Adherence and Feasibility of a Multidisciplinary Lifestyle program for Patients with Atrial Fibrillation and Obesity (Preprint)

BACKGROUND Atrial Fibrillation (AF) is commonly associated with obesity. Observational studies showed that weight loss and improvement of physical fitness are associated with improved prognosis and a decrease in AF symptoms. However, despite these benefits, non-adherence is common. OBJECTIVE In this study we evaluated the adherence and feasibility of a multidisciplinary lifestyle program focusing on behavioural change in patients with AF and obesity. METHODS Patients with AF and obesity received a goal-oriented CR program for three months including 4 fixed modules: lifestyle counselling by an Advanced Nurse Practitioner, exercise training, dietary consultation and psychosocial therapy; relaxation sessions were an additional optional treatment module. After this CR program the Advanced Nurse Practitioner monitored the personal lifestyle of each individual patient 3 and 9 months of discharge CR. The primary endpoints were compliance and completion rates of the CR program, the latter being defined as performing at least of 80 % of the prescribed sessions. In addition, we performed an exploratory analysis of effects on weight and AF burden and frequency. RESULTS Ten patients with AF and obesity were recruited. The majority of patients were male (8/2), the mean age was 57.2 ± 9.0 and the BMI 32.4 ± 3.5 kg / m2. Eight patients completed the 3-months CR program. Two patients did not complete their CR program, both because of private issues. Adherence to the fixed treatment modules was 95% for lifestyle counselling, 86% for physiotherapy sessions, 88% for dietician consultations and 60% received psychosocial therapy; concerning the optional additional modules, 70% of patients were referred to the relaxation sessions and the adherence was 86%. Both weight and physical condition were improved. Frequency of AF-related symptoms was considerably reduced immediately after rehabilitation and was even lower after 1 year. Severity of AF complaints post-CR was similar to the baseline, but significantly lower after 1 year. CONCLUSIONS A one-year multidisciplinary lifestyle program was feasible in obese patients with AF with high compliance and completion rates. An exploratory analysis revealed a sustained reduction in AF symptoms, however, these results remain to be confirmed in larger studies. CLINICALTRIAL The study protocol was submitted for approval to Medical Research Ethics Committee of Máxima Medical Center (Veldhoven, the Netherlands) which confirmed that the Dutch Medical Research Involving Human Subjects Act does not apply to this study and therefore waived formal approval.

Impulsive Lifestyle Counselling Versus Treatment as Usual to Reduce Offending in People with Co-Occurring Antisocial Personality Disorder and Substance Use Disorder: A Post Hoc Analysis - BMC

Objectives: To assess the impact of a psychoeducation for antisocial personality disorder on offending after randomization to treatment.Design: Multicentre, superiority, non-blinded randomized controlled trial. Random assignment was conducted in blocks of varying sizes at a central randomization centre.Setting: Nine outpatient uptake areas in Denmark.Participants: One hundred and seventy six patients with antisocial personality disorder in treatment for substance use disorders were randomized to treatment as usual or ILC (n=80; n=96). A total of 165 patients could be linked to criminal records collected between randomization and November 2019 (n=91; n=74).Intervention: The Impulsive Lifestyle Counselling program (ILC), is a brief psycho-educational program targeting antisocial behavior. The trial was conducted between January of 2012 and June 2014, and participants were tracked until December 2018, migration, or death, whichever occurred first. Outcomes: Number of offences in the 12 months following trial randomization from official national registers.Results: The mean number of offences was 2.76 in the TAU group (95% Poisson confidence interval [CI]=2.39, 3.16) and 1.87 in the ILC group (CI=0.97, 1.43). Negative binomial regression was used to assess number of convictions within the first year; violent, property, driving under the influence, and drug-related convictions. In both adjusted and unadjusted analyses, random assignment to ILC was associated with a lower number of total (incremental risk ration [IRR]=0.43, p=.013; adjusted IRR=0.33, p<.001), violent (IRR=0.19, p=.001; adjusted IRR=0.16, p=.018). Results were not significant for driving under the influence (unadjusted IRR=0.60, p=.371; adjusted IRR=0.87, p=.521), or drug offences (unadjusted IRR =1.06, p=.905; adjusted IRR=0.50, p=.180).Conclusions: The ILC program shows promise in reducing offending behavior in people with comorbid substance use and antisocial personality disorder.Trial registration: ISRCTN registry, ISRCTN67266318, 17/7/2012, https://doi.org/10.1186/ISRCTN67266318.

Communication based on partnership: experiences of lifestyle counselling by patients and caregivers in primary care

Funding Acknowledgements Type of funding sources: None. Background Despite the knowledge of the effect of lifestyle changes in preventing cardiovascular disease, a large proportion of people have unhealthy lifestyle habits. To enhance the care of patients at high cardiovascular risk we started a one-year, structured lifestyle program in primary care. Purpose To explore patients´ at high cardiovascular risk and community health nurses´ experiences of lifestyle counselling after participation in a lifestyle program. Methods A qualitative explorative design was used to collect data on participants ‘experiences and an inductive content analysis was performed. Sixteen patients (eight men and eight women, aged 51 – 75 years) diagnosed with either type 2 diabetes mellitus or hypertension and three community health nurses were interviewed. Results The participants emphasised that lifestyle counselling should be based on partnership where patients and community health nurses collaborates to reach the set treatment and behavioural goals. Five categories describe this partnership; "Collaboration based on respect and mutual interest", "Enable understanding of illness and lifestyle habits", "Measurements and goalsetting are valuable tools", "The value of continuous support" and "Organisation structure should support lifestyle counselling". Conclusion Our results indicate that a trustful relationship, increased knowledge on lifestyle habits and how they effect illness, repeated measurements and recurrent support are important for successful lifestyle counselling. Additionally, the organisation of the structured lifestyle counselling needs to be supported by the primary care unit.

ILC-OPI: impulsive lifestyle counselling versus cognitive behavioral therapy to improve retention of patients with opioid use disorders and externalizing behavior: study protocol for a multicenter, randomized, controlled, superiority trial

Background Substance use disorders show a high comorbidity with externalizing behavior difficulties, creating treatment challenges, including difficulties with compliance, a high risk of conflict, and a high rate of offending post-treatment. Compared with people with other substance use disorders those with opioid use disorders have the highest risk of criminal activity, but studies on the evidence base for psychosocial treatment in opioid agonist treatment (OAT) are scarce. The Impulsive Lifestyle Counselling (ILC) program may be associated with better retention and outcomes among difficult-to-treat patients with this comorbidity. Methods The study is a multicenter, randomized, controlled, superiority clinical trial. Participants will be a total of 137 hard-to-treat individuals enrolled in opioid agonist treatment (OAT). Participants will be randomized to either a standard treatment (14 sessions of individual manual-based cognitive behavioral therapy and motivational interviewing (MOVE-I)) or six sessions of ILC followed by nine sessions of MOVE-I. All participants will receive personalized text reminders prior to each session and vouchers for attendance, as well as medication as needed. The primary outcome is retention in treatment. Secondary measures include severity of drug use and days of criminal offending for profit three and nine months post-randomization. A secondary aim is, through a case-control study, to investigate whether participants in the trial differ from patients receiving treatment as usual in municipalities where ILC and MOVE-I have not been implemented in OAT. This will be done by comparing number of offences leading to conviction 12 months post-randomization recorded in the national criminal justice register and number of emergency room contacts 12 months post-randomization recorded in the national hospital register. Discussion This is the first randomized, controlled clinical trial in OAT to test the effectiveness of ILC against a standardized comparison with structural elements to increase the likelihood of exposure to the elements of treatment. Results obtained from this study may have important clinical, social, and economic implications for publicly funded treatment of opioid use disorder. Trial registration ISRCTN, ISRCTN19554367, registered on 04/09/2020.

Impact of an educational intervention combining clinical obesity preceptorship with electronic networking tools on primary care professionals: a prospective study

Background Primary care providers’ (PCPs) attitude toward obesity is often negative, and their confidence level for helping patients manage their weight is low. Continuing professional development (CPD) on the subject of obesity is often based on a single activity using a traditional passive approach such as lectures known to have little effect on performance or patient outcomes. The aim of this study was to evaluate the impact of an educational intervention for obesity management on PCPs’ attitude, self-efficacy, practice changes and patient-related outcomes. Methods Prospective interventional study with 12 months follow-up. A two-day clinical obesity preceptorship was offered where participants were actively involved in competence building using real-life situations, in addition to electronic networking tools, including a discussion forum and interactive monthly webinars. Thirty-five participants (12 nurses and 23 physicians) from seven Family medicine groups were enrolled. Questionnaires were used to evaluate the impact on primary care nurses’ and physicians’ attitudes and self-efficacy for obesity management. Practice changes and patient outcomes were evaluated using clinical vignettes, de-identified electronic patient records and qualitative analyses from group interviews. Results Physicians’ general attitude towards patients with obesity was improved (61 ± 22 mm vs 85 ± 17 mm, p < 0.001). Self-efficacy for obesity management and lifestyle counselling were also improved immediately and 1 year after the intervention (all Ps < 0.05). De-identified patient records and clinical vignettes both showed improvement in recording of weight, waist circumference and evaluation of readiness to change lifestyle (all Ps < 0.05) that was confirmed by group interviews. Also, 15% of patients who were prospectively registered for weight management had lost more than 5% of their initial weight at the time of their last visit (P < 0.0001, median follow-up of 152 days). Conclusion A multimodal educational intervention for obesity management can improve PCPs’attitude and self-efficacy for obesity management and lifestyle counselling. This translates into beneficial practice changes and patient-related outcomes. Trial registration clinicaltrials.gov Identifier: NCT01385397. Retrospectively registered, 28 June 2011.

MON-LB105 Resident Obesity Management: Comfort Correlates With Action

The projected prevalence of obesity in the US is 50% by 2030.1 Little data exists on resident physician obesity management in their primary care clinics.2 We aimed to explore internal medicine (IM) resident comfort, knowledge, and treatment practice of obesity in primary care. IM residents at one academic medical center (N=125), at 5 primary care sites were anonymously surveyed about knowledge, comfort, and practice behaviors around obesity management. In this exploratory analysis, respondents self-reported comfort with lifestyle counselling and weight management medication (WMM) prescription on 4-point Likert scales; scores were combined into an overall Comfort Score (CS). Correlation analysis (Pearson’s correlation) compared CS with the following Clinical Actions: referral to lifestyle specialists, lifestyle counseling, WMM prescription, and bariatric surgery referral. The response rate was 70/125 (56%). Most residents (91%) reported discomfort with prescribing WMMs and most (84%) had never prescribed one. While most residents (81%) were “comfortable” or “somewhat comfortable” with lifestyle counseling, only 33% reported consistently providing it. Of the 31% of residents that correctly identified indications for bariatric surgery, only 9% reported referring patients they considered appropriate for surgery. Notably, a higher CS was significantly correlated with more frequent bariatric surgery referrals (r = 0.29; p = 0.015), lifestyle counselling (r = 0.33; p = 0.004), WMM prescription (r = 0.32; p=0.006), and lifestyle specialist referral (r = 0.25; p = 0.035). Reported barriers to lifestyle counseling were lack of time (93%), poor familiarity with resources (50%), and lack of training in motivational interviewing (36%). Barriers to WMM prescription were unfamiliarity with the medications (84%) and side effect concerns (61%). Finally, 90% desired more training in pharmacotherapy, and 77% wanted more information on referral processes for surgical and medical interventions. Most residents surveyed do not feel adequately prepared to provide evidence-based management of obesity via lifestyle changes counseling, WMM prescription, or specialty care referral. Comfort and knowledge of system processes/resources and WMMs are critical to resident management of obesity. These are potential targets for educational intervention in residency curricula that may improve care for patients with obesity. Citations: 1. Ward ZJ, Bleich SN, Cradock AL, et al. Projected U.S. State-Level Prevalence of Adult Obesity and Severe Obesity. N Engl J Med. 2019;381(25):2440-2450. doi:10.1056/NEJMsa19093012. Huang J, Yu H, Marin E, Brock S, Carden D, Davis T. Physicians’ Weight Loss Counseling in Two Public Hospital Primary Care Clinics. Acad Med. 2004. doi:10.1097/00001888-200402000-00012