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Adding web-based behavioural support to exercise referral schemes for inactive adults with chronic health conditions: the e-coachER RCT.
Taylor, AH, Taylor, RS, Ingram, WM, Anokye, N, Dean, S, Jolly, K, Mutrie, N, Lambert, J, Yardley, L, Greaves, C, et al
Health technology assessment (Winchester, England). 2020;(63):1-106
Abstract
BACKGROUND There is modest evidence that exercise referral schemes increase physical activity in inactive individuals with chronic health conditions. There is a need to identify additional ways to improve the effects of exercise referral schemes on long-term physical activity. OBJECTIVES To determine if adding the e-coachER intervention to exercise referral schemes is more clinically effective and cost-effective in increasing physical activity after 1 year than usual exercise referral schemes. DESIGN A pragmatic, multicentre, two-arm randomised controlled trial, with a mixed-methods process evaluation and health economic analysis. Participants were allocated in a 1 : 1 ratio to either exercise referral schemes plus e-coachER (intervention) or exercise referral schemes alone (control). SETTING Patients were referred to exercise referral schemes in Plymouth, Birmingham and Glasgow. PARTICIPANTS There were 450 participants aged 16-74 years, with a body mass index of 30-40 kg/m2, with hypertension, prediabetes, type 2 diabetes, lower limb osteoarthritis or a current/recent history of treatment for depression, who were also inactive, contactable via e-mail and internet users. INTERVENTION e-coachER was designed to augment exercise referral schemes. Participants received a pedometer and fridge magnet with physical activity recording sheets, and a user guide to access the web-based support in the form of seven 'steps to health'. e-coachER aimed to build the use of behavioural skills (e.g. self-monitoring) while strengthening favourable beliefs in the importance of physical activity, competence, autonomy in physical activity choices and relatedness. All participants were referred to a standard exercise referral scheme. PRIMARY OUTCOME MEASURE Minutes of moderate and vigorous physical activity in ≥ 10-minute bouts measured by an accelerometer over 1 week at 12 months, worn ≥ 16 hours per day for ≥ 4 days including ≥ 1 weekend day. SECONDARY OUTCOMES Other accelerometer-derived physical activity measures, self-reported physical activity, exercise referral scheme attendance and EuroQol-5 Dimensions, five-level version, and Hospital Anxiety and Depression Scale scores were collected at 4 and 12 months post randomisation. RESULTS Participants had a mean body mass index of 32.6 (standard deviation) 4.4 kg/m2, were referred primarily for weight loss and were mostly confident self-rated information technology users. Primary outcome analysis involving those with usable data showed a weak indicative effect in favour of the intervention group (n = 108) compared with the control group (n = 124); 11.8 weekly minutes of moderate and vigorous physical activity (95% confidence interval -2.1 to 26.0 minutes; p = 0.10). Sixty-four per cent of intervention participants logged on at least once; they gave generally positive feedback on the web-based support. The intervention had no effect on other physical activity outcomes, exercise referral scheme attendance (78% in the control group vs. 75% in the intervention group) or EuroQol-5 Dimensions, five-level version, or Hospital Anxiety and Depression Scale scores, but did enhance a number of process outcomes (i.e. confidence, importance and competence) compared with the control group at 4 months, but not at 12 months. At 12 months, the intervention group incurred an additional mean cost of £439 (95% confidence interval -£182 to £1060) compared with the control group, but generated more quality-adjusted life-years (mean 0.026, 95% confidence interval 0.013 to 0.040), with an incremental cost-effectiveness ratio of an additional £16,885 per quality-adjusted life-year. LIMITATIONS A significant proportion (46%) of participants were not included in the primary analysis because of study withdrawal and insufficient device wear-time, so the results must be interpreted with caution. The regression model fit for the primary outcome was poor because of the considerable proportion of participants [142/243 (58%)] who recorded no instances of ≥ 10-minute bouts of moderate and vigorous physical activity at 12 months post randomisation. FUTURE WORK The design and rigorous evaluation of cost-effective and scalable ways to increase exercise referral scheme uptake and maintenance of moderate and vigorous physical activity are needed among patients with chronic conditions. CONCLUSIONS Adding e-coachER to usual exercise referral schemes had only a weak indicative effect on long-term rigorously defined, objectively assessed moderate and vigorous physical activity. The provision of the e-coachER support package led to an additional cost and has a 63% probability of being cost-effective based on the UK threshold of £30,000 per quality-adjusted life-year. The intervention did improve some process outcomes as specified in our logic model. TRIAL REGISTRATION Current Controlled Trials ISRCTN15644451. FUNDING This project was funded by the National Institute for Health Research (NIHR) Health Technology Assessment programme and will be published in full in Health Technology Assessment; Vol. 24, No. 63. See the NIHR Journals Library website for further project information.
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Effectiveness of embedding a specialist preventive care clinician in a community mental health service in increasing preventive care provision: A randomised controlled trial.
Fehily, CM, Bartlem, KM, Wiggers, JH, Wye, PM, Clancy, RV, Castle, DJ, Wilson, A, Rissel, CE, Wutzke, S, Hodder, RK, et al
The Australian and New Zealand journal of psychiatry. 2020;(6):620-632
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Abstract
OBJECTIVE Clinical practice guidelines recommend that community mental health services provide preventive care for clients' chronic disease risk behaviours; however, such care is often not routinely provided. This study aimed to assess the effectiveness of offering clients an additional consultation with a specialist clinician embedded within a community mental health service, in increasing client-reported receipt of, and satisfaction with, preventive care. METHOD A randomised controlled trial was undertaken in one Australian community mental health service. Participants (N = 811) were randomised to receive usual care (preventive care in routine consultations; n = 405) or usual care plus the offer of an additional consultation with a specialist preventive care clinician (n = 406). Blinded interviewers assessed at baseline and 1-month follow-up the client-reported receipt of preventive care (assessment, advice and referral) for four key risk behaviours individually (smoking, poor nutrition, alcohol overconsumption and physical inactivity) and all applicable risks combined, acceptance of referrals and satisfaction with preventive care received. RESULTS Analyses indicated significantly greater increases in 12 of the 18 preventive care delivery outcomes in the intervention compared to the usual care condition from baseline to follow-up, including assessment for all risks combined (risk ratio = 4.00; 95% confidence interval = [1.57, 10.22]), advice for all applicable risks combined (risk ratio = 2.40; 95% confidence interval = [1.89, 6.47]) and offer of referral to applicable telephone services combined (risk ratio = 20.13; 95% confidence interval = [2.56, 158.04]). For each component of care, there was a significant intervention effect for at least one of the individual risk behaviours. Participants reported high levels of satisfaction with preventive care received, ranging from 77% (assessment) to 87% (referral), with no significant differences between conditions. CONCLUSION The intervention had a significant effect on the provision of the majority of recommended elements of preventive care. Further research is needed to maximise its impact, including identifying strategies to increase client uptake.
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Understanding Self-Guided Web-Based Educational Interventions for Patients With Chronic Health Conditions: Systematic Review of Intervention Features and Adherence.
Xie, LF, Itzkovitz, A, Roy-Fleming, A, Da Costa, D, Brazeau, AS
Journal of medical Internet research. 2020;(8):e18355
Abstract
BACKGROUND Chronic diseases contribute to 71% of deaths worldwide every year, and an estimated 15 million people between the ages of 30 and 69 years die mainly because of cardiovascular disease, cancer, chronic respiratory diseases, or diabetes. Web-based educational interventions may facilitate disease management. These are also considered to be a flexible and low-cost method to deliver tailored information to patients. Previous studies concluded that the implementation of different features and the degree of adherence to the intervention are key factors in determining the success of the intervention. However, limited research has been conducted to understand the acceptability of specific features and user adherence to self-guided web interventions. OBJECTIVE This systematic review aims to understand how web-based intervention features are evaluated, to investigate their acceptability, and to describe how adherence to web-based self-guided interventions is defined and measured. METHODS Studies published on self-guided web-based educational interventions for people (≥14 years old) with chronic health conditions published between January 2005 and June 2020 were reviewed following the PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-Analyses) Statement protocol. The search was performed using the PubMed, Cochrane Library, and EMBASE (Excerpta Medica dataBASE) databases; the reference lists of the selected articles were also reviewed. The comparison of the interventions and analysis of the features were based on the published content from the selected articles. RESULTS A total of 20 studies were included. Seven principal features were identified, with goal setting, self-monitoring, and feedback being the most frequently used. The acceptability of the features was measured based on the comments collected from users, their association with clinical outcomes, or device adherence. The use of quizzes was positively reported by participants. Self-monitoring, goal setting, feedback, and discussion forums yielded mixed results. The negative acceptability was related to the choice of the discussion topic, lack of face-to-face contact, and technical issues. This review shows that the evaluation of adherence to educational interventions was inconsistent among the studies, limiting comparisons. A clear definition of adherence to an intervention is lacking. CONCLUSIONS Although limited information was available, it appears that features related to interaction and personalization are important for improving clinical outcomes and users' experience. When designing web-based interventions, the selection of features should be based on the targeted population's needs, the balance between positive and negative impacts of having human involvement in the intervention, and the reduction of technical barriers. There is a lack of consensus on the method of evaluating adherence to an intervention. Both investigations of the acceptability features and adherence should be considered when designing and evaluating web-based interventions. A proof-of-concept or pilot study would be useful for establishing the required level of engagement needed to define adherence.
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Consequences of physical inactivity in older adults: A systematic review of reviews and meta-analyses.
Cunningham, C, O' Sullivan, R, Caserotti, P, Tully, MA
Scandinavian journal of medicine & science in sports. 2020;(5):816-827
Abstract
BACKGROUND Globally, populations are ageing. Typically, physical activity levels decline and health worsens as we age; however, estimates of the impact of physical inactivity for population health often fail to specifically focus on older adults. METHODS Multiple databases were searched for systematic reviews and/or meta-analyses of longitudinal observational studies, investigating the relationship between physical activity and any physical or mental health outcome in adults aged ≥60 years. Quality of included reviews was assessed using AMSTAR. RESULTS Twenty-four systematic reviews and meta-analyses were included. The majority of reviews were of moderate or high methodological quality. Physically active older adults (≥60 years) are at a reduced risk of all-cause and cardiovascular mortality, breast and prostate cancer, fractures, recurrent falls, ADL disability and functional limitation and cognitive decline, dementia, Alzheimer's disease, and depression. They also experience healthier ageing trajectories, better quality of life and improved cognitive functioning. CONCLUSION This review of reviews provides a comprehensive and systematic overview of epidemiological evidence from previously conducted research to assess the associations of physical activity with physical and mental health outcomes in older adults.
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Clinical Significance of Analysis of Vitamin D Status in Various Diseases.
Kowalówka, M, Główka, AK, Karaźniewicz-Łada, M, Kosewski, G
Nutrients. 2020;(9)
Abstract
Vitamin D plays a role not only in the proper functioning of the skeletal system and the calcium-phosphate equilibrium, but also in the immune system, the cardiovascular system and the growth and division of cells. Although numerous studies have reported on the analysis of vitamin D status in various groups of patients, the clinical significance of measurements of vitamin D forms and metabolites remains ambiguous. This article reviews the reports analyzing the status of vitamin D in various chronic states. Particular attention is given to factors affecting measurement of vitamin D forms and metabolites. Relevant papers published during recent years were identified by an extensive PubMed search using appropriate keywords. Measurement of vitamin D status proved to be a useful tool in diagnosis and progression of metabolic syndrome, neurological disorders and cancer. High performance liquid chromatography coupled with tandem mass spectrometry has become the preferred method for analyzing the various forms and metabolites of vitamin D in biological fluids. Factors influencing vitamin D concentration, including socio-demographic and biochemical factors as well as the genetic polymorphism of the vitamin D receptor, along with vitamin D transporters and enzymes participating in vitamin D metabolism should be considered as potential confounders of the interpretation of plasma total 25(OH)D concentrations.
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Sedentary Behavior and Chronic Disease: Mechanisms and Future Directions.
Dempsey, PC, Matthews, CE, Dashti, SG, Doherty, AR, Bergouignan, A, van Roekel, EH, Dunstan, DW, Wareham, NJ, Yates, TE, Wijndaele, K, et al
Journal of physical activity & health. 2020;(1):52-61
Abstract
BACKGROUND Recent updates to physical activity guidelines highlight the importance of reducing sedentary time. However, at present, only general recommendations are possible (ie, "Sit less, move more"). There remains a need to investigate the strength, temporality, specificity, and dose-response nature of sedentary behavior associations with chronic disease, along with potential underlying mechanisms. METHODS Stemming from a recent research workshop organized by the Sedentary Behavior Council themed "Sedentary behaviour mechanisms-biological and behavioural pathways linking sitting to adverse health outcomes," this paper (1) discusses existing challenges and scientific discussions within this advancing area of science, (2) highlights and discusses emerging areas of interest, and (3) points to potential future directions. RESULTS A brief knowledge update is provided, reflecting upon current and evolving thinking/discussions, and the rapid accumulation of new evidence linking sedentary behavior to chronic disease. Research "action points" are made at the end of each section-spanning from measurement systems and analytic methods, genetic epidemiology, causal mediation, and experimental studies to biological and behavioral determinants and mechanisms. CONCLUSION A better understanding of whether and how sedentary behavior is causally related to chronic disease will allow for more meaningful conclusions in the future and assist in refining clinical and public health policies/recommendations.
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Coenzyme Q10 Supplementation for the Reduction of Oxidative Stress: Clinical Implications in the Treatment of Chronic Diseases.
Gutierrez-Mariscal, FM, Arenas-de Larriva, AP, Limia-Perez, L, Romero-Cabrera, JL, Yubero-Serrano, EM, López-Miranda, J
International journal of molecular sciences. 2020;(21)
Abstract
Apart from its main function in the mitochondria as a key element in electron transport, Coenzyme Q10 (CoQ10) has been described as having multiple functions, such as oxidant action in the generation of signals and the control of membrane structure and phospholipid and cellular redox status. Among these, the most relevant and most frequently studied function is the potent antioxidant capability of its coexistent redox forms. Different clinical trials have investigated the effect of CoQ10 supplementation and its ability to reduce oxidative stress. In this review, we focused on recent advances in CoQ10 supplementation, its role as an antioxidant, and the clinical implications that this entails in the treatment of chronic diseases, in particular cardiovascular diseases, kidney disease, chronic obstructive pulmonary disease, non-alcoholic fatty liver disease, and neurodegenerative diseases. As an antioxidant, CoQ10 has proved to be of potential use as a treatment in diseases in which oxidative stress is a hallmark, and beneficial effects of CoQ10 have been reported in the treatment of chronic diseases. However, it is crucial to reach a consensus on the optimal dose and the use of different formulations, which vary from ubiquinol or ubiquinone Ubisol-Q10 or Qter®, to new analogues such as MitoQ, before we can draw a clear conclusion about its clinical use. In addition, a major effort must be made to demonstrate its beneficial effects in clinical trials, with a view to making the implementation of CoQ10 possible in clinical practice.
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The Impact of Diet on Microbiota Evolution and Human Health. Is Diet an Adequate Tool for Microbiota Modulation?
Moles, L, Otaegui, D
Nutrients. 2020;(6)
Abstract
The human microbiome is emerging as an interesting field in research into the prevention of health problems and recovery from illness in humans. The complex ecosystem formed by the microbiota is continuously interacting with its host and the environment. Diet could be assumed to be one of the most prominent factors influencing the microbiota composition. Nevertheless, and in spite of numerous strategies proposed to modulate the human microbiota through dietary means, guidelines to achieve this goal have yet to be established. This review assesses the correlation between social and dietary changes over the course of human evolution and the adaptation of the human microbiota to those changes. In addition, it discusses the main dietary strategies for modulating the microbiota and the difficulties of putting them properly into practice.
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Diet Quality as Assessed by the Healthy Eating Index, Alternate Healthy Eating Index, Dietary Approaches to Stop Hypertension Score, and Health Outcomes: A Second Update of a Systematic Review and Meta-Analysis of Cohort Studies.
Morze, J, Danielewicz, A, Hoffmann, G, Schwingshackl, L
Journal of the Academy of Nutrition and Dietetics. 2020;(12):1998-2031.e15
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BACKGROUND Suboptimal diet quality has a large impact on noncommunicable disease burden. OBJECTIVE This study aimed to update the body of evidence on the associations between diet quality, as assessed by the Healthy Eating Index, Alternate Healthy Eating Index, and the Dietary Approaches to Stop Hypertension score, and health status. Moreover, results of the previous systematic reviews and meta-analyses were extended by evaluating the credibility of the evidence. METHODS PubMed, Embase, and Scopus databases were searched to identify eligible studies published between May 15, 2017 and March 14, 2020. Pooled relative risk (RR) with 95% CI for highest vs lowest category of diet quality were estimated using a random-effects model. Heterogeneity was explored using Cochran's Q test and I2 statistic with 95% CI. Presence of publication bias was detected by using funnel plots and Egger's regression test. The NutriGrade tool was used to assess the credibility of evidence. RESULTS The current update identified 47 new reports, resulting in a total of 113 reports including data from 3,277,684 participants. Diets of the highest quality, as assessed by the Healthy Eating Index, Alternate Healthy Eating Index, and Dietary Approaches to Stop Hypertension scores, were inversely associated with risk of all-cause mortality (RR 0.80, 95% CI 0.79 to 0.82, I2 = 68%, n= 23), cardiovascular disease incidence or mortality (RR 0.80, 95% CI 0.78 to 0.82, I2 = 59%, n= 45), cancer incidence or mortality (RR 0.86, 95% CI 0.84 to 0.89, I2 = 73%, n= 45), incidence of type 2 diabetes (RR 0.81, 95% CI 0.78 to 0.85, I2 = 76%, n= 16), and incidence of neurodegenerative diseases (RR 0.82, 95% CI 0.75 to 0.89, I2 = 71%, n= 12). In cancer survivors, the highest diet quality was linked with lower risk of all-cause (RR 0.83, 95% CI 0.77 to 0.88, I2 = 45%, n= 12) and cancer mortality (RR 0.82, 95% CI 0.75 to 0.89, I2 = 44%, n= 12). The credibility of evidence for identified associations between overall healthy dietary patterns and included health outcomes was moderate. CONCLUSION This updated systematic review and meta-analysis suggests that high diet quality (assessed by the Healthy Eating Index, Alternate Healthy Eating Index, and Dietary Approaches to Stop Hypertension) is inversely associated with risk of all-cause mortality, cardiovascular disease incidence or mortality, cancer incidence or mortality, type 2 diabetes, and neurodegenerative disease, as well as all-cause mortality and cancer mortality among cancer survivors. Moderate credibility of evidence for identified associations complements the recent 2020 Dietary Guidelines Advisory Committee report recommending healthy dietary patterns for disease prevention.
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Can consumer wearable activity tracker-based interventions improve physical activity and cardiometabolic health in patients with chronic diseases? A systematic review and meta-analysis of randomised controlled trials.
Franssen, WMA, Franssen, GHLM, Spaas, J, Solmi, F, Eijnde, BO
The international journal of behavioral nutrition and physical activity. 2020;(1):57
Abstract
BACKGROUND To date, it is unclear if consumer wearable activity trackers (CWATs), with or without behaviour multi-component strategies, effectively improve adherence to physical activity and health outcomes under free living conditions in populations with chronic diseases. Therefore, we systematically evaluated the efficacy of CWAT-based interventions to promote physical activity levels and cardiometabolic health in populations with chronic diseases. METHODS Randomised controlled trials were collected from five bibliographic databases (PubMed, Embase, Web of Science, The Cochrane Central Register of Controlled Trials and CINAHL). Studies were eligible for inclusion if they evaluated a CWAT-based counselling intervention versus control intervention among patients with chronic respiratory diseases, type 2 diabetes mellitus, cardiovascular diseases, overweight/obesity, cognitive disorders, or sedentary older adults. Data were pooled using a random-effects model. RESULTS After deduplication 8147 were identified of which 35 studies met inclusion criteria (chronic respiratory diseases: 7, type 2 diabetes mellitus: 12, cardiovascular diseases: 6, overweight/obesity: 3, cognitive disorders: 1, sedentary older adults: 6). Compared to control groups, CWAT-based interventions significantly increased physical activity by 2123 steps per day (95% confidence interval [CI], [1605-2641]; p < 0.001). In addition, CWAT-based interventions in these populations significantly decreased systolic blood pressure (- 3.79 mm Hg; 95% CI: [- 4.53, - 3.04] mm Hg; p < 0.001), waist circumference (- 0.99 cm; 95% CI: [- 1.48, - 0.50] cm; p < 0.001) and low-density lipoprotein cholesterol concentration (- 5.70 mg/dl; 95% CI: [- 9.24, - 2.15] mg/dl; p = 0.002). CONCLUSION CWAT-based interventions increase physical activity and have beneficial effects on important health-related outcomes such as systolic blood pressure, waist circumference and LDL cholesterol concentration in patients with chronic diseases.