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ComparEuEtdsWeb
QUESTION | |
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7. Should monitoring, action-based and emotional-based behavioural techniques vs. usual care be used for adult patients living with obesity? | |
Population | adult patients living with obesity |
Intervention | Monitoring, action-based and emotional-based behavioural techniques See more |
Comparison | Usual Care |
Main outcomes | Adherence; Blood Pressure - Diastolic Blood Pressure; Blood pressure - Systolic Blood Pressure; Weight management- BMI; Weight management- Body fat; Weight management - waist; Quality of life; Depression; Eating self-efficacy; Exercise self-efficacy; |
Setting | European Union, outpatient care |
Perspective | Clinical recommendation- Population perspective |
Background | Overweight and obesity are chronic metabolic diseases considered as a global public health problem, highly prevalent among adult population (i.e., ̴40%). Obesity increases the risk for many other diseases like diabetes, hypertension, and cancer, thus is a leading cause of disability and death. Some self-management interventions, as behavioural-based weight-loss interventions, have shown more weight loss than usual care and a decreased risk of developing diabetes. However, other health outcomes and long-term effects have been less well reported. Also, the association between weight loss and other health outcomes is still not clear. |
Conflict of interest |
This work was supported by the EU Horizon 2020 research and innovation programme (grant agreement no. 754936). The funder had no role in developing the protocol or obtaining the results for this study. |
ASSESSMENT | ||||||||||||||||||||||||||||
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Priority of problem Is the problem a priority? |
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JUDGEMENT | RESEARCH EVIDENCE | |||||||||||||||||||||||||||
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Overweight and obesity are chronic metabolic diseases considered as a global public health problem, highly prevalent among adult population (i.e., ̴40%). Obesity increases the risk for many other diseases like diabetes, hypertension, and cancer, thus is a leading cause of disability and death. Some self-management interventions, as behavioural-based weight-loss interventions, have shown more weight loss than usual care and a decreased risk of developing diabetes. However, other health outcomes and long-term effects have been less well reported. Also, the association between weight loss and other health outcomes is still not clear. |
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Desirable Effects How substantial are the desirable anticipated effects? |
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JUDGEMENT | RESEARCH EVIDENCE | |||||||||||||||||||||||||||
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View summary of findings of network meta-analysis
View summary of findings of component network meta-analysis |
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ADDITIONAL CONSIDERATIONS | ||||||||||||||||||||||||||||
The guideline panel judged the desirable effects as marginal.
Fiberconsumption (SMD): 0,196 (-0,3157 to 0,7077) Fruitandvegetableconsumption (SMD): 0,4111 (-0,109 to 0,9312) Physicalactivity (SMD): 0,0614 (-0,2783 to 0,4012) Totalsteps(MD): 857,4632 (-466,5886 to 2181,5149) Carbohydrates(SMD): -0,5083 (-1,1463 to 0,1297) Consumption of fat (SMD):-0,755 (-1,001 to -0,5094) Coping with the disease (SMD):-0,189 (-0,644 to 0,266) Dietary habits (SMD): -0,4033 (-0,6288 to -0,1777)
Studies including the intervention: Ahern-2017 - Attendance of a weight-management program once a week - Group/individual face-to-face sessions - Duration: 12 or 52 weeks, respectively (two study arms included) - Expected patient (or carer) self-management behaviours: o Lifestyle related behaviours § Eating behaviours § Doing physical activity o Clinical management § Self-monitoring
Sattin-2016 - Faith-based lifestyle intervention among African-Americans - 12 group/individual face-to-face sessions, phone calls when needed - Duration 12 months - Expected patient (or carer) self-management behaviours: o Lifestyle related behaviours § Eating behaviours § Doing physical activity o Clinical management § Condition-specific behaviours § Self-monitoring § Early recognition of symptoms § Managing devices o Psychological management § Handling/managing emotions o Social management § Social roles
Wekker-2018 - Lifestyle intervention in women with infertility, targeting physical activity, diet and behavior modification - 6 face-to-face sessions, 4 phone calls, 3 internet-based contacts; all individual - Duration 6 months - Expected patient (or carer) self-management behaviours: o Lifestyle related behaviours § Eating behaviours § Doing physical activity o Clinical management § Self-monitoring § Managing devices
Ruusunen-2012 - Individualized counselling aimed at reducing weight and increasing physical activity - 15 individual/group face-to-face sessions - Duration 3 years - Expected patient (or carer) self-management behaviours: o Lifestyle related behaviours § Eating behaviours § Doing physical activity o Clinical management § Self-monitoring
Nakade-2012 - Individual-based counseling using a behavioral approach - 5 individual/group face-to-face sessions - Duration 24 months - Expected patient (or carer) self-management behaviours: o Lifestyle related behaviours § Eating behaviours § Doing physical activity o Clinical management § Self-monitoring
Kalter-Leibovici-2010 - Lifestyle intervention in Arab women; cultural issues were addressed - 11 individual and 11 group counseling sessions per year with a dietitian and 22 physical activity group sessions per year - Duration 12 months o Lifestyle related behaviours § Eating behaviours § Doing physical activity o Clinical management § Self-monitoring
Wang-2017 - Lifestyle intervention program guided by the Health Promotion Model - 1 face-to-face session when needed, 6 phone calls; all individual - Expected patient (or carer) self-management behaviours: o Lifestyle related behaviours § Eating behaviours § Doing physical activity o Clinical management § Self-monitoring § Medication use and adherence o Psychological management § Handling/managing emotions
Williams-2018 - Advice and education and referral to a 6-month telephone-based healthy lifestyle coaching service, in patients with chronic low back pain - 1 face-to-face session when needed, 10 phone calls when needed; all individual - Duration 6 months - Expected patient (or carer) self-management behaviours: o Lifestyle related behaviours § Eating behaviours § Doing physical activity § Smoking cessation or reduction o Clinical management § Self-monitoring § Physical management
Proportion of direct evidence contributing to the final NMA estimate per outcome: - DBP: 56% - SBP: 52% - BMI: 51% - Body fat: 76% - Waist size: 69% - QoL: 100% - Depression: 100% - Eating self-efficacy: 80% - Excercise self-efficacy: 70%
- Self-monitoring (weight) [SMD]: NR *Self monitoring results reported in a standard meta-analysis. All NMA outcomes resulted in trivial to no effect.
Modeling estimations for long term consequences We used the COMPAR-EU model developed for the cost-effectiveness analysis to also inform about long-term health outcomes. Decision analysis models estimate provide valuable information for outcomes when empirical evidence is not available or is unfeasible (Trikalinos TA, 2009). The following events were estimated over a lifetime and informed by the effect each SMIs over BMI from the NMA (see below). We suggest cautious interpretation as the certainty of the evidence for those input parameters was low to very low across comparisons.
- Life-Years (LY): 74 days of additional life per person - Years with diabetes: 95 fewer days per person - Quality-Adjusted Life Years (QALY): 87 days of additional life equivalent to full health per person (undiscounted) - Diabetes mellitus: 12 fewer events per 1,000 persons - Myocardial infarction: 5 fewer events per 1,000 persons - Stroke: 5 fewer events per 1,000 persons |
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Undesirable Effects How substantial are the undesirable anticipated effects? |
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View summary of findings of network meta-analysis
There are no undesirable observed effects. |
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ADDITIONAL CONSIDERATIONS | ||||||||||||||||||||||||||||
The guideline panel judged the undesirable effects as trivial or no effect, or causing no harmful effects except for the potential associated burden of the intervention. |
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Certainty of the evidence What is the overall certainty of the evidence of effects? |
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Very low |
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ADDITIONAL CONSIDERATIONS | ||||||||||||||||||||||||||||
The guideline panel judged the certainty of evidence as very low . |
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Values Is there important uncertainty about or variability in how much people value the main outcomes? |
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An overview of systematic reviews provided information about how patients value several of the outcomes of interest (critical/important) included in this clinical question:
Abbreviations: CI: confidence interval, EQ5D: EuroQol-5D a Utility values findings were assessed using the GRADE approach guidance (Zang 2019), and for findings assessing the burden for patients, we applied the CERQual approach (https://www.cerqual.org/) 1: Serious risk of indirectness (findings derived from a Japanese population) and imprecision (wide range of values reported). 2: Moderate concerns in the adequacy of findings (scarce and thin data) 3: Moderate concerns in relevance of findings, since these were reported in populations not participating in self-management interventions, they were collected based on general experiences with diabetes management. 4: Serious risk of indirectness regarding how the outcome was assessed, in studies of utility values, exploring the final state of having a specific BMI, and only some studies explored the weight change as BMI excess over 25, reporting it as the value per unit of excess. 5 Moderate concerns in the relevance of findings referred explicitly to adherence to medication (insulin and others) that can be integrated into SM treatment but were not collected from patients who explicitly participated in SM interventions. |
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ADDITIONAL CONSIDERATIONS | ||||||||||||||||||||||||||||
The guideline panel judged that there is no important uncertainty or variability of how patients value the main outcomes. |
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Balance of effects Does the balance between desirable and undesirable effects favor the intervention or the comparison? |
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ADDITIONAL CONSIDERATIONS | ||||||||||||||||||||||||||||
The guideline panel judged that the balance of effects probably favorus the intervention. This is due to the large desirable effects, the trivial undesirable effects, the lack of uncertainty and variability of how patients value outcomes, as well as the very low certainty of evidence of effects. |
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Resources required How large are the resource requirements (costs)? |
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Estimated costs for the intervention across all types of self-management interventions (SMIs), as described in the included studies of the network meta-analysis were on average 438 euros, with a range from 11 to 1565 euros.
Incremental health costs (without the intervention) was 783 euros. |
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ADDITIONAL CONSIDERATIONS | ||||||||||||||||||||||||||||
The guideline panel considered that the resources required for this intervention varies.
We could not provide cost for any specific type of SMI intervention. Instead the cost described is the average across all the SMIs assessed in the overall network meta-analysis.
Costing data for SMIs should be interpreted with caution. We used the data collected from the included studies on the number of sessions, duration of sessions, group size, and primary person performing the intervention to estimate the labor cost of providing the intervention. In many instances, detailed information was missing in the available literature (for example the average group size or duration of sessions). In those cases, we assumed an average of what was reported within a comparison. Some costs were omitted such as information on booklets and other training materials,
Therefore, these estimates provide uncertain evidence of the potential cost for any given intervention.
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Certainty of evidence of required resources What is the certainty of the evidence of resource requirements (costs)? |
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ADDITIONAL CONSIDERATIONS | ||||||||||||||||||||||||||||
The guideline panel has agreed on a very low certainty of the evidence on this domain. |
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Cost-effectiveness Does the cost-effectiveness of the intervention favor the intervention or the comparison? |
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Estimated costs for the intervention across all types of self-management interventions (SMIs), as described in the included studies of the network meta-analysis were on average 438 euros, with a range from 11 to 1565 euros.
NA: non applicable; QALY: quality adjusted life years; ICER: incremental cost-effectiveness ratio Explanations The cost-effectiveness results are for the UK setting. For more information on the cost-effectiveness analysis and the results for other countries, please see the cost-effectiveness section. The ICER calculation is based on total costs and QALY estimations from the cost-effectiveness analyses. While total cost in the cost-effectiveness analyses exclude intervention costs, a minimum and maximum intervention cost was estimated based on literature and added to the total costs to estimate the ICER. As such, the ICERs indicate the potential range of cost per QALY including intervention cost.
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ADDITIONAL CONSIDERATIONS | ||||||||||||||||||||||||||||
The guideline panel judged that these SMIs may be cost-effective, in particular when the range of cost estimates is in the same range as the headroom estimates. Overall interpretation should be that there is a possibility that these SMIs are cost-effective, in particular because the average cost of SMI for obesity in the literature (438 euro: range 11-1565 euro) is lower than the headroom estimate (see the explanation of headroom analysis).
Given the uncertainty in the cost estimates, it is important to be very cautious when comparing the ICERs (incremental cost-effectiveness ratio) for specific SMIs to the headroom to determine the most efficient intervention.
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Equity What would be the impact on health equity? |
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Equity (sub-group analyses): In a study investigating a specific faith-based lifestyle intervention in African American churches in the south of the USA, participants who attended 10 or more of 12 weekly group sessions lost, on average, significantly more weight compared with those who attended fewer than 10 weekly sessions (3.72 kg vs 1.52 kg, respectively) (Bonferroni-Sidak, p<0.001). Furthermore, 22% of participants with pre-diabetes achieved a 7% weight loss at 12 months (Sattin, 2016)
A UK study on a specific weight-management program (Weight Watchers) used by the Nationale Health Service (NHS) noted that intervention effects did not vary by gender or socioeconomic status. (Ahern, 2017). |
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ADDITIONAL CONSIDERATIONS | ||||||||||||||||||||||||||||
The panel agreed that if implemented tailored to culture and health literacy it could increase equity.
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Acceptability Is the intervention acceptable to key stakeholders? |
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JUDGEMENT | RESEARCH EVIDENCE | |||||||||||||||||||||||||||
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The information below has been obtained through an overview of systematic reviews of contextual factors, as well as a scoping review and one overview of systematic reviews of values and preferences. It also includes considerations from a Delphi study that was conducted in COMPAR-EU that included the most important contextual factors for the implementation of components (e.g. groups, peers) of self-management interventions according to stakeholders.
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ADDITIONAL CONSIDERATIONS | ||||||||||||||||||||||||||||
The guideline panel judged that this type of SMI is probably acceptable to key stakeholders. Patients/caregivers: overall acceptable but may vary since it could be influenced by setting, accessibility, tailoring, and other factors.
Studies' Interventions
Sattin-2016 - Faith-based lifestyle intervention among African-Americans - 12 group/individual face-to-face sessions, phone calls when needed - Duration 12 months - Expected patient (or carer) self-management behaviours: o Lifestyle related behaviours § Eating behaviours § Doing physical activity o Clinical management § Condition-specific behaviours § Self-monitoring § Early recognition of symptoms § Managing devices o Psychological management § Handling/managing emotions o Social management § Social roles
Wang-2017 - Lifestyle intervention program guided by the Health Promotion Model - 1 face-to-face session when needed, 6 phone calls; all individual - Expected patient (or carer) self-management behaviours: o Lifestyle related behaviours § Eating behaviours § Doing physical activity o Clinical management § Self-monitoring § Medication use and adherence o Psychological management § Handling/managing emotions
Wekker-2018 - Lifestyle intervention in women with infertility, targeting physical activity, diet and behavior modification - 6 face-to-face sessions, 4 phone calls, 3 internet-based contacts; all individual - Duration 6 months - Expected patient (or carer) self-management behaviours: o Lifestyle related behaviours § Eating behaviours § Doing physical activity o Clinical management § Self-monitoring § Managing devices
Williams-2018 - Advice and education and referral to a 6-month telephone-based healthy lifestyle coaching service, in patients with chronic low back pain - 1 face-to-face session when needed, 10 phone calls when needed; all individual - Duration 6 months - Expected patient (or carer) self-management behaviours: o Lifestyle related behaviours § Eating behaviours § Doing physical activity § Smoking cessation or reduction o Clinical management § Self-monitoring § Physical management
Kalter-Leibovici-2010 - Lifestyle intervention in Arab women; cultural issues were addressed - 11 individual and 11 group counseling sessions per year with a dietitian and 22 physical activity group sessions per year - Duration 12 months o Lifestyle related behaviours § Eating behaviours § Doing physical activity o Clinical management § Self-monitoring
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Feasibility Is the intervention feasible to implement? |
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JUDGEMENT | RESEARCH EVIDENCE | |||||||||||||||||||||||||||
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The information below has been obtained through an overview of systematic reviews of contextual factors, as well as a scoping review and one overview of systematic reviews of values and preferences. It also includes considerations from a Delphi study that was conducted in COMPAR-EU that included the most important contextual factors for the implementation of components (e.g. groups,peers) of self-management interventions according to stakeholders.
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ADDITIONAL CONSIDERATIONS | ||||||||||||||||||||||||||||
The guideline panel judged that this type of SMI is probably feasible.
This type of SMI are probably more feasible in organizations/settings with a tradition of engaging peers in these type of interventions. Lack of human resources may make the implementation difficult.
Usually, duration of follow-up was not provided in the studies.
Studies' Interventions
Ahern-2017 - Attendance of a weight-management program once a week - Group/individual face-to-face sessions - Duration: 12 or 52 weeks, respectively (two study arms included) - Expected patient (or carer) self-management behaviours: o Lifestyle related behaviours § Eating behaviours § Doing physical activity o Clinical management § Self-monitoring
Sattin-2016 - Faith-based lifestyle intervention among African-Americans - 12 group/individual face-to-face sessions, phone calls when needed - Duration 12 months - Expected patient (or carer) self-management behaviours: o Lifestyle related behaviours § Eating behaviours § Doing physical activity o Clinical management § Condition-specific behaviours § Self-monitoring § Early recognition of symptoms § Managing devices o Psychological management § Handling/managing emotions o Social management § Social roles
Wekker-2018 - Lifestyle intervention in women with infertility, targeting physical activity, diet and behavior modification - 6 face-to-face sessions, 4 phone calls, 3 internet-based contacts; all individual - Duration 6 months - Expected patient (or carer) self-management behaviours: o Lifestyle related behaviours § Eating behaviours § Doing physical activity o Clinical management § Self-monitoring § Managing devices
Ruusunen-2012 - Individualized counselling aimed at reducing weight and increasing physical activity - 15 individual/group face-to-face sessions - Duration 3 years - Expected patient (or carer) self-management behaviours: o Lifestyle related behaviours § Eating behaviours § Doing physical activity o Clinical management § Self-monitoring
Nakade-2012 - Individual-based counseling using a behavioral approach - 5 individual/group face-to-face sessions - Duration 24 months - Expected patient (or carer) self-management behaviours: o Lifestyle related behaviours § Eating behaviours § Doing physical activity o Clinical management § Self-monitoring
Kalter-Leibovici-2010 - Lifestyle intervention in Arab women; cultural issues were addressed - 11 individual and 11 group counseling sessions per year with a dietitian and 22 physical activity group sessions per year - Duration 12 months o Lifestyle related behaviours § Eating behaviours § Doing physical activity o Clinical management § Self-monitoring
Wang-2017 - Lifestyle intervention program guided by the Health Promotion Model - 1 face-to-face session when needed, 6 phone calls; all individual - Expected patient (or carer) self-management behaviours: o Lifestyle related behaviours § Eating behaviours § Doing physical activity o Clinical management § Self-monitoring § Medication use and adherence o Psychological management § Handling/managing emotions
Williams-2018 - Advice and education and referral to a 6-month telephone-based healthy lifestyle coaching service, in patients with chronic low back pain - 1 face-to-face session when needed, 10 phone calls when needed; all individual - Duration 6 months - Expected patient (or carer) self-management behaviours: o Lifestyle related behaviours § Eating behaviours § Doing physical activity § Smoking cessation or reduction o Clinical management § Self-monitoring § Physical management
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TYPE OF RECOMMENDATION | ||||
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Strong recommendation against the intervention | Conditional recommendation against the intervention | Conditional recommendation for either the intervention or the comparison | Conditional recommendation for the intervention | Strong recommendation for the intervention |
CONCLUSIONS |
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Recommendation |
In patients with Obesity, the COMPAR-EU Obesity panel, suggests in favour of the use of monitoring, action-based behavioural techniques (problem solving and/or goal settings) and emotional-based (coaching, motivation and stress management), rather than usual care (conditional, very low certainty of the evidence about the effects). |
Justification |
The COMPAR-EU Obesity panel made a conditional recommendation in favour of Monitoring, action-based behavioural techniques (problem solving and/or goal settings) and emotional-based (coaching, motivation and stress management), rather than usual care alone, due to a probably favourable balance of effects and cost-effectiveness that probably favours the intervention. |
Subgroup considerations |
None. |
Implementation considerations |
When implementing SMI in general, the most important contextual factors to keep in mind are:
When implementing monitoring techniques, the most important contextual factors to keep in mind are:
When implementing action-based behavioural techniques (problem solving and/or goal setting), the most important contextual factors to keep in mind are:
When implementing Emotional-based behavioural techniques, the most important contextual factors to keep in mind are:
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Monitoring and evaluation |
No suggestions. |
Research priorities |
- Future studies should measure patient important outcomes, both critical and important (list below), have adequate sample size and follow-up, including after the intervention is finished. - Future studies should address also preferences and values of patients in relation to their self management, cost effectiveness and sub-categories of self-monitoring interventions. - Future studies should describe in detail the aspects of the intervention and evalute the long term effectiveness. - Future studies should addresss practical outcomes for patients with obesity, for example, levels of cortisol, inflammation markers and include psychological needs of the patients. - Future studies should address patient's related costs.
Critical outcomes Self-Efficacy Eating self-efficacy Exercise self-efficacy ((Physical activity; Steps per day) Qol (Stress; Depression) Blood pressure (SBP; DBP) Long term complications Weight management (BMI; waist; weight; body fat)
Important outcomes Patient activation Self-monitoring (dietary; weight) Adherence (to medication; to programme) Comorbidities (diabetes) Dietary habits (Dietary habits; Fat consumption, fibre consumption; carbohydrates; fruit and vegetable; consumption of fat) Coping with the disease
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REFERENCES SUMMARY |
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Summary of findings of network meta-analysis
COMPAR-EU Isof Web
Summary of findings of component network meta-analysis
COMPONENT NETWORK META-ANALYSIS: N/A
*All NMA outomes reported trivial to no effect results.
Components
Education (E)
Education (E)
Sharing information. This form of support consists in sharing of information about self-management topics like coping with symptoms, diet, exercise, medication, information about what other people are doing, and information about the disease itself, or about any other relevant aspects that could lead to improved self-management, and ultimately better health. This information can be told or distributed in printed materials like a folder or workbook, or via website or DVD.
Examples: Educational session on healthy eating for people with obesity, provision of a printed leaflet on the importance of foot care in diabetes, or a link to a website with information on chronic obstructive pulmonary disease care.
Monitoring techniques (MT)
Monitoring techniques (MT)
Self-monitoring training and feedback. Training and encouraging people to recognize, monitor, and record behaviours, symptoms, or clinical data. This process may include regular feedback from a clinician, or a synopsis of information registered in a digital tool to encourage you to continue monitoring your illness and behaviours.
Example: Showing a patient how to record blood sugar levels, physical activity, or pain.
Action-based behavioural change techniques (AB)
Action-based behavioural change techniques (AB)
There are different action-based behavioural change techniques:
Enhancing problem-solving skills. This technique consists in teaching on how to analyse factors that influence your behaviour and provide you or help you to develop strategies to reduce or overcome barriers and/or support facilitators (e.g., not eating unhealthy foods when you feel depressed). Strategies include anticipation, self-treatment, resource utilization, and problem management. Ideally, there should be an initial plan, but this is not a requisite.
Example: Identification and attenuation of environmental barriers (e.g., no gym in the neighbourhood when one want to exercise) and facilitators (e.g., someone who keeps you company during exercise) to everyday physical activities.
Goal setting and action planning. This technique consists in encouraging you to set one or more achievable goals based on your needs and preferences. These goals may be behaviours (e.g., a consuming a healthy meal three times a day) or outcomes (e.g., less pain) and can be used as a starting point. The process usually involves the formulation of a detailed action plan, specifying what you would do and at least when and/or where you will do it. It could also include an assessment of your behaviours with your health care provider and a discussion of goals and the writing up of agreed-on action plans, including plans for emergency situations.
Examples of goals: achieving a daily walking distance of 2 km or a weight loss of some kilograms in x months with diet and exercise.
Emotional-based change techniques (EB)
Emotional-based change techniques (EB)
There are different emotional-based behavioural change techniques:
Stress and/or emotional management. This technique consists in helping you to understand the role of stress and emotions and teaching them to use different coping strategies to manage, for example, stress and painful emotions caused by your disease.
Examples: Mindfulness, exercise, stretching, listening to music, deep breathing, or meditation.
Coaching and motivational interviewing. This kind of support helps you to change behaviours by looking what’s important to you, and then offering support, taking into account your needs and preferences. One provider (healthcare professional, peer or lay person) is usually your coach. Motivational interviewing and counselling are included, as well as collaborative conversations with a practitioner, helping with motivation and commitment, minimizing resistance, and resolve ambivalence to change.
Examples: coaching sessions led by a nurse to ease the transition from hospital to home, or rehabilitation programs using coaching methods.
Individual sessions
A single person receives the self-management support. Examples: self-guided actions (without the participation of any other person) during a clinical visit or within the context of a support or educational session
Face-to-face
Self-management support delivered in a face-to-face encounter between the providers and patients and/or caregivers.