Elsevier

Psychiatry Research

Volume 220, Issues 1–2, 15 December 2014, Pages 63-70
Psychiatry Research

‘Better Health Choices’ by telephone: A feasibility trial of improving diet and physical activity in people diagnosed with psychotic disorders

https://doi.org/10.1016/j.psychres.2014.06.035Get rights and content

Highlights

  • Fruit and vegetable intake and physical inactivity deserve more research attention.

  • Telephone delivered interventions targeting these behaviours appear to be feasible.

  • Diet quality and global functioning improved and overall sitting time decreased.

  • Reductions in leisure screen time were largely replaced by non-sedentary activity.

  • Results support the need for telephone-based RCT׳s with longer follow-up.

Abstract

The study objective was to evaluate the feasibility of a telephone delivered intervention consisting of motivational interviewing and cognitive behavioural strategies aimed at improving diet and physical activity in people diagnosed with psychotic disorders. Twenty participants diagnosed with a non-acute psychotic disorder were recruited. The intervention consisted of eight telephone delivered sessions targeting fruit and vegetable (F&V) consumption and leisure screen time, as well as smoking and alcohol use (as appropriate). F&V frequency and variety, and overall diet quality (measured by the Australian Recommended Food Score, ARFS), leisure screen time, overall sitting and walking time, smoking, alcohol consumption, mood, quality of life, and global functioning were examined before and 4-weeks post-treatment. Nineteen participants (95%) completed all intervention sessions, and 17 (85%) completed follow-up assessments. Significant increases from baseline to post-treatment were seen in ARFS fruit, vegetable and overall diet quality scores, quality of life and global functioning. Significant reductions in leisure screen time and overall sitting time were also seen. Results indicated that a telephone delivered intervention targeting key cardiovascular disease risk behaviours appears to be feasible and relatively effective in the short-term for people diagnosed with psychosis. A randomized controlled trial is warranted to replicate and extend these findings.

Introduction

The physical health of people diagnosed with psychotic disorders is poor compared to the general population, and life expectancy is 15 years shorter (Brown et al., 2000, Osby et al., 2001, Lawrence et al., 2003, Bushe et al., 2010, Laursen, 2011). Rates of cardiovascular disease (CVD) in people diagnosed with psychotic disorders are higher (27%) than in the general population (16%) (Morgan et al., 2011) and account for more premature deaths than suicide (Brown et al., 2000, Osby et al., 2001, Lawrence et al., 2003, Bushe et al., 2010). The Australian National Report Card on Mental Health recommended a clear set of strategies to reduce known CVD risk factors, namely improved diet and nutrition, increased physical activity, and reduced smoking (National Mental Health Commission, 2012). However, several factors may prevent people with psychotic disorders from receiving good physical health care: (i) lower rates of reporting physical symptoms spontaneously; (ii) features of the disorder, such as cognitive impairment, social isolation, and suspicion, that reduce treatment seeking or adherence; (iii) poorer social skills, and mental illness stigma, that reduce the likelihood of accessing good care; (iv) relatively short consultations in primary health care settings, which may not suit individuals with psychotic disorders; and (iv) mental health clinicians limited training in physical care or their pessimism about the possibility of change (Phelan et al., 2001).

Systematic reviews of randomised controlled trials (RCTs) of smoking cessation interventions targeting people with severe mental illness (SMI), including a large Australian RCT (Baker et al., 2006), have found comparable cessation rates to that achieved in general population studies (e.g., Banham and Gilbody, 2010). However, despite inadequate fruit and vegetable (F&V) consumption and physical inactivity being the most prevalent and preventable CVD risk behaviours, there is a paucity of research targeting these behaviours in people with SMI. Population surveys of people with SMI indicate that rates of adherence to national targets for daily F&V consumption (two serves of fruit; five serves of vegetables) are close to zero, and almost all respondents (97%) engage in low or very low levels of physical activity (e.g., Morgan et al., 2011). Higher diet quality scores are associated with reduced mortality, including from all causes (17–42% reduction), CVD (18–53% reduction) and cancer (13–30% reduction) (Wirt and Collins, 2009). Strong established links have been found between television watching and obesity, type II diabetes, CVD, metabolic syndrome and abnormal glucose (Clark et al., 2009).

Research into non-pharmacological interventions targeting diet and physical activity among people with SMI has generally focussed on weight loss or management (Bonfioli et al., 2012, van Hasselt et al., 2013). Weight loss studies (and their requisite control arms) tend to be complex and lengthy, and target people for whom substantial weight loss is the primary objective. Whilst around 75% of people with psychotic disorders are overweight/obese (Morgan et al., 2011), almost none meet guidelines for F&V consumption and physical activity, which are independent risk factors for CVD and specific cancers, regardless of weight. Thus, targeting F&V consumption and physical inactivity, rather than weight, may increase intervention reach, in addition to offering a less complicated, potentially more scalable and translatable approach.

Studies of health promotion lifestyle interventions for people with psychotic disorders do not report F&V consumption as an outcome (Bonfioli et al., 2012, van Hasselt et al., 2013), suggesting that this CVD risk behaviour is commonly overlooked. In a broadly focused behaviour change intervention in people with psychotic disorders, Baker et al. (2011) found no increase in F&V intake in either the intervention or control groups. Dietary goals addressed a range of areas rather than targeting F&V, suggesting that F&V consumption must be specifically targeted in order for changes to occur. Further, past research in both children (Epstein et al., 2008) and adults (Jenkins et al., 2011) indicates that encouraging people to eat more ‘healthy’ food is more effective than restricting ‘unhealthy’ foods.

However, the few existing RCTs specifically targeting F&V consumption or physical activity in people with psychotic disorders have produced poor results. These include loss of short term gains (McCreadie et al., 2005), low rates of attendance at external organisations (Beebe et al., 2011), and high rates of loss to follow-up (Scheewe et al., 2013), which are also seen in other lifestyle behaviour intervention studies among people with psychotic disorders (van Hasselt et al., 2013). These findings suggest a need for alternatives to interventions requiring attendance at external organisations.

Telephone interventions for CVD risk behaviours in the general population have been shown to be cost-effective (Graves et al., 2009, Smith et al., 2011) and at a lower cost than face-to-face interventions (Radcliff et al., 2012). A telephone intervention may also overcome attendance barriers. The authors recently completed an RCT evaluating a healthy lifestyle intervention targeting smoking, physical activity and diet in people with psychotic disorders (Baker et al., 2011). The number of sessions completed in the telephone based comparison group [mean=11.3 (S.D.=6.1)] was significantly higher than by the face-to-face group [mean=8.5 (S.D.=6.4), p<0.001)] (unpublished data). Further, tobacco ‘quitlines’ are being increasingly recognised as potentially effective for smokers with mental illnesses (e.g., Morris et al., 2009, Morris et al., 2011).

Spring et al. (2012) have argued that suboptimal diet and a sedentary lifestyle tend to cluster together as health risk behaviours, increasing risk for disease, the opportunity exists to intervene more efficiently and perhaps synergistically by addressing multiple behaviours. In order to test which combination of diet and activity advice maximised healthy change, they randomly assigned 204 people with elevated saturated fat intake and low F&V consumption, high sedentary leisure (screen) time and low physical activity to one of four treatments: 1) increase F&V intake and physical activity; 2) decrease fat and sedentary leisure; 3) decrease fat and increase physical activity; or 4) increase F&V and decrease sedentary leisure. Coaches trained participants to monitor dietary intake and activity levels using a handheld device. Following two weeks of monitoring participants were randomly assigned to one of the four intervention conditions, focusing on one dietary and one activity goal. Coaches tailored behavioural strategies based on the individual׳s baseline data. Daily goals were set midway between the baseline level for each of the target behaviours and the ultimate daily goal for the first week. At the beginning of the second week, full goals were set and these were expected to be maintained during week 3. During the three treatment weeks, participants uploaded data daily and communicated as needed with their coaches via telephone or email, whichever they preferred. Goal thermometers were updated in response to data entry and participants were also able to look up potential impact of a food or activity choice. Participants could earn up to $175 as an incentive for meeting the goals for both targeted behaviours during the treatment phase.

During the 20 week follow-up period, incentives were continued in the Spring et al. (2012) study and contingent upon provision of recording and transmitting handheld device data. The intervention which targeted increasing F&V consumption and decreasing sedentary time increased composite diet-activity improvement scores more than other interventions in the first week of treatment (p<0.01) and maintained superiority during the treatment and follow-up period. Substantial improvements were seen in daily F&V consumption (1.2 to 5.5 serves/day), screen time (219.2 to 89.3 min/day), and serendipitously, saturated fat intake (12% to 9.5% energy). The traditional approach (decreasing saturated fat and increasing physical activity) achieved lower levels of improvement than did the other three treatments in the first week of intervention (p<0.05) and through to the end of follow-up.

The aim of this pilot study was to evaluate the feasibility of an adaptation of the intervention developed by Spring et al. (2012) in reducing CVD risk behaviours among people with psychotic disorders, namely, the Better Health Choices intervention. Better Health Choices is a telephone-delivered intervention that uses motivational interviewing (Miller and Rollnick, 2012) and cognitive behavioural strategies to target low F&V intake and physical inactivity (leisure screen time) in people with a psychotic disorder. Conducted among the general population, Spring et al. (2012) intervention involved detailed daily self-monitoring and uploading of data and swift and sizeable dietary and activity goal setting, with directive suggestions for change, to be accomplished over three weeks. Allowing for possible socioeconomic, social, emotional and/or cognitive difficulties experienced by people with a psychotic disorder (Kavanagh and Connolly, 2007), the Better Health Choices intervention allowed behaviour change to occur over a longer interval, simplified self-monitoring to a weekly diary plus a 24 h snapshot interview during each session, elicited self-motivational statements to identify a variety of possible goals and change strategies, and encouraged incremental goal attainments and behavioural activation in the form of increasing non-screen related activities. It was predicted that completion of the Better Health Choices intervention would be associated with a significant increase in F&V intake and a significant reduction in leisure screen time compared to baseline. It was also hypothesised that the Better Health Choices telephone-intervention would be acceptable and satisfactory to participants.

Section snippets

Participants and procedures

This was a feasibility study, utilising a pre- versus post-treatment design, with no control group. Participants were recruited from the Australian Schizophrenia Research Bank (ASRB, http://www.schizophreniaresearch.org.au/bank/). Inclusion criteria were: age ≥18 years; currently consuming <7 F&V serves per day and >2 h of non-work sitting time per day; and a lifetime diagnosis of a psychotic disorder, as assessed by ASRB administration of the Diagnostic Interview for Psychosis (Castle et al.,

Sample characteristics

As shown in Fig. 1, a total of 110 letters were sent to ASRB registrants inviting them to participate. Of 30 respondents, 24 could be contacted and were screened, and 20 (18%) were recruited into the study (one refused and three were ineligible, two due to reporting fewer than the required CVD risk behaviours, and one with a history of brain injury). Nineteen (95%) completed all eight therapy sessions (one participant withdrew due to lack of privacy in their boarding house). Seventeen (85%)

Discussion

Completion of the Better Health Choices telephone intervention was associated with improvements in F&V and overall diet quality, reductions in leisure screen time and overall sitting time, and improved QoL and global functioning. The results support previous findings in the general population (Spring et al., 2012) and in people with psychosis (Baker et al., 2009, Baker et al., 2011) indicating that behaviour change across multiple domains is possible using non face-to-face modalities of

Acknowledgements

This study was supported by the Australian Schizophrenia Research Bank (ASRB), which is supported by the National Health and Medical Research Council of Australia, the Pratt Foundation, Ramsay Health Care, the Viertel Charitable Foundation and the Schizophrenia Research Institute (Carr V, Schall U, Scott R, Jablensky A, Mowry B, Michie P, Catts S, Henskens F, Pantelis C, Loughland C). We wish to thank project staff including Michelle Andrews, Katrina Bell, Vanessa Clark, Sarah Edwards, Emma

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