research problem.

The role of lifestyle change in the prevention and treatment of NAFLD.

Healthy habits in terms of food intake and physical activity are first-line approach to prevention and treatment of nonalcoholic fatty liver disease, but difficulties arise in turning attempts into practice. Independently of the specific role of individual nutrients, not universally proven, overweight, obesity and diabetes are the specific conditions most frequently associated with hepatic fat accumulation. Accordingly, weight loss is mandatory in the majority of patients; this can be achieved by dietary restriction, but is rarely maintained in the long-term. Physical activity programs, both aerobic and resistance exercise may improve cardiorespiratory fitness, reduce the multiple conditions associated with the metabolic syndrome and help weight loss maintenance. However, motivating sedentary individuals to move is difficult and is favored by structured programs carried out along the lines of cognitive-behavior therapy. The role of behavior therapy is now supported by pilot studies, observational studies and finally by a randomized controlled study with histological outcomes. In the future, behavior interventions might be supported by important technological advances, such as smart phone technology and webbased platforms to facilitate interactive engagement amongst patients and with their health care providers. Lifestyle programs must also incorporate methods of overcoming barriers to accessing health service, engaging with workplace health programs and linking with community attempts to improve public health.

Stage of change and motivation to healthier lifestyle in non-alcoholic fatty liver disease.

BACKGROUNDS & AIMS: Healthy diet and physical activity are the treatment cornerstones of non-alcoholic fatty liver disease (NAFLD); their effectiveness is however limited by difficulties in implementing lifestyle changes. We aimed at determining the stage of change and associated psychological factors as a prerequisite to refine strategies to implement behavior changes. METHODS: We studied 138 consecutive NAFLD patients (73% male, age 19-73 years). The diagnosis was confirmed by liver biopsy in 64 cases (steatohepatitis, 47%). All cases completed the validated EMME-3 questionnaire, consisting of two parallel sets of instruments (for diet and physical activity, respectively) and providing stages of change according to transtheoretical model. Logistic regression analysis was used to identify factors associated with stages making behavioral changes more demanding. RESULTS: The individual profiles were variable; for diet, no cases had precontemplation as prevalent stage of change (highest score in individual profiles); 36% had contemplation. For physical activity, 50% were classified in either precontemplation or contemplation. Minor differences were recorded in relation to associated metabolic complications or steatohepatitis. Logistic regression identified male sex (odds ratio, 4.51; 95% confidence interval, 1.69-12.08) and age (1.70; 1.20-2.43 per decade) as the independent parameters predicting precontemplation or contemplation for diet. No predictors were identified for physical activity. CONCLUSIONS: NAFLD cases have scarce readiness to lifestyle changes, particularly with regard to physical activity. Defining stages of change and motivation offers the opportunity to improve clinical care of NAFLD people through individual programs exploiting the powerful potential of behavioral counseling, an issue to be tested in longitudinal studies.

A psychological support program for individuals with Type 1 diabetes.

We aimed to test the effects of a psychological support program on the psychological distress, mood, and quality of life of well-educated individuals with type 1 diabetes. A newly developed support program was offered to 60 patients with type 1 diabetes on intensive insulin treatment, previously enrolled in group-care educational programs. Thirty-three subjects participated (experimental group, in groups of 8-12 subjects); 22, who postponed their entry, were used as controls. The program consisted of 7 weekly work sessions of 2 hours chaired by a psychologist and covered aspects of daily living with diabetes using role-playing, metaplan, and problem solving. At baseline and approximately 6 months later, all participants completed a battery of questionnaires, and the differences between the experimental and the control group were analyzed by repeated-measurements ANOVA. In response to the psychological support program, subjects in the experimental group reduced their depressive mood (Beck Depression Inventory and depression scales of the Psychological Well-Being Index) and anxiety (Self-rating Anxiety Scale), improved disease-specific quality of life (Symptom and Well-Being scales of the Well-Being Enquiry for Diabetes), increased their internal and decreased their external locus of control. These changes were accompanied by a 0.3% decrease in glycosylated hemoglobin, whereas no significant changes were observed in the control group (ANOVA, P = 0.032). These results underline the importance of psychological aspects in individuals with type 1 diabetes; treating the psychological aspects related to the disease may be as important as medical control in order to improve living with diabetes.

Cognitive-behavioral strategies to increase the adherence to exercise in the management of obesity.

Physical activity plays a major role in the development and management of obesity. High levels of physical activity provide an advantage in maintaining energy balance at a healthy weight, but the amount of exercise needed to produce weight loss and weight loss maintenance may be difficult to achieve in obese subjects. Barriers to physical activity may hardly be overcome in individual cases, and group support may make the difference. The key role of cognitive processes in the failure/success of weight management suggests that new cognitive procedures and strategies should be included in the traditional behavioral treatment of obesity, in order to help patients build a mindset of long-term weight control. We reviewed the role of physical activity in the management of obesity, and the principal cognitive-behavioral strategies to increase adherence to exercise. Also in this area, we need to move from the traditional prescriptive approach towards a multidisciplinary intervention.

The effect of lifestyle changes in non-alcoholic fatty liver disease.

Non-alcoholic fatty liver disease (NAFLD) is a clinical/biochemical condition associated with the metabolic syndrome. As the disease stems from excess calorie intake and lack of physical activity, the correction of unhealthy lifestyles is the background of any prevention and treatment strategy; drugs should remain a second-line treatment. Several studies have shown that weight loss and physical activity, the cornerstones of a healthy lifestyle, have a specific therapeutic role in NAFLD, preventing disease progression and reducing the burden of disease. Prescriptive diets have a limited long-term efficacy; after a short period, most patients resume their old habits and weight regain is the rule. Physical activity, usually in combination with diet, but also independent of weight loss, improves liver enzymes and reduces liver fat, with uncertain results on hepatic necroinflammation; however, making patients increase their physical activity is very difficult. Only a behavioral approach may give patients the practical instruments to achieve their eating and exercise goals, incorporate them into lifestyle, and maintain the results for a long period, thereby possibly guaranteeing long-term durability of change. Cognitive-behavior treatment should be provided to patients at risk of advanced liver disease, and this action should be coupled with prevention strategies at the population level. Only a synergistic approach and a global societal response might be effective in reducing the burden of advanced liver disease and premature death due to NAFLD/NASH (non-alcoholic steatohepatitis).

Lifestyle modification in the management of the metabolic syndrome: achievements and challenges.

Lifestyle modification based on behavior therapy is the most important and effective strategy to manage the metabolic syndrome. Modern lifestyle modification therapy combines specific recommendations on diet and exercise with behavioral and cognitive strategies. The intervention may be delivered face-to-face or in groups, or in groups combined with individual sessions. The main challenge of treatment is helping patients maintain healthy behavior changes in the long term. In the last few years, several strategies have been evaluated to improve the long-term effect of lifestyle modification. Promising results have been achieved by combining lifestyle modification with pharmacotherapy, using meals replacement, setting higher physical activity goals, and long-term care. The key role of cognitive processes in the success/failure of weight loss and maintenance suggests that new cognitive procedures and strategies should be included in the traditional lifestyle modification interventions, in order to help patients build a mind-set favoring long-term lifestyle changes. These new strategies raise optimistic expectations for an effective treatment of metabolic syndrome with lifestyle modifications, provided public health programs to change the environment where patients live support them.