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University of Groningen

Metabolic risk in people with psychotic disordersBruins, Jojanneke

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Citation for published version (APA):Bruins, J. (2016). Metabolic risk in people with psychotic disorders: No mental health without physicalhealth [Groningen]: Rijksuniversiteit Groningen

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91

Chapter 6

The effects of lifestyle interventions on (long-term) weight management, cardiometabolic risk and depres-

sive symptoms in people with psychotic disorders: a meta-analysis

Bruins J, Jörg F, Bruggeman R, Slooff C, Corpeleijn E, Pijnenborg GHM

PLoS ONE, 2014; 9 (12)

6Layout Proefschrift.indd 91 13-9-2016 22:08:56

92

ABSTRACT

Objective: The aim of this study was to estimate the effects of lifestyle interventions on body weight and other cardiometabolic risk factors in people with psychotic disorders. Ad-ditionally, the long-term effects on body weight and the effects on depressive symptoms were examined.

Methods: We searched four databases for randomised controlled trials (RCTs) that compa-red lifestyle interventions to control conditions in patients with psychotic disorders. Lifestyle interventions were aimed at weight loss or weight gain prevention, and the study outcomes included body weight or metabolic parameters.

Results: The search resulted in 25 RCTs -only 4 were considered high quality- showing an over-all effect of lifestyle interventions on body weight (effect size (ES)=-0.63, p<0.0001). Lifestyle interventions were effective in both weight loss (ES=-0.52, p<0.0001) and weight-gain-pre-vention (ES=-0.84, p=0.0002). There were significant long-term effects, two to six months post-intervention, for both weight-gain-prevention interventions (ES=-0.85, p=0.0002) and weight loss studies (ES=-0.46, p=0.02). Up to ten studies reported on cardiometabolic risk factors and showed that lifestyle interventions led to significant improvements in waist cir-cumference, triglycerides, fasting glucose and insulin. No significant effects were found for blood pressure and cholesterol levels. Four studies reported on depressive symptoms and showed a significant effect (ES=-0.95, p=0.05).

Discussion: Lifestyle interventions are effective in treating and preventing obesity, and in reducing cardiometabolic risk factors. However, the quality of the studies leaves much to be desired.

Chapter 6

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93

INTRODUCTION

Psychosis is the psychiatric term for a state of mind in which a person suff ers from delusions (false beliefs that hinder a persons’ ability to functi on) or hallucinati ons (false sensory per-cepti ons) that are not accompanied by insight.251 Psychoti c disorders include schizophrenia, schizophreniform disorder, schizoaff ecti ve disorder and delusional disorder among others. The hallucinati ons and delusions can be treated eff ecti vely with diff erent types of anti psy-choti c drugs. However, the use of anti psychoti c drugs oft en coincides with metabolic side eff ects, such as dyslipidaemia, hyperglycaemia and an increase in body weight and waist circumference.129,204,205 Obesity is a serious problem in people with psychoti c disorders. The prevalence of obesity among people with psychoti c disorders is 41-50%, which is substan-ti ally higher than the 20-27% prevalence in the general populati on.252 A recent study map-ped the body weight of people with schizophrenia during three years of anti psychoti c drug use. This study showed that 34-55% of the pati ents with normal weight or underweight (Body Mass Index [BMI]) <25 kg/m2) at baseline gained ≥7% of their body weight. Among the pati ents who were already overweight or obese (BMI ≥25 kg/m2) at baseline this per-centage was 12-42%.98 Since obesity is a known risk factor for cardiovascular disease, this phenomenon is of major importance for the development of comorbiditi es in people with psychoti c disorders. The cardiovascular risk that is imposed by obesity is about four ti mes higher in people with psychoti c disorders than in the general populati on.11 Cardiovascular disease is one of the major causes for premature mortality in these pati ents.11,253 Not only weight gain but also increased waist circumference, high blood pressure, higher levels of triglycerides, high cholesterol and higher levels of fasti ng glucose and insulin contribute to the risk of cardiovascular disease and premature mortality.11,64

Clinical guidelines emphasise the importance of health monitoring in these pati ents and recommend at least annual check-ups, but they off er no recommendati ons with regard to lifestyle interventi ons.254 Studies in the general populati on as well as studies in people with psychiatric disorders consistently suggest that healthy lifestyle interventi ons might decre-ase cardiovascular risk.255 Interventi ons that include physical acti vity and improved nutriti -onal habits presumably lead to weight reducti on and increased cardiovascular fi tness.256,257

Behavioural interventi ons aimed at weight loss seem promising as well, with two studies suggesti ng that these interventi ons could improve health outcomes associated with cardio-metabolic risk.256,258

To date, several studies have examined the eff ecti veness of diff erent lifestyle interventi ons in pati ents with psychoti c disorders; numerous randomised controlled trials (RCTs) as well as a number of meta-analyses115,116,259 and systemati c reviews have been published.258,260,261

6

The eff ects of lifestyle interventi ons on cardiometabolic risk


94

The available reviews to date however show several limitations. First, the only meta-analysis that reported long-term post-intervention results259 did not include all available studies.262-268 Second, the quality of RCTs included in the available meta-analyses has not been assessed. Including low quality trials may yield biased results. Third, only two of the available me-ta-analyses included the effects of lifestyle interventions on cardiometabolic risk.115,259 The authors of these studies however did not report results on all relevant metabolic outcomes that were available, even though these are important factors with regard to comorbidities and mortality in this patient group. Fourth, two of the reviews had a limited patient sample: one only included studies in patients with diabetes260 and one could not include any study because their inclusion criteria stated patients should be in primary care.261 Last, none of the available meta-analyses reported on the effects of lifestyle interventions on depressive symptoms, although it has been widely recognised that patients with psychotic disorders often suffer from comorbid depressive symptoms,269-271 and that increased physical activity in these patients has been associated with lower levels of depression.272

AimsThis study aims to investigate the effect sizes (ES) of lifestyle interventions on body weight and other cardiometabolic risk factors, such as waist circumference, blood pressure, blood lipids, glucose and insulin concentrations, in patients with psychotic disorders. The long-term effects of lifestyle interventions on body weight are included in the analysis as well. In addition, the effects of lifestyle interventions on depressive symptoms are investigated. Furthermore, we attempt to find effective components of the interventions, by comparing the studies with the largest ES and examine potential overlap and differences between the elements used in these successful interventions.

MATERIAL AND METHODS

Inclusion criteriaA systematic search for all randomised controlled trials evaluating the effects of lifestyle in-terventions on weight management in patients with psychotic disorders was conducted un-til April 2014. The following electronic databases were searched: PubMed, Web of Science, PsycINFO and MEDLINE. Search terms included: schizophrenia or schizophrenic or psychotic or schizoaffective disorder or mental disorder or mentally ill or psychiatric disorders or se-vere mental illness or antipsychotic AND lifestyle intervention or diet or physical activity or nutrition or lifestyle or body weight or weight loss or weight management or exercise AND/OR weight gain or metabolic or metabolic syndrome or diabetes or health or somatic AND/OR psychological intervention or counselling or directive counselling or cognitive behaviou-

Chapter 6


95

ral treatment. We included all randomised controlled trials (RCTs) that examined lifestyle interventi ons; i.e. interventi ons either targeti ng overweight pati ents in order to help them lose weight, or pati ents in the early stages of their illness in order to help them prevent an-ti psychoti c induced weight gain. Interventi ons were considered lifestyle interventi ons when they had a nutriti onal element, physical acti vity and/or a psychological interventi on aimed at weight loss or weight gain preventi on. In eligible studies, all included subjects were di-agnosed with psychoti c disorders and study outcomes were either body weight or cardio-metabolic risk factors (e.g. waist circumference, blood pressure, blood lipids, glucose and/or insulin). Pharmacological interventi ons were excluded, as were non-randomised studies and studies that did not qualify as lifestyle interventi ons. These selecti on criteria were fi rst applied to the ti tle. When the ti tle did not present exclusion criteria (e.g. non-RCT, no inter-venti on, no psychoti c disorders) or was inconclusive, the abstracts of the arti cles were read and -where necessary- the full arti cles. Finally, the bibliographies of selected arti cles were searched for relevant references to be included in our analysis.

Outcomes and calculati onsThe fi rst outcome was mean body weight change, measured directly at the end of the in-terventi on. An overall ES for lifestyle interventi ons was calculated as well as separate ES for weight loss interventi ons and weight gain preventi on interventi ons. The same analyses were performed for the long-term eff ects. A sensiti vity analysis was performed using the ‘Clinical Trials Assessment Measure for psychological treatments’ (CTAM) to assess the qua-lity of the studies.273 The CTAM determines the quality of a study based on sample size and recruitment method, allocati on to treatment, assessment of outcome, control groups, de-scripti on of treatments and analysis. The psychometric properti es of the CTAM were found to be adequate.273 Only the studies marked as high quality (CTAM ≥ 65) were included in the sensiti vity analysis. Next, we calculated the ES of lifestyle interventi ons on cardiometabolic risk factors and depressive symptoms. With regard to cardiometabolic risk, we examined all available metabolic parameters, which include waist circumference, systolic and diastolic blood pressure, total cholesterol, HDL-cholesterol, LDL-cholesterol, triglyceride concentra-ti ons, fasti ng glucose concentrati ons and fasti ng insulin concentrati ons. For depression we considered the mean changes on the depression scales reported in the studies.

Data extracti onRelevant data that were extracted include a) pati ent characteristi cs [gender, age, diagno-ses], b) interventi on characteristi cs [durati on, components, aim], c) study characteristi cs [dropouts, number of parti cipants, blind assessments, control conditi on], d) means and standard deviati ons of baseline and endpoint or change scores of the outcome body weight, e) means and standard deviati ons of body weight at follow-up, f) means and standard devi-

6



96

ations of baseline and endpoint or change scores of the components of all cardiometabolic risk factors as described above, g) means and standard deviations of baseline and endpoint or change scores of the outcome depressive symptoms. In a meta-analysis all data is pooled and some variation in the intervention effects are to be expected. When the observed inter-vention effects are more different from each other than would be expected from random error (chance) alone it is called heterogeneity. Heterogeneity, characterised by the I2 statis-tic, is considered low when I2 ≤ 25% and high when I2 ≥ 75%.274

Meta-analytic procedure To standardise the outcome among studies, Cohen’s d was used as a measure of ES.213 It was calculated using the following equation:

Effect size (Cohen's d) = ( MI - MC ) / SDpooled

The MI indicates the mean pre-post intervention difference in the intervention group, whe-reas MC is the mean pre-post intervention difference in the control group. SDpooled indicates the pooled standard deviation for both groups within one report. The Standard Error of the ES (Cohen’s d) was calculated by using the following equation:275

Standard Error (Cohen's d) = sqrt ( [ni + nc ] / [ni x nc ] ) + (d x 2 / [2 x (ni + nc - 2)] )

in which ni and nc indicate the number of participants in the intervention group and the number of participants in the control group respectively, whereas d stands for Cohen’s d. We calculated separate ES for the intervention and control group in studies that did not re-port the mean weight change, but only the mean weight at baseline and endpoint. Cohen’s d was then estimated by subtracting the ES of the control group from the ES of the inter-vention group. Standard Error of the ES was established by the formula mentioned above. Missing data with regard to standard deviations were imputed from the included studies. This meta-analysis was performed and written in accordance with the PRISMA-guidelines.276

Statistical methodThe data were analysed in RevMan Version 5.0 (Cochrane Collaboration software for me-ta-analyses) with the Inverse Variance method, using random effects models.277 The χ2 test, based on the Q-statistic, was performed to check for the homogeneity of the effects with I2 as a quantifiable measure of heterogeneity.274 Funnel plots were checked for asymmetry and Eggers’ tests were performed for each outcome to rule out publication bias.278 Z-scores were calculated to test for overall effects.

Chapter 6


97

RESULTS

Study overviewThe search resulted in 656 records in four databases. A screening of the arti cles and their re-ferences initi ally resulted in 32 eligible studies that were discussed within the research group (JB, FJ, EC, MP), which led to the exclusion of seven more studies: in fi ve of these studies the parti cipants were not randomly assigned to the experimental or the control group,279-283 and the two other studies did not meet the criteria of a lifestyle interventi on.284,285 The remaining 25 RCT’s were included in the meta-analysis (see Figure 1). Twenty-four RCT’s reported on body weight (sixteen on weight loss and eight on weight gain preventi on), seven RCT’s had long-term follow-up data on body weight (four on weight loss and three on weight gain pre-venti on), fi ft een RCT’s reported on one or more cardiometabolic risk factors and four RCT’s reported depression. Six of the studies had missing standard deviati ons,286-291 which were imputed from the data pool. All arti cles were published in English up to the last date of the search (April 2014).

Study characteristi csA total of 1518 parti cipants were included in the me-ta-analysis. Sample sizes across the studies varied from 14 to 291 parti cipants with 52% male pati ents. The mean age across the studies varied from 26.1 (SD=10.2) to 54.0 (SD=9.3). Fift een of the studies reported the use of mental health professio-nals, dieti cians and/or exer-cise specialists to implement the interventi on. Interventi -ons were performed in the US,263,266,291-296 South-Ameri-ca,268 Canada,289 the UK,286,287 Spain,297,298 Italy,288,290,299 Sweden,300 Switzerland,265 the Netherlands,301 Austra-lia,264 Korea,302 Thailand,303

656 of records identifiedthrough database searching

PubMed: 145Web of Science: 297ClinicalTrial.gov: 182PsychInfo: 32

117 of records screenedby reading abstract

51 full-tekst articlesassessed for eligibility

32 studies retrieved from search

25 studies included in quantativesynthesis (meta-analysis)

66 of records excluded for notmeeting the criteria

Not intervention: 34Not SMI: 32

19 of full-tekst articles excludedfor not meeting the criteria

No control group: 12Study outcomes not reported: 2Not RCT: 5

7 studies excluded for notmeeting the criteria

Participants not randomised: 5Not lifestyle intervention: 2

Figure 1: PRISMA 2009 Flow Diagram

6



98

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Chapter 6


99

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Chapter 6


101

Taiwan304 and China.305 An overview of the study characteristi cs is provided in Table 1. The classifi cati on of weight loss study or weight preventi on study was solely based on the aim of the researchers of the study. There were no diff erences with regard to the content of lifestyle interventi ons.

Overall results for interventi ons on body weightThe overall ES of lifestyle interventi ons on weight was -0.63 (95% CI=-0.84 to -0.42). Lifestyle interventi ons had a signifi cant, benefi cial eff ect on weight loss (p<0.00001) (see Figure 2a). The experimental groups in the weight loss interventi on studies showed a higher reducti on of the mean body weight than the control groups (ES=-0.52 with the 95% CI=-0.72 to -0.31, p<0.00001) (see Figure S1a). In the weight gain preventi on studies the experimental groups gained less body weight than the control groups (ES=-0.84 with the 95% CI=-1.28 to -0.40, p=0.0002) (see Figure S1b). The included studies in this meta-analysis showed moderate heterogeneity. The overall interventi on eff ect had an I2 of 70%. Among the weight loss inter-

Study or SubgroupPoulin 2007Mauri 2008Wu MK 2007Evans 2005Wu RR 2008McKibbin 2006Jean-Baptiste 2007Kwon 2006Littrell 2003Alvarez-Jimenez 2006Brown&Smith 2009Weber&Wyne 2006Methapatara 2011Brown&Chan 2006Daumit 2013Attux 2013Brar 2005Skrinar 2005Milano 2007Khazaal 2007Brown 2011Forsberg 2008Iglesias-García 2010Scocco 2006

Total (95% CI)Heterogeneity: Tau² = 0.17; Chi² = 77.20, df = 23 (P < 0.00001); I² = 70%Test for overall effect: Z = 5.92 (P < 0.00001)

Std. Mean Difference-1.86-1.34

-1.295-1.25

-1.165-1.07

-1.0532-0.76

-0.695-0.6708

-0.67-0.5844

-0.57-0.39

-0.372-0.3016

-0.26-0.2124-0.1947-0.1371-0.1279-0.0280.00750.0365

SE0.22990.39130.30460.33230.27170.28460.461

0.32180.24660.26450.40960.53230.25540.38310.11830.17940.23860.43610.33340.25150.20980.31460.53510.4495

Total59152822322811333528158

3215

14460349

223147247

10

749

Total51182522322911153533117

3213

147663711143042177

10

715

Weight5.0%3.5%4.3%4.0%4.6%4.5%2.9%4.1%4.9%4.7%3.3%2.5%4.8%3.6%6.1%5.5%4.9%3.1%4.0%4.8%5.2%4.2%2.5%3.0%

100.0%

IV, Random, 95% CI-1.86 [-2.31, -1.41]-1.34 [-2.11, -0.57]-1.29 [-1.89, -0.70]-1.25 [-1.90, -0.60]-1.17 [-1.70, -0.63]-1.07 [-1.63, -0.51]-1.05 [-1.96, -0.15]-0.76 [-1.39, -0.13]-0.69 [-1.18, -0.21]-0.67 [-1.19, -0.15]-0.67 [-1.47, 0.13]-0.58 [-1.63, 0.46]

-0.57 [-1.07, -0.07]-0.39 [-1.14, 0.36]

-0.37 [-0.60, -0.14]-0.30 [-0.65, 0.05]-0.26 [-0.73, 0.21]-0.21 [-1.07, 0.64]-0.19 [-0.85, 0.46]-0.14 [-0.63, 0.36]-0.13 [-0.54, 0.28]-0.03 [-0.64, 0.59]0.01 [-1.04, 1.06]0.04 [-0.84, 0.92]

-0.63 [-0.84, -0.42]

Experimental Control Std. Mean Difference Std. Mean DifferenceIV, Random, 95% CI

-2 -1 0 1 2Favours Intervention Favours Control

Figure 2a: Forest plot describing the eff ects of lifestyle interventi ons on body weight

6



102

Figure 2b: Forest plot describing the long-term effects of lifestyle interventions on body weight

Study or SubgroupEvans 2005McKibbin 2010Littrell 2003Attux 2013Alvarez-Jimenez 2010Khazaal 2007Brown 2011

Total (95% CI)Heterogeneity: Tau² = 0.11; Chi² = 16.43, df = 6 (P = 0.01); I² = 63%Test for overall effect: Z = 3.93 (P < 0.0001)


-0.885-0.4608

-0.46-0.3214

-0.088

SE0.31160.28460.25110.22010.26050.24520.2099

Total29283544283147

242

Total22293541333042

232

Weight12.0%13.0%14.4%15.7%14.0%14.6%16.2%

100.0%

IV, Random, 95% CI-1.27 [-1.88, -0.66]-1.07 [-1.63, -0.51]-0.89 [-1.38, -0.39]-0.46 [-0.89, -0.03]-0.46 [-0.97, 0.05]-0.32 [-0.80, 0.16]-0.09 [-0.50, 0.32]

-0.62 [-0.93, -0.31]

Intervention Control Std. Mean Difference Std. Mean DifferenceIV, Random, 95% CI


Study quality assessment First, the funnel plots did not show asymmetry, but the Egger’s tests showed that publica-tion bias could not be ruled out for diastolic blood pressure (p=0.078) and long-term body weight (p=0.027). All other outcomes had p-values above the recommended 0.1 on the Egger’s test, varying from 0.185 to 0.961 (see Table S1).278 All studies report randomizati-on, but only 10 studies describe the randomization process.263,268,286,287,293,297,298,300,303,305 Five studies report the use of assessors independent from the study;296-298,304,305 assessors were reported to be blind to group allocation in nine studies.268,286,287,289,293,296-298,305 One study fai-led to adequately describe the treatment.298 The mean drop-out rate among the studies was 17%, varying from 0-39%, but only four studies described an acceptable strategy for investigating drop-outs.292,293,297,305 Intention-to-treat analyses were reported in twelve stu-dies.268,286,287,292,293,297,299-303,305 Four of the studies were considered to be of sufficient quality and had a CTAM score of at least 65.293,297,300,305 Sensitivity analyses including these studies resulted in a decreased but still statistically significant ES of -0.55 (95% CI=-0.96 to -0.14, p=0.008) of lifestyle interventions on body weight (see figure S2a).

Long term effectsSeven studies reported follow up data between two and six months after the completion of the intervention.262-268 Their combined ES was -0.62 (95% CI=-0.93 to -0.31, p<0.0001) as is described in Figure 2b, which is in favour of the intervention. When we analysed weight loss and weight gain prevention studies separately, we found that interventions aimed at weight gain prevention have a large long-term effect (ES=-0.85, 95% CI=-1.29 to -0.41, p=0.0002) (see figure S3b) while the long-term effect of the weight loss interventions was moderate (ES=-0.46, 95% CI=-0.83 to -0.08, p=0.02) (see figure S3a). With regard to heterogeneity,

Chapter 6


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venti on studies I2 was 55% while the I2 was 76% in the weight gain preventi on studies. I2 was 63% for the overall long-term eff ects of the interventi on, 51% in the weight gain preventi on studies and 62% in the weight loss studies.

Cardiometabolic riskTen studies reported cardiometabolic risk factors and in these studies there were no disti nct diff erences between the weight loss interventi ons and the weight gain preventi on interven-ti ons with respect to the content of the interventi on. Therefore, in the analyses of the meta-bolic parameters, the two types were taken together. The lifestyle interventi ons demonstra-ted signifi cant eff ects for waist circumference, triglycerides, fasti ng glucose and insulin. The ES for cholesterol (total, HDL-C and LDL-C) and systolic and diastolic blood pressure were not signifi cant. An overview is provided in Table 2. Three of the high quality studies also reported on waist circumference and insulin.293,300,305 A sensiti vity analysis that only included the three high quality studies resulted in slightly decreased eff ect sizes that were no longer stati sti cally signifi cant for both waist circumference (ES=-0.30, 95% CI=-0.63 to 0.03, p=0.08) (see fi gure S2b) and insulin (ES=-0.26, 95% CI=-0.64 to 0.12, p=0.18) (see fi gure S2c). Regar-ding heterogeneity, only in the studies with fasti ng glucose I2 was 0%. The remaining com-ponents had moderate to high heterogeneity with I2 varying from 51% to 91% (see Table 2).

Depressive symptoms Four studies reported the eff ects of lifestyle interventi ons on depressive symptoms based on a conti nuous depression scale. Skrinar et al. (2005) used the depression scale of the SCL-90-R, Scheewe et al. (2013) used the Montgomery Åsberg Depression Rati ng Scale (MADRS) and the remaining studies reported the depression score of the Hospital Anxiety and De-pression Scale (HADS).286,287 The overall ES for lifestyle interventi ons on depressive symp-toms was -0.95 (95% CI=-1.90 to -0.00, p=0.05). An overview of the results is shown in Figure 2c. None of the studies reporti ng depression had a CTAM score of 65 or above, so these

Figure 2c: Forest plot describing the eff ects of lifestyle interventi ons on depressive symp-toms

Study or SubgroupScheewe 2013Skrinar 2005Brown&Chan 2006Brown&Smith 2009

Total (95% CI)Heterogeneity: Tau² = 0.86; Chi² = 40.81, df = 3 (P < 0.00001); I² = 93%Test for overall effect: Z = 1.96 (P = 0.05)


-0.62-0.065

SE0.20310.245

0.26010.39

Total25111011

57

Total2997

15

60

Weight26.0%25.5%25.3%23.2%

100.0%

IV, Random, 95% CI-2.21 [-2.61, -1.81]-0.79 [-1.27, -0.31]-0.62 [-1.13, -0.11]-0.07 [-0.83, 0.70]

-0.95 [-1.90, -0.00]

Control Intervention Std. Mean Difference Std. Mean DifferenceIV, Random, 95% CI


6



104

results should interpreted with caution. Heterogeneity among the studies with outcome depression was high (I2 =93%).

Intervention characteristicsMost of the studies had an intervention period of three months or less.264,265,268,286-

288,290,291,297-299,302,303,305 Seven studies had an intervention period between three and six months266,292,294-296,301,304 and four studies had an intervention period of twelve months or more.263,289,293,300 There were also differences between the intensity and duration of the su-pervised exercise sessions. Exercise sessions varied from two hours per week289,300,301 to 45 minutes supervised exercise four times a week291 or daily 30 minutes sessions.263 We studied the interventions with large effect sizes for corresponding intervention elements. However, we did not find any element present in all or most of the interventions with the largest ef-fect sizes, nor did we find corresponding elements for the interventions with the smallest effect sizes. We did find a difference in the ES of interventions depending on whether group-

Parameters N studies Ni Nc Cohen's d 95% CI Cohen's d p I2

Waist circumference• 10 385 320 -0.37 [-0.60 ; -0.13] <0.01** 56%

Systolic blood pressure+ 7 308 307 -0.22 [-0.49 ; 0.05] 0.10 60%

Diastolic blood pressure# 3 95 76 -0.08 [-0.57 ; 0.41] 0.74 64%

Triglycerides$ 8 338 321 -0.27 [-0.49 ; -0.04] 0.02* 51%

HDL-cholesterol~ 8 319 308 0.28 [-0.16 ; 0.73] 0.21 91%

LDL-cholesterol¶ 5 258 259 -0.27 [-0.75 ; 0.22] 0.28 87%

Total cholesterol£ 7 295 295 -0.27 [-0.59 ; 0.05] 0.10 72%

Fasting glucose^ 8 347 341 -0.24 [-0.32 ; -0.10] <0.01** 0%

Insulin§ 6 241 240 -0.28 [-0.56 ; -0.01] 0.04* 52%

Table 2: Effects of lifestyle interventions on cardiometabolic risk

Ni = total n in intervention group. Nc = total n in control group.CI = confidence interval. *Significant at 0.05 level. **Significant at 0.01 level.

• Attux et al.(2013), Daumit et al. (2013), Evans et al. (2005), Forsberg et al. (2008), Iglesias-Garcia et al. (2010), McKibbin et al. (2006), Methapatara et al. (2011), Poulin et al. (2007), Scheewe et al. (2013) & Wu RR et al. (2008)+ Attux et al.(2013), Brar et al. (2005), Brown&Smith et al. (2009), Daumit et al. (2013), Forsberg et al. (2008), McKibbin et al. (2006) & Scheewe et al. (2013)# Forsberg et al. (2008), McKibbin et al. (2006) & Scheewe et al. (2013)$ Attux et al.(2013), Daumit et al. (2013), Forsberg et al. (2008), Mauri et al. (2008), McKibbin et al. (2006), Poulin et al. (2007), Scheewe et al. (2013 &, Wu MK et al. (2007)~ Attux et al.(2013), Daumit et al. (2013), Forsberg et al. (2008), Mauri et al. (2008), McKibbin et al. (2006), Poulin et al. (2007), Scheewe et al. (2013) & Skrinar et al. (2005)¶ Attux et al.(2013), Daumit et al. (2013), Mauri et al. (2008), McKibbin et al. (2006) & Poulin et al. (2007)£ Attux et al.(2013), Daumit et al. (2013), Forsberg et al. (2008), Mauri et al. (2008), McKibbin et al. (2006), Poulin et al. (2007) & Wu MK et al. (2007)^Attux et al.(2013), Daumit et al. (2013), Mauri et al. (2008), McKibbin et al. (2006), Poulin et al. (2007), Scheewe et al. (2013), Wu MK et al. (2007) & Wu RR et al. (2008)§ Attux et al.(2013), Daumit et al. (2013), Forsberg et al. (2008), Mauri et al. (2008), Wu MK et al. (2007) & Wu RR et al. (2008)

Chapter 6


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or individually based interventi ons were used. Five studies used an individual approach in their interventi on.264,286,290,297,302 Their combined ES was -0.67 (p=0.0004) (see fi gure S4a). Ten studies presented their pati ents with a group interventi on.263,265,266,268,291,292,296,298,300,304 The group interventi ons had an overall ES of -0.36 (p=0.002) (see fi gure S4b). A combined approach of a group interventi ons accompanied by individual sessions was used in fi ve stu-dies.289,293,294,303,305 They showed the largest overall ES (ES=-0.99, p=0.002) (see fi gure S4c).

DISCUSSION

Lifestyle interventi ons led to weight reducti on and weight gain preventi on. Signifi cant po-siti ve eff ects on body weight remained at follow-up. Eff ect sizes for weight gain preventi on interventi ons were large and the eff ects of the weight loss interventi ons moderate. Results showed that lifestyle interventi ons also led to reducti ons in waist circumference, triglyce-rides, fasti ng glucose and insulin. No signifi cant eff ects were found for blood pressure and cholesterol levels. Only four of 25 studies were of good quality. Sensiti vity analyses including only these high quality studies showed a somewhat lower, but sti ll signifi cant, eff ect size for body weight. The overall eff ects on waist circumference and insulin were no longer signi-fi cant in the sensiti vity analysis. Depressive symptoms were only reported in four studies, which were of low quality. These results should thus be interpreted cauti ously. In parti cular, in three of the four studies, the control conditi on consisted of a waiti ng list without acti ve control treatment, indicati ng that non-specifi c eff ects of the interventi on (e.g. extra att enti -on, peer support) were not controlled for. Because these studies were of low quality and the eff ect size was on the border of signifi cance, we cannot state with absolute certainty that lifestyle interventi ons eff ecti vely reduce depression. Our fi ndings are mostly consistent with the existi ng literature regarding the eff ects of lifes-tyle interventi ons on cardiometabolic risk in the general populati on. These studies found signifi cant eff ects for waist circumference, fasti ng glucose, triglycerides306 and insulin con-centrati ons,307 but not one of them found a change in cholesterol levels.306-308 In one study a signifi cant eff ect for lifestyle interventi ons on systolic blood pressure was reported;308 a fi n-ding that could not be replicated in our meta-analysis. In sum, lifestyle interventi ons seem to be eff ecti ve in reducing most metabolic risk factors; only cholesterol and blood pressure seemed unaff ected. However, the eff ects on waist circumference and insulin were no longer signifi cant in the sensiti vity analysis in which only the high quality studies were considered. The characteristi cs of treatments were examined to provide guidelines for future clini-cal practi ce. Studies characterised by an individual approach seemed more eff ecti ve than

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group-based interventions, while combining group treatment with individual interventions appeared to get the best result on body weight. Apparently the benefits of an individual approach, such as personal attention, advice, a tailor-made action plan and meeting pa-tient-specific needs, surpass the benefits of group-sessions, such as group cohesiveness, interpersonal learning, imitative behaviour, recognition of similarities in other group mem-bers309,310 and peer support.311 That a combined approach is most effective could well be ex-plained by the fact that these interventions encompass ‘the best of both worlds’: imitative behaviour, peer support and recognition of similarities in others during group-sessions and addressing personal needs during the individual meetings. Unfortunately, we could not identify elements specific for successful interventions. This is at odds with previous literature suggesting that diet, physical activity and psychological inter-ventions all had an individual contribution to losing weight.256-258 A previous meta-analysis performed subgroup analyses to calculate effect sizes for diet, no diet, CBT, psycho-educati-on, physical activity and no physical activity among others.116 However, these pooled effect sizes are difficult to interpret and may lead to unreliable conclusions since none of the inter-ventions consisted of just one of these elements. Thus, when examining for example the ef-fects of psychological interventions, effects of other interventions such as diet-instructions could not be filtered out, making a direct comparison of specific elements of interventions impossible. Finally, we found that interventions based in Asia show larger effect sizes than the studies based in Central or Northern Europe, even though there were no differences between the continents with regard to the duration, intensity or elements used in the interventions or weight of the patients at the start of the intervention. This aspect has not been studies be-fore. We find ourselves unable to explain these differences with the data currently available. Future research might elucidate these findings. Limitations There was significant heterogeneity among the studies, suggesting that there were diffe-rences in the effectiveness of the lifestyle interventions that could not be a result of chance alone. Therefore, Cohen’s d has to be interpreted with caution. Based on the funnel plots and Egger’s test for asymmetry, we could not rule out the possibility of publication bias with regard to long term effects on body weight and the effects on diastolic blood pressure. This could indicate an overestimation of the reported effect sizes for these outcomes. Further-more, the effects for some parameters of the metabolic syndrome and depression were based on a small number of studies.

Chapter 6


107

The CTAM revealed that the quality of the included studies was quite poor, with 21 out of 25 studies not meeti ng its standards. This questi ons the reliability of the eff ect sizes, since low quality studies tend to overesti mate eff ects. Last, BMI change could be seen as a more meaningful outcome than weight change as it takes the height of the pati ents into account. Alternati vely, we chose to report waist circumference and other metabolic parameters al-ongside body weight. Waist circumference is one of the main risk factors for cardiovascular morbidity.312-314 Abdominal obesity sti mulates insulin resistance, which can result in elevated triglyceride concentrati ons, diabetes and hypertension. All of these present an increased risk of developing cardiovascular diseases.314,315

Clinical implicati ons and future researchLifestyle interventi ons in general lead to body weight loss and prevent weight gain. However, as we found no evidence for the superiority of a specifi c interventi on model of component –other than using an individual approach- we cannot make recommendati ons regarding the content of lifestyle interventi ons. To fi nd out which elements are more eff ecti ve than others, we should test them all separately, which would be an expensive and ti me-consu-ming exercise. Also, an interventi on could be more than the sum of its separate elements. It might help if future studies provided clear and detailed depicti ons of the content of their lifestyle interventi ons.

Lifestyle interventi ons might improve other metabolic risk factors than body weight alone, and might also improve depressive symptoms, even though only few studies reported on these outcome measures. We urge researchers investi gati ng eff ects of lifestyle interventi ons in people with psychoti c disorders to include these measures to further substanti ate these fi ndings. Given their positi ve eff ects on multi ple outcomes, we recommend lifestyle inter-venti ons to be listed among other evidence based psychosocial treatments for psychosis and to be included in clinical guidelines.

The CTAM considered most of the included studies to be of poor quality. We would like to underline the importance of high quality research in order to obtain reliable results, as well as to urge researchers to properly describe the design and executi on of their studies.

AcknowledgementsWe thank Steven de Jong for his revision of the English language and Renske Zielman for reviewing the literature. Eli Lilly provided fi nancial support for this study.

6



108

SUPPLEMENTARY FILES

Study outcome N studies Cohen's d (SMD) p

Bodyweight 24 -0.63 0.191

Longterm bodyweight 7 -0.62 0.027*

Waist circumference 10 -0.37 0.680

Systolic blood pressure 7 -0.22 0.234

Diastolic blood pressure 3 -0.08 0.078

Triglycerides 8 -0.27 0.906

HDL cholesterol 8 0.28 0.608

LDL cholesterol 5 -0.27 0.373

Total cholesterol 7 -0.27 0.220

Fasting glucose 8 -0.24 0.946

Insulin 6 -0.28 0.961

Depression 4 -0.95 0.185

Table S2: Results of the Egger's test

SMD = Standardised Mean Difference. * Significant at 0.05 level.

Supplementary figure 1a: Forest plot describing the effects of weight loss intervention

Study or SubgroupMauri 2008Wu MK 2007Wu RR 2008McKibbin 2006Brown&Smith 2009Weber&Wyne 2006Methapatara 2011Brown&Chan 2006Daumit 2013Attux 2013Brar 2005Skrinar 2005Khazaal 2007Brown 2011Forsberg 2008Iglesias-García 2010

Total (95% CI)Heterogeneity: Tau² = 0.08; Chi² = 33.60, df = 15 (P = 0.004); I² = 55%Test for overall effect: Z = 4.96 (P < 0.00001)

Std. Mean Difference-1.34

-1.295-1.165-1.07-0.67

-0.5844-0.57-0.39

-0.372-0.3016

-0.26-0.2124-0.1371-0.1279-0.0280.0075

SE0.39130.30460.27170.28460.40960.53230.25540.38310.11830.17940.23860.43610.25150.20980.31460.5351

Total15283228158

3215

14460349

3147247

529

Total18253229117

3213

1476637113042177

524

Weight4.6%6.1%6.9%6.6%4.3%3.0%7.3%4.7%

11.0%9.3%7.7%4.0%7.4%8.5%5.9%2.9%

100.0%

IV, Random, 95% CI-1.34 [-2.11, -0.57]-1.29 [-1.89, -0.70]-1.17 [-1.70, -0.63]-1.07 [-1.63, -0.51]-0.67 [-1.47, 0.13]-0.58 [-1.63, 0.46]

-0.57 [-1.07, -0.07]-0.39 [-1.14, 0.36]

-0.37 [-0.60, -0.14]-0.30 [-0.65, 0.05]-0.26 [-0.73, 0.21]-0.21 [-1.07, 0.64]-0.14 [-0.63, 0.36]-0.13 [-0.54, 0.28]-0.03 [-0.64, 0.59]0.01 [-1.04, 1.06]

-0.52 [-0.72, -0.31]


-2 -1 0 1 2Favours intervention Favours control

Chapter 6


109

Supplementary fi gure 1b: Forest plot describing the eff ects of weight gain preventi on in-terventi on

Study or SubgroupPoulin 2007Evans 2005Jean-Baptiste 2007Kwon 2006Littrell 2003Alvarez-Jimenez 2006Milano 2007Scocco 2006

Total (95% CI)Heterogeneity: Tau² = 0.30; Chi² = 29.00, df = 7 (P = 0.0001); I² = 76%Test for overall effect: Z = 3.72 (P = 0.0002)


-1.0532-0.76

-0.695-0.6708-0.19470.0365

SE0.22990.3323

0.4610.32180.24660.26450.33340.4495

Total5922113335282210

220

Total5122111535331410

191

Weight14.5%12.4%

9.9%12.6%14.2%13.8%12.4%10.1%

100.0%

IV, Random, 95% CI-1.86 [-2.31, -1.41]-1.25 [-1.90, -0.60]-1.05 [-1.96, -0.15]-0.76 [-1.39, -0.13]-0.69 [-1.18, -0.21]-0.67 [-1.19, -0.15]-0.19 [-0.85, 0.46]0.04 [-0.84, 0.92]

-0.84 [-1.28, -0.40]



Supplementary fi gure 2a: Forest plot describing the sensiti vity analysis of the eff ects of lifestyle interventi ons on body weight

Study or SubgroupWu RR 2008Alvarez-Jimenez 2006Daumit 2013Forsberg 2008



-0.6708-0.372-0.028

SE0.27170.26450.11830.3146

Total3228

14424

228

Total3233

14717

229

Weight22.9%23.4%33.4%20.2%

100.0%

IV, Random, 95% CI-1.17 [-1.70, -0.63]-0.67 [-1.19, -0.15]-0.37 [-0.60, -0.14]-0.03 [-0.64, 0.59]

-0.55 [-0.96, -0.14]



Supplementary fi gure 2b: Forest plot describing the sensiti vity analysis of the eff ects of lifestyle interventi ons on waist circumference

Study or SubgroupWu RR 2008Daumit 2013Forsberg 2008


Std. Mean Difference-0.6554-0.22880.0584

SE0.25710.14250.3555

Total329421

147

Total32

10513

150

Weight28.8%53.3%17.9%

100.0%

IV, Random, 95% CI-0.66 [-1.16, -0.15]-0.23 [-0.51, 0.05]0.06 [-0.64, 0.76]

-0.30 [-0.63, 0.03]



6



110

Supplementary figure 2c: Forest plot describing the sensitivity analysis of the effects of lifestyle interventions on insulin

Study or SubgroupWu RR 2008Daumit 2013Forsberg 2008


Std. Mean Difference-0.6279-0.21240.2038

SE0.25610.15290.3646

Total328620

138

Total328613

131

Weight31.4%48.6%20.0%

100.0%

IV, Random, 95% CI-0.63 [-1.13, -0.13]-0.21 [-0.51, 0.09]0.20 [-0.51, 0.92]

-0.26 [-0.64, 0.12]



Supplementary figure 3a: Forest plot describing the long-term follow-up effects of weight loss interventions on body weight

Supplementary figure 3b: Forest plot describing the long-term follow-up effects of weight gain prevention interventions on body weight

Study or SubgroupEvans 2005Littrell 2003Alvarez-Jimenez 2010



-0.885-0.46

SE0.31160.25110.2605

Total293528

92

Total223533

90

Weight29.0%36.1%34.9%

100.0%

IV, Random, 95% CI-1.27 [-1.88, -0.66]-0.89 [-1.38, -0.39]-0.46 [-0.97, 0.05]

-0.85 [-1.29, -0.41]



Study or SubgroupMcKibbin 2010Attux 2013Khazaal 2007Brown 2011



-0.4608-0.3214

-0.088

SE0.28460.22010.24520.2099

Total28443147

150

Total29413042

142

Weight21.6%26.5%24.5%27.4%

100.0%

IV, Random, 95% CI-1.07 [-1.63, -0.51]-0.46 [-0.89, -0.03]-0.32 [-0.80, 0.16]-0.09 [-0.50, 0.32]

-0.46 [-0.83, -0.08]



Chapter 6


111

Supplementary fi gure 4a: Forest plot describing the eff ects of individual interventi ons

Study or SubgroupEvans 2005Kwon 2006Alvarez-Jimenez 2006Brown&Chan 2006Scocco 2006



-0.6708-0.39

0.0365

SE0.33230.32180.26450.38310.4495

Total2233281510

108

Total2215331310

93

Weight20.7%21.6%27.1%17.1%13.5%

100.0%

IV, Random, 95% CI-1.25 [-1.90, -0.60]-0.76 [-1.39, -0.13]-0.67 [-1.19, -0.15]-0.39 [-1.14, 0.36]0.04 [-0.84, 0.92]

-0.67 [-1.04, -0.30]



Supplementary fi gure 4b: Forest plot describing the eff ects of group interventi ons

Supplementary fi gure 4c: Forest plot describing the eff ects of combined interventi ons

Study or SubgroupPoulin 2007Wu RR 2008Jean-Baptiste 2007Methapatara 2011Daumit 2013

Total (95% CI)Heterogeneity: Tau² = 0.43; Chi² = 36.76, df = 4 (P < 0.00001); I² = 89%Test for overall effect: Z = 3.12 (P = 0.002)


-1.165-1.0532

-0.57-0.372

SE0.22990.2717

0.4610.25540.1183

Total59321132

144

278

Total51321132

147

273

Weight21.0%20.1%15.7%20.4%22.8%

100.0%

IV, Random, 95% CI-1.86 [-2.31, -1.41]-1.17 [-1.70, -0.63]-1.05 [-1.96, -0.15]-0.57 [-1.07, -0.07]-0.37 [-0.60, -0.14]

-0.99 [-1.61, -0.37]



Study or SubgroupWu MK 2007Littrell 2003Weber&Wyne 2006Attux 2013Brar 2005Skrinar 2005Khazaal 2007Brown 2011Forsberg 2008Iglesias-García 2010



-0.5844-0.3016

-0.26-0.2124-0.1371-0.1279

-0.0280.0075

SE0.30460.24660.53230.17940.23860.43610.25150.20980.31460.5351

Total2835

86034

9314724

7

283

Total2535

7663711304217

7

277

Weight9.5%

12.2%4.2%

16.2%12.6%

5.7%11.9%14.3%

9.2%4.1%

100.0%

IV, Random, 95% CI-1.29 [-1.89, -0.70]-0.69 [-1.18, -0.21]-0.58 [-1.63, 0.46]-0.30 [-0.65, 0.05]-0.26 [-0.73, 0.21]-0.21 [-1.07, 0.64]-0.14 [-0.63, 0.36]-0.13 [-0.54, 0.28]-0.03 [-0.64, 0.59]0.01 [-1.04, 1.06]

-0.36 [-0.60, -0.13]



6



112


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