Exercise Only Works If You Do It! The Holy Grail of Adherence

Initial participant perspectives about participating in an online, semi-supervised, cirrhosis-specific nutrition and exercise intervention

OBJECTIVES

In chronic diseases, there have been issues with low levels of participant adherence and retention during well-supported lifestyle behaviour change interventional studies. Theoretically informed, the objective was to explore the types of challenges participants are experiencing to inform future designs.

DESIGN

We conducted an exploratory descriptive study in an adult cirrhosis population after the first 4-6 weeks of a 12-week semi-supervised nutrition and exercise online program.

METHODS

Participants in the parent feasibility study, assessing the nutrition and exercise intervention (Heal-Me), were eligible for this nested study. Heal-Me is a multimodal program that is tailorable to a participant's abilities through regular interaction with the study's registered dietician and exercise specialist. Interviews (~60 min) with participants were recorded then analysed descriptively, guided by the capability, opportunity and motivational behaviour change model.

RESULTS

The 20 participants preferred the expert-led group online nutrition and exercise classes over independent activities such as protein tracking and the exercise videos. Social gamification (e.g., weekly polls on favourite things like movies or sports teams) contributed to the group experience. All except one person required program tailoring to address preferences, abilities and new onset health events. Findings led to the inclusion of 4 behaviour change techniques to the initial 17, whereas 2 others were expanded.

CONCLUSIONS

While program tailoring, awareness of cirrhosis nutrition and regular interactions with staff influenced participant retention and adherence in the first 4-6 weeks of the online program.

An open label feasibility study of a nutrition and exercise app-based solution in cirrhosis

Background

Nutrition and exercise are the mainstay of therapy for the prevention and treatment of frailty in cirrhosis. This pilot study assessed feasibility of the online delivery of an app-based semi-supervised nutrition and exercise intervention in this population.

Methods

The 11-week pilot recruited adults with cirrhosis who owned internet-connected devices. Patients were encouraged to participate in exercise sessions 3× per week including a combination of online group exercise (weekly) and home-based follow-along exercise (biweekly). They also participated in group nutrition classes (five sessions) and one-to-one exercise and nutrition check-ins delivered through the app. Primary outcome measures pertained to program feasibility: recruitment, retention, adherence, and satisfaction. Exploratory measures included physical performance (liver frailty index [LFI], 6-minute walk test [6MWT]), health behaviour domains, and quality of life.

Results

Twenty three patients completed baseline measures. Of these, 18 (72%) completed end of study measures (mean MELD-Na, 9.2; female, 44.4%). Over 70% of participants fulfilled 75% or more of the feasibility criteria. Satisfaction with the program was high (mean, 89%). Exercise program modifications were required for 17 patients to accommodate health events or abilities. Exploratory evaluation showed improvement in the LFI and the 6MWT by -0.58-units (95% CI: -0.91 to -0.25) and 46.0 m (95% CI: 22.7-69.3) respectively without changes in quality of life or health behaviour domains.

Conclusions

Outcomes demonstrate feasibility of the app-based delivery of programming with promising exploratory impact on efficacy for physical performance. Findings can guide the design of a large-scale app-based randomized controlled trials in cirrhosis.

A randomized controlled trial of a multicomponent online stress reduction intervention in inflammatory bowel disease

BACKGROUND

Psychological stress negatively impacts inflammatory bowel disease (IBD) outcomes. Patients have prioritized access to online interventions; yet, the data on these have been limited by mixed in-person/online interventions, low adherence, and non-randomized controlled trial (RCT) design.

OBJECTIVES

We assessed the efficacy of and adherence to a 12-week online multicomponent stress reduction intervention in IBD.

DESIGN

This is a RCT.

METHODS

Adult participants on stable IBD medical therapy with elevated stress levels from four centers were randomized to intervention or control groups. Intervention participants received a 12-week online program including a weekly yoga, breathwork and meditation video (target 2-3 times/week), a weekly cognitive behavioral therapy/positive psychology informed video activity, and weekly 10-min check-ins by a study team member. Control participants received weekly motivational messages by email. All patients received standard of care IBD therapy. The primary outcome was Cohen's Perceived Stress Scale (PSS). Secondary outcomes evaluated mental health, resilience, health-related quality of life (HRQoL), symptom indices, acceptability, adherence, and inflammatory biomarkers. Analysis of covariance was used to determine between-group differences.

RESULTS

Of 150 screened patients, 101 were randomized to the intervention (n = 49) and control (n = 52) groups (mean age: 42.5 ± 14.1 years; M:F 1:3, 48% with ulcerative colitis and 52% with Crohn's disease). The between-group PSS improved by 22.4% (95% confidence interval, 10.5-34.3, p < 0.001). Significant improvements were seen in mental health, resilience, and HRQoL measures, with a median satisfaction score of 89/100 at the end of the 12 weeks. In the 44/49 patients who completed the intervention, 91% achieved program adherence targets.

CONCLUSION

This 12-week online intervention improved perceived stress, mental health, and HRQoL, but did not impact IBD symptom indices or inflammatory biomarkers. The program was readily adopted and adhered to by participants with high retention rates. After iterative refinement based on participant feedback, future studies will evaluate the impact of a longer/more intense intervention on disease course.

REGISTRATION

ClinicalTrials.gov Identifier NCT03831750.

PLAIN LANGUAGE SUMMARY

An online stress reduction intervention in inflammatory bowel disease patients improves stress, mental health, and quality of life People with inflammatory bowel disease (IBD) have high levels of stress, anxiety, and depression. Although IBD patients have expressed the need for online mental wellness interventions, the existing data to support these interventions in IBD are limited. In this trial, 101 IBD patients had the chance to participate in a 12-week online stress reduction intervention. In those patients randomly selected to participate in the online intervention, each week they received the following: a 20- to 30-min yoga, breathwork, and meditation video that they were asked to do 2-3 times a week, a 10- to 20-min mental wellness activity they were asked to do once during the week, and a 10-min telephone check-in with a study team member. Participants who were not selected to use the online intervention received a weekly motivational message by email. In all, 90 of the 101 participants (89%) completed the study with the mean age of participants being 43 years and the majority being females (75%). Ninety-one percent of participants who completed the intervention met the program target of doing the yoga, breathwork, and meditation video at least 2 times per week. Significant improvements were seen in perceived stress (by 22.4%), depression (by 29.5%), anxiety (by 23.7%), resilience (by 10.6%), and quality of life (by 8.9%). No changes were seen in IBD severity or in blood markers of inflammation. In conclusion, this study demonstrates evidence that a 12-week online stress reduction intervention had low dropout rates, high adherence and beneficial effects on stress, mental health, and quality of life measures. Continued feedback will be sought from study participants and our IBD patient partners to refine the intervention and assess the impact in future studies of patients with active IBD, as well as the impact of a longer/more intense intervention.

Use of digital technologies in the nutritional management of catabolism-prone chronic diseases: A rapid review

BACKGROUND

Diet and nutrition applications (apps) have become more readily accessible as smartphone ownership increases. These apps have the potential to improve nutritional outcomes, but it remains unclear whether they are effective in patients with catabolism-prone conditions and specialized nutritional needs.

AIMS

The primary aim of this rapid review was to determine if delivery of a nutrition intervention via an app was more effective than standard care in improving nutritional outcomes in patients with a selected set of catabolism-prone chronic diseases. Secondary aims included summarizing intervention components and reviewing adherence and acceptance.

METHODS

The research question was developed using the Population, Intervention, Comparison, Outcomes (PICO) framework. Comprehensive literature searches were conducted across three databases. Screening, study selection, extraction, and risk of bias (RoB) assessment were conducted for the included randomized controlled trials (RCTs).

RESULTS

15 articles were included, including 5 RCTs; 3/5 RCTs were judged to be at high RoB. The study aims, measured outcomes, and intervention components were diverse. Adherence and acceptance to the app interventions were encouraging.

CONCLUSIONS

Due to the heterogeneity of study design, nutrition interventions, outcomes, and reporting across studies, we were unable to aggregate data regarding the impact on nutritional outcomes. Reassuringly though, the available evidence suggests high adherence and acceptance, which needs to be interpreted in light of the associated personnel support provided within each study. The use of digital technology to deliver diet and nutrition interventions in catabolism-prone conditions is feasible, easy to adhere to, and well-accepted by participants.