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Supervisor : dr. Sabar P.
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BACKGROUNDPhysical inactivity
Unhealthy diets
Psychotropic
medications
Schizophrenia
Bipolar disorder
Major depression
Increased
appetite
High caloric
intake
DM
Hyperten
Dyslipide
Certain Ca2-3x more risk
Impairement in
memory & executive
function
Impede learning and
adoption of new
behaviours
Low Socio-
economic
Status
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to determine the
effectiveness of an 1
tailored behavioral w
loss intervention in a
with serious mental
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STUDY
Institutional reviewJohn
UniversityandSheppard Pra
System
Independent data and safety
Randomized Trial of Ach
Lifestyles in Psychiatric Reh
(ACHIEVE)
SETTING AND STUDY POPULATION Outpatient psychiatric rehabilitation programs
Obese adults (18 years of age) who attended 1 of
10 communitypsychiatric rehabilitation programs in
central Marylandor their affiliated out-patient
mental health clinics
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We excluded persons
with:
a medical
contraindication to
weight loss,
a cardiovascular event
within the previous 6
months,
an inability to walk, or
an active alcohol-use or
substance-use disorder
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InterventionThe intervention was compos
contact types: group weight-mana
sessions, individual weight-manag
sessions, and group exercise sessio
ControlThe control group received st
nutrition and physical activity inf
base-line.
January 2009 to February 2011STUDY PERIODS
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Information on sociodemographic characteristics and
were obtained from participant self-reports and progr
Psychiatric diagnoses were abstracted from program r
Data
the rehabilitation
programs
to determine study eligibility
to perform follow-up
assessments
at 6, 12, and 18 months
Measurements :
Weight
Height
Blood pressure
Waist circumference
Fasting blood chemical levels were obtbaseline and at 6 and 18 months.
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Statistical
Analysis
Done with intention-to-treat
Primary Outcome :
BMI changes
Persentage of weight change
Other weight-related outcomes included :
- Percentage of weight change from baseline
- Percentage of participants at or below base
weight,
- Percentages of participants who lost at leastheir initial weight and those who lost at lea
- Change from baseline in body-mass index
Chi-square test
Sensitivity analysis
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Figure 2.Mean Weight Change, According to Stud
As compared with t
group, the mean ne
in the intervention g
increased progressi18-month study per
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Table 2. Weight-Loss Outcomes at 6, 12, and 18 Mon
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INTERVENTION PARTICIPATION
The median number of
attended sessions was
the first 6 months and
months 7 through 18.
Attendance at the grou
exercise sessions cont
most to the total numb
contacts.
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InterventioGroup 2 death
6 cardiovascular events
18,3% of the participants reporteda medical hospitalization
14,8% of the participants reported
a psychiatric hospitalization
Control
Group
3 death
8 cardiovascular events
13,0% of the participants remedical hospitalization
20,6% of the participants re
psychiatric hospitalization
ADVERSE
EFFECT
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In overweight and obese adults with serious me
were participating in psychiatric rehabilitation p
behavioral weight-loss intervention incorporatin
management counseling and group exercise sig
participant weight over a period of 18 months.
Despite substantial challenges, persons with ser
are able to lose weight with a tailored in-terven Incorporating lifestyle interventions into rehabil
placing such programs in other mental health se
require financial and organizational resources.
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STUDY STRENGTHS
Enrolled a diverse population of patients with seriousmental illnesses from multiple community-basedprograms.
Throughout the trial, we attained high follow-up ratesfor outcome data.
The intervention was offered over a period of 18months, in contrast to the short-term interventions inprevious randomized trials of behavioral weight-lossinterventions in this population.
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STUDY WEAKNESS
Efforts to provide healthy meal options were available to all
in the rehabilitation programs.
Attendance at the intervention sessions andrehabilitation programs decreased.
The trial was not designed or powered to determine the effe
reduction on cardiovascular risk factors in this population.
The trial was not designed to influence the prescribing of
medication.
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Conclusion
Over-weight and obese adults with serious ment
can make substantial lifestyle changes despite thechallenges they face.
Suggestion
Given the epidemic of obesity and weight-related dispersons with serious mental illness, our findings sup
implementation of targeted behavioral weight-loss in
this high-risk population.
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CRITICAL
APPRAISAL
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JoJournal identityThe study come from :
- Johns Hopkins University
The Welch Center for Prevention, Epidemiology, and Clinical Research Johns
Hopkins University, Division of General Internal Medicine and Department o
Psychiatry Johns Hopkins University School of Medicine, Departments of
Epidemiology Health Policy and Management, Mental Health, and Biostatis
Johns Hopkins Bloomberg School of Public Health- University of Maryland
Department of Veterans Affairs Capitol Health Care Network (VISN 5) Mental Illness
Education, and Clinical Research Center (R.W.G.), and Department of Psychiatry, Uni
Maryland School of Medicine (R.W.G.), Baltimore; Sheppard Pratt Health System (F.B
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Jo
- Towson University
Department of Kinesiology, Towson University and Social and Scientific Systems
- University of California
Division of Preventive Medicine, Department of Family and Preventive Medicin
of California, San Diego, La Jolla (C.A.M.A.)
- Department of Research and Evaluation, Kaiser Permane
Southern California, Pasadena (D.R.Y.)
- The National Center for Cardiovascular Research, Madrid
Published on March 21th, 2013, at NEJM.org.
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Jo
TitlesA Behavioral Weight-Loss Intervention in Pewith Serious Mental Illness
Positive: Clearly shows that variables that were investigated
Bold written with a capital letter at the beginning of th
There is no abbreviation
Less than 12 words
Negative: No location
No time
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Jo
Consist of 4 paragraphs
Background
Methods
Results
Conclusion
> 250 words
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Jo
Positive: Participant of study is clear, followed by the inclu
and exclusion criteria
Intergroup interventions are clear
Analysis tools mentioned clearly Measurable outcomes are clear
Technique sampling is randomized
Negative:
Not blind
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Jo
Positive Tables are presented in accordance with the
international journal writing format (without tvertical and horizontal lines in a) with no serianumber and table title and description of the
contents of the table
The values of the statistics written
Negative :
Theres no interpretation of BMI
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Jo
Positive
There is a comparison test of previous research and
There are disadvantages and advantages of the me
research results that have been achieved
There is an emphasis if the results of the research w
applied
There are suggestions for future research
Negative : -
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PICO ANALYSIS POPULATION
Adult patients with serious mental disorders excess
weight or obesity from 10 community rehabilitation
program of outpatient psychiatry at central Marylan
affiliates
INTERVENTION
Behavioral weight loss through lifestyle in adult pati
with serious mental disorders excess body weight o
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COMPARATION
Persentage of weight change at 6, 12, and 18 mbetween intervention group and control group
OUTCOME
A behavioral weight-loss intervention significanreduced weight over a period of 18 months in
overweight and obese adults with serious men
illness.
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VALID EVIDENCEQUESTIONSIs the allocation of patients in the study randomized? Y
Is patient observation done quite long and complete? Y
Are all patients in the randomized, analyzed? Y
Whether patients and physicians remain blind in doing
therapy, apart from the therapy being tested?
Is the treatment and control groups equally? Y
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I
WEIGHT LOSS FROM BASELINE AT 18 MONTHS FOLLOW UP
THE IMPORTANCE OF STUDY
WEIGHT LOSSTota
(+) (-)
Intervention 88 49 137
Control 70 72 142
Total 158 121 279
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IEBM for RCT RRR = -0.303 (95% CI: -0.605 to -0.058)
Weight loss from baseline in the
intervention group was 30.3% higher than
the control group
ARR = -0.149 (95% CI: -0.26 to -0.033)
ARR = -0.149 means absolute advantage
derived from behavioral interventions for
weight loss is a 14.9% increase in the
weight loss from baseline.
NNT = -7 (-4 to -30)
The number of patients who must be
treated (for the duration of the study) inorder to increase the weight loss from
baseline in obese adult patients with
mental disorders are 7 people
All 95%CI does not include the number 1,
indicating that the RRR, ARR, and NNT
meaningful.
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I
WEIGHT LOSS 5% FROM BASELINE AT 18 MONTHS FOLLOW UP
WEIGHT LOSS
Total(+) (-)
Intervention 52 85 137
Control 32 110 142
Total 84 195 297
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IEBM for RCT RRR = -0.684 (95% CI: -1.445 to -0.16)
Weight loss in the intervention group by 5%from baseline was 68.4% higher than thecontrol group
ARR = -0.154 (95% CI: -0.258 to -0.046)
ARR = -0.154 means absolute advantagederived from behavioral interventions forweight loss is a 15.4% increase in the weightloss of 5% from the baseline.
NNT = -7 (-4 to -22)
The number of patients who must be treated(for the duration of the study) in order toincrease the 5% weight loss from baseline inobese adult patients with mental disordersare 7 people.
All 95% CI does not include the number 1,indicating that the RRR, ARR, and NNT
meaningful.
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A
QUESTIONSIs there a difference in our patients
when compared with that found in
previous studies so that the results
can not be applied to our patients?
NO
Whether such therapy may be
applied to our patients?
YES
Does the patient have a potential
beneficial or detrimental treatment
or when the program implemented?
Profitable. Behavioral weight loss in
can significantly reduce body weigh
period of 18 months in adults with o
and obesity with serious mental DIS
APPLICABILITY OF TEST
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CONCLUSION1
Clinical study is valid
2
Clinical study is important
3Clinical study is applicable
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Thank
You