TAKE 5 intervention components

4.10.1.1.1 Diet

To facilitate a healthy sustainable weight loss of 0.5-1 kg per week, an energy deficit of 600 kcal per day deficit through modification of dietary intake is advocated by clinical guidelines (NICE 2014; SIGN 2010). This recommendation is supported by high quality evidence from a systematic review and meta-analysis of randomised controlled trials of dietary interventions (NICE 2006). Interventions were included if they had a minimum 12 months duration and were conducted in overweight and obese adults (BMI range 27.9 kg/m2 to 34.0 kg/m2). The effect size was reported for studies categorised as including either a 600 kcal EDD or a low fat diet due to limitations in the reporting of primary studies, preventing a clear distinction between dietary approaches. Twelve studies were included and found that the WMD at 12 months between studies utilising a 600 kcal EDD or low fat diets and control was -5.31 kg (95% CI -5.86 kg to – 7.77 kg).

Participants’ individual EDD was calculated as the estimated total energy expenditure (TEE) of each participant minus an energy deficit of 600kcal per day. TEE for each participant was calculated using the following equations:

• TEE = Basal metabolic rate (BMR) x physical activity level (PAL)

BMR was calculated based on age, gender, weight and height (Mifflin et al., 1990):

• Females: BMR = 10 x weight (kg) + 6.25 x height (cm) – 5 x age (years) – 161. • Males: BMR = 10 x weight (kg) + 6.25 x height (cm) – 5 x age (years) + 5.

The equation by Mifflin and colleagues (Mifflin, St Jeor, Hill, Scott, Daugherty, & Koh, 1990) was used as it has been shown to more accurately estimate BMR in comparison to

2010).

A PAL of 1.3 was used as results from the pilot single stranded study of the TAKE 5 multi- component intervention reported that individuals with intellectual disabilities and obesity are extremely sedentary and engage in low levels of physical activity, engaging on average 13.1 (SD 6.2) minutes per day in moderate-to-vigorous-intensity physical activity (Melville

et al., 2011). Thus, it is believed that the PAL of 1.4 used in the single stranded study may

have overestimated total energy requirements. To account for this, a PAL of 1.3 was used in this study which is consistent with the available evidence of another randomised controlled trial in the general population, examining the efficacy of a 600kcal EDD in comparison to a generalised 1500 kcal low-calorie diet in overweight and obese participants (Leslie, Lean, Baillie & Hankey, 2002).

The EDD provides daily energy intake from a specified number of daily portions individually calculated for each participant by the research dietitians. This is based on the five food groups in the Eatwell plate: starchy foods such as bread, rice, potatoes and pasta; meat/fish and alternatives; fruit and vegetables; milk and dairy products; foods high in sugar and fat [Food Standards Agency (FSA), 2009].

The amount of energy intake of each individual was dependent on the variables above, gender, age, height and weight. Therefore, larger participants consumed more calories on their EDD in comparison to someone of a lesser body weight. To ensure nutrient adequacy (NICE, 2014) the energy intake was limited to between 1200 and 3000 kcal per day.

An example EDD prescribed for participants on 1500kcal energy intake and 3000 kcal energy intake is illustrated in Figure 4.2. This figure also presents an example of the images used for participants with intellectual disabilities in the TAKE 5 intervention. The five segments of the eat well plate indicate the amount of portions to be consumed from the diet, with fruit and vegetables (~30-40% of energy intake) and starchy foods (~30%) being the largest, followed by milk and dairy products (~10-20% of energy intake) and meat fish and alternatives (~10-15% of energy intake) and the smallest intake from foods high in fat and sugar (~5-10% of energy intake). This is based on recommendations of energy intake from macronutrients in the form of 50% of energy intake from carbohydrates, less than 35% from fat and 20% from protein (Department of Health, 1991).

The EDD was designed to be used flexibly with participants and carers, portions could be swapped for alternatives and extra kcal allowances were provided, for example to provide energy intake for treats at the weekend.

Figure 4.2. Example of energy intake from the five food groups of participants on an energy

prescription of 1500 kcal and 3000 kcal. Eatwell plate images from the TAKE 5 resources.

4.10.1.1.2 Physical activity

The physical activity component was based on health education of the benefits of being physically active and followed consensus guidelines on physical activity interventions for beginners (O’Donovan et al., 2010). The guidelines focus on supporting people to gradually increase their participation in physical activity and work towards achieving health recommendations on the duration and intensity of physical activity (Department of Health 2004; NHS Health Scotland 2009).

Participants’ physical activity patterns were assessed at the start of the intervention and individualised physical activity plans made, primarily focussing on the following physical activities:

1) Lifestyle physical activity: Physical activity that could be performed in the home environment such as housework, walking up stairs and following the interactive You

2) Walking: based on baseline average steps per day, individuals were encouraged to set targets to progressively increase walking behaviour and used pedometers to monitor step counts

3) Sport and exercise: information was given to each participant on local leisure facilities and clubs with accessible sports and exercise groups/classes (Melville et

al., 2011).

Since many adults with learning disabilities have been shown to live sedentary lifestyles and to be less physically active compared to the general population (McGuire et al. 2007; Temple & Walkley, 2007), a major focus of this intervention component was also to interrupt time spent inactive and engaged in sedentary behaviours This was achieved throughout the intervention, by assessing the participants’ lifestyle habits such as watching television and sitting for long periods, and encouraging activity during add breaks when watching television such as walking or dancing when music is played.

In order to discourage the participants from being physically active by overloading them with unachievable goals, activity was gradually increased particularly in the early stages, by setting achievable goals in order to build confidence and increase the participants’ motivation to being physically active. Furthermore, small increases in physical activity have shown to have health benefits independent of weight loss (NICE, 2014).

4.10.1.1.3 Behaviour change techniques

As previously mentioned the success of behaviour change interventions is dependent on them being tailored to the individual’s needs (NICE 2014). Following recommendations by clinical guidelines (SIGN 2010; NICE 2014) and based on the evidence on behaviour change techniques based on Control Theory (Carver & Scheier, 1982), goal setting, self-monitoring, review of goals and feedback on performance are considered to be successful techniques in supporting healthy lifestyle changes (Michie et al., 2009), therefore these were used in every session.

However, it is noted that due to the cognitive abilities of individuals with intellectual disabilities some of these techniques may be challenging for this population group. Therefore, other techniques were designed to be incorporated flexibly in relation to the needs

identification/problem solving. For a full list of the behaviour change techniques utilised in the TAKE 5 intervention see Figure 4.3. The principal techniques are discussed in more detail below:

4.10.1.1.3.1 Goal setting

The primary goal for participants was to achieve a clinically significant weight loss of 5- 10% body weight. This was communicated with participants at the start of the intervention period and subsequent goals made in relation to this overall aim throughout. This was achieved by setting smaller achievable weight loss goals of 0.5-1kg per week. This is in accordance with clinical guidance (SIGN 2010; NICE 2014). Goals were set at the end of each session (and reviewed at the following session) and focused on dietary habits and physical activity. Goals were Specific, Measurable, Achievable, Relevant and Time specific [SMART] (Doran, 1981) to each individual.

4.10.1.1.3.2 Self-monitoring

Participants were encouraged to monitor their food intake with support from carers, to the specified number of portions of the EDD. Participants were provided with food and physical activity diaries and asked to record their food intake by putting a dot by the food group when they had consumed it. In addition, participants were given a pedometer and asked with support from carers to note the number of steps they performed per day and any other physical activities they had engaged with.

4.10.1.1.3.3 Provide feedback on performance

At the start of each session participants were weighed and the research dietitians provided participants with a record of their body weight.

4.10.1.1.3.4 Relapse prevention/ coping planning

Participants were prepared to deal with small lapses such as increases in weight gain throughout the intervention as and when the research dietitians felt appropriate. Coping strategies were rehearsed to prepare the participant to deal with uncertain situations such as eating out and when faced with unfamiliar foods. In addition, session eight devoted a focus to relapse prevention of weight gain.

4.10.1.1.3.5 Barrier identification/ problem solving

Due the one to one interaction with the research dietitians in the TAKE 5 intervention, this allowed exploration of the participants’ individual context and environment. Any issues that prevented the participant form eating healthily or participating in physical activity were attempted to be resolved such as, engaging in physical activity due to difficulty accessing physical activity facilities. A solution provided was examples of lifestyle physical activity that can be conducted in the participant’s home environment.

4.10.1.1.3.6 Stress management

At each session participant’s dietary intake and physical activity werereviewed. At this point cues, internal or external were identified that positively or negatively influenced the participant’s behaviour. Any positive cues were encouraged and negative cues discussed to find strategies to overcome these. For example, avoiding cues that would facilitate over- eating such as watching television and participating in sedentary behaviour.

4.10.1.1.3.7 Prompt reward contingent on effort or progress towards behaviour

Motivation was achieved through reinforcement of the diet and physical activity messages, and encouragement when a participant achieved a lifestyle goal or weight loss.

Theme Sub-theme

Session 1 Benefits of losing weight and motivation

towards a healthy lifestyle

Introduction to TAKE 5 booklets

Introduction to food groups that make up healthy balanced diet

Set first weight loss goal

Session 2 Introduction to individualised

energy deficit diet and the importance of physical activity

Food portions

Benefits and ways to being active

Session 3 Principles of healthy eating and

improving physical activity levels

Taking control of diet Meals, snacks and fluid Introduction to physical activity diaries and pedometer

Session 4 Healthy ways to cook and healthy

shopping lists

Menu planning

Emotions and overeating

Session 5 Changing behaviour and stopping “bad

habits” Disadvantages of eating out and take-aways

Session 6 Coping with cravings and

evaluating knowledge of physical activity

Techniques to help with cravings

Physical activity quiz

Session 7 Motivation to being active New ways to motivate

physical activity Diet myths

Session 8 Relapse prevention Lapses and ways to prevent

them

Coping with setbacks Getting support from others

Session 9 Review Evaluate success in the

programme

Review healthy balanced diet and physical activity

4.10.1.2 Phase 2: Weight maintenance 4.10.1.2.1 Diet

Dietary intake for the weight maintenance phase was modified based on the six month weight loss during the weight loss phase. If participants had lost a clinical weight loss of 5% of initial body weight, they were offered a personalised energy prescription diet to maintain their body weight. The diet followed the same dietary principles used in the weight loss phase, without an energy deficit of 600 kcal per day. It was aimed to ensure a eucaloric dietary prescription and intake. If participants did not achieve a weight loss of 5% they were offered the option of continuing on their current EDD for a three month period followed by three months of a eucaloric energy prescribed diet to maintain their body weight.

4.10.1.2.2 Physical activity

The importance of physical activity was highlighted in the maintenance phase as it plays an important role in sustaining any reductions in body weight (Catenacci & Wyatt, 2007; SIGN 2010; NICE 2014). Individuals were encouraged to build on the levels of physical activity they achieved in phase one and continued to aim to meet clinical recommendations.

4.10.1.2.3 Behaviour change techniques

To maintain body weight loss participants were encouraged with support from carers where appropriate to maintain the healthy lifestyle habits from phase one. Behavioural strategies used in the weight loss phase were continued to be used flexibly. Specific approaches, in particular, relapse prevention/ coping planning and barrier identification/ problem solving were used to prevent large fluctuations in increased body weight and a negating of any benefits of the weight lost from baseline. In addition to self-monitoring of key lifestyle behaviours of food intake and habitual physical activity, participants were encouraged to

self-monitor their body weight as this has been shown to help with weight maintenance

(Wing & Phelan, 2005) and also aimed to help to imbed this as part of their routine and facilitate weight maintenance after the intervention has finished.

Table 4.2. TAKE 5 key themes for weight maintenance intervention

Theme Sub-theme

Session 1 Weight maintenance and new

individualised maintenance dietary plan

Importance of not regaining the weight loss

New diet plan

Session 2 Importance of being active and adopting

regular eating patterns

Meal planning

Maintaining motivation for physical activity and new options to be active

Session 3 Regular self-monitoring Importance of food diaries and

monitoring physical activity (e.g. step counts)

Introduction to self-weighing

Session 4 Overview of barriers to healthy eating and

physical activity

Strategies to choose healthy meal options and saying no to

unhealthy food

Finding time to be active

Session 5 Snacking, lapses, eating out/social

activities

Healthy snack options

Not returning to bad / old habits Healthy menu choices from restaurants

Session 6 Healthy menu plan and review of

principles of weight maintenance

Overview of programme Healthy meal plan for the future Importance of regular self- monitoring of body weight

4.10.1.2 TAKE 5 resources

The TAKE 5 intervention included four information booklets, specifically designed to support adults with intellectual disabilities to lose weight with support from their carers. The acceptability and utility of the booklets was investigated in the qualitative study with family and paid carers (Spanos et al., 2013b) and found to be a useful source of information and suitable to the developmental needs of adults with intellectual disabilities. The use of images was highly regarded by carers who reported that all adults with intellectual disabilities could engage with the books irrespective of their ability to read. Further details on the title and aim of the booklets have been described below:

Booklet 1: Eat well- Feel well: The aim of the booklet was to provide basic information

regarding healthy eating based on the “Eat Well” plate (FSA, 2009).

Booklet 2: You can do it: The aim of the booklet, accompanied by a DVD, aimed to

motivate participants to improve their physical activity

Booklet 3: How to help someone lose weight: The aim of the booklet was to motivate the

carers to support participants who were attempting to lose weight

Booklet 4: Get help with losing weight: The aim of the booklet was to introduce the

importance of losing weight and the need of involving other people in this difficult process

Additional resources included for the TAKE 5 intervention sessions were: • Food diaries – based on the Eatwell plate

• Physical activity diaries • Hand-outs for each session