Patients' acceptability of self-selected digital health services to support diet and exercise among people with complex chronic conditions: Mixed methods study.

Objective: The acceptability of being offered a choice from a suite of digital health service options to support optimal diet and exercise behaviors in adults with complex chronic conditions was evaluated. This study sought to understand many areas of acceptability including satisfaction, ease of use, usefulness and user appropriateness and perceived effectiveness. Methods: This mixed-methods study was embedded within a randomized-controlled feasibility trial providing digital health services managing diet and exercise for adults from specialist kidney and liver disease clinics. Post study surveys and semistructured interviews were used to determine patients' acceptability of the trial interventions. Quantitative (surveys) and qualitative (surveys and interviews) results were merged using integrative analysis and mapped to each construct of the modified version of the Theoretical Framework of Acceptability. Results: Seventeen interviews (intervention group) and 50 surveys (n = 24 intervention, n = 26 comparator) completed from a possible 67 participants were analyzed. In the intervention group, the survey results revealed high areas of acceptability for the digital health services including overall support received, ease of use, timely advice and feeling safe. The interviews also revealed high areas of acceptability including convenience, ability to adopt healthier behaviors and having regular interactions with health professionals. However, the interviews also revealed lower areas of acceptability as a result of absence of individualization, low digital literacy, and limitations from life circumstances. Conclusions: Recipients of digital health services that supported diet and exercise interventions found these useful, effective, and safe. Individualized care, technical support and patient confidence remain important to improve the acceptability of digital health service interventions.

Evaluating the Potential of a Novel Metabolic Syndrome Severity Score to Inform Exercise Interventions for People with Complex Chronic Conditions.

Aims: Exercise interventions positively affect numerous cardiometabolic risk factors. To better evaluate the health effects of exercise training, it may be more appropriate to evaluate risk factors together. The Metabolic Syndrome Severity Score (MetSSS) is a composite score representing cardiometabolic risk. Purpose: To evaluate the relationships between physical activity, neuromuscular fitness, exercise capacity, and the MetSSS in a heterogenous sample of people with complex chronic disease. Material and Methods: Fifty-three people with kidney or liver disease and at least one feature of the metabolic syndrome (MetS) were included. Pearson correlations were conducted between physical activity, neuromuscular fitness, exercise capacity, and the MetSSS. Linear regressions were performed for multi-level categorical variables. Independent variables with an association with MetSSS (P ≤ 0.2) were included in a multiple regression analysis. Results: The 6-minute walk test (6MWT) distance was inversely and independently associated with MetSSS [standardized beta coefficient (ß) = -0.31, P = 0.04]. No relationship was found between MetSSS and physical activity or neuromuscular fitness. Mean 6MWT in the highest tertile was 550 m (range: 505-620 m) and 346 m (range: 233-408 m) in the lowest. The analysis showed a medium-large between-group effect for the difference in MetSSS for the lowest and highest tertile of 6MWT [Eta squared (η2) = 0.16, P = 0.01]. Conclusions: Exercise capacity was inversely and independently associated with MetSSS in people with complex chronic disease. Clinical trials with exercise interventions are needed to further investigate if improvements in exercise capacity result in clinically significant changes in the MetSSS.

Trust and confidence in using telehealth in people with chronic kidney disease: A cross-sectional study.

Consumer trust and confidence in telehealth is pivotal to successful service implementation and effective consultations. This cross-sectional study measured trust and confidence in telephone and video consultations and associated with experience in telehealth modalities among people with chronic kidney disease at a metropolitan hospital in Australia. Self-report data were collected using validated trust and confidence in telehealth scales and 5-point Likert responses. Non-parametric tests were used to compare trust and confidence in telephone and video consultations (Wilcoxon Matched Pairs) and associations with telehealth experience (Mann-Whitney). Of the 156 survey participants, 96.2% had used telephone consultations and 28.9% had used video. Overall trust and confidence in using telehealth were high. Confidence (range 1-5) in using telephone consultations (mean 3.75 ± 0.71) was significantly higher than video consultation (mean 3.64 ± 0.74), p = 0.039. Trust in telephone consultations (mean 3.93 ± 0.64) was significantly higher than in video consultations (mean 3.67 ± 0.66), p < 0.001. There was a significant association between experience with telephone consultations and reported levels of trust and confidence in telephone consultations. Experience with video was significantly related to trust in video consultations, but not confidence. Given the substantial difference in experience between telehealth modalities, trust and confidence may change as further exposure occurs.

A discrete choice experiment to elicit preferences for a liver screening programme in Queensland, Australia: a mixed methods study to select attributes and levels.

BACKGROUND: In Australia, the overall prevalence of liver disease is increasing. Maximising uptake of community screening programmes by understanding patient preferences is integral to developing consumer-centred care models for liver disease. Discrete choice experiments (DCEs) are widely used to elicit preferences for various healthcare services. Attribute development is a vital component of a well-designed DCE and should be described in sufficient detail for others to assess the validity of outcomes. Hence, this study aimed to create a list of potential attributes and levels which can be used in a DCE study to elicit preferences for chronic liver disease screening programmes. METHODS: Key attributes were developed through a multi-stage, mixed methods design. Focus groups were held with consumers and health care providers on attributes of community screening programmes for liver disease. Stakeholders then prioritised attributes generated from the focus group in order of importance via an online prioritisation survey. The outcomes of the prioritisation exercise were then reviewed and refined by an expert panel to ensure clinically meaningful levels and relevance for a DCE survey. RESULTS: Fifteen attributes were generated during the focus group sessions deemed necessary to design liver disease screening services. Outcomes of the prioritisation exercise and expert panel stages recognised five attributes, with three levels each, for inclusion in a DCE survey to elicit consumer preferences for community screening for liver disease. This study also highlights broader social issues such as the stigma around liver disease that require careful consideration by policy makers when designing or implementing a liver screening programme. CONCLUSIONS: The attributes and levels identified will inform future DCE surveys to understand consumer preferences for community screening programmes for liver disease. In addition, the outcomes will help inform the implementation of the LOCATE-NAFLD programme in real-world practice, and could be relevant for other liver and non-liver related chronic disease screening programmes.

Exercise in the Management of Metabolic-Associated Fatty Liver Disease (MAFLD) in Adults: A Position Statement from Exercise and Sport Science Australia.

Metabolic-associated fatty liver disease (MAFLD) is the most prevalent chronic liver disease worldwide, affecting 25% of people globally and up to 80% of people with obesity. MAFLD is characterised by fat accumulation in the liver (hepatic steatosis) with varying degrees of inflammation and fibrosis. MAFLD is strongly linked with cardiometabolic disease and lifestyle-related cancers, in addition to heightened liver-related morbidity and mortality. This position statement examines evidence for exercise in the management of MAFLD and describes the role of the exercise professional in the context of the multi-disciplinary care team. The purpose of these guidelines is to equip the exercise professional with a broad understanding of the pathophysiological underpinnings of MAFLD, how it is diagnosed and managed in clinical practice, and to provide evidence- and consensus-based recommendations for exercise therapy in MAFLD management. The majority of research evidence indicates that 150-240 min per week of at least moderate-intensity aerobic exercise can reduce hepatic steatosis by ~ 2-4% (absolute reduction), but as little as 135 min/week has been shown to be effective. While emerging evidence shows that high-intensity interval training (HIIT) approaches may provide comparable benefit on hepatic steatosis, there does not appear to be an intensity-dependent benefit, as long as the recommended exercise volume is achieved. This dose of exercise is likely to also reduce central adiposity, increase cardiorespiratory fitness and improve cardiometabolic health, irrespective of weight loss. Resistance training should be considered in addition to, and not instead of, aerobic exercise targets. The information in this statement is relevant and appropriate for people living with the condition historically termed non-alcoholic fatty liver disease (NAFLD), regardless of terminology.

Dietitian-led micronutrient management in a public bariatric surgery outpatient clinic.

AIMS: This study aimed to explore the multidisciplinary team attitudes and knowledge of bariatric surgery micronutrient management (pre- and postoperative care) and to evaluate the implementation of an extended-scope of practice dietitian-led model of care for micronutrient monitoring and management. METHODS: A mixed method study design included quantitative evaluation of micronutrient testing practices and deficiency rates. Qualitative reflexive thematic analysis was used to interpret multidisciplinary experience with micronutrient monitoring in a traditional and dietitian-led model of care. In addition, deductive analysis used normalisation process theory mapping of multidisciplinary experience with the implementation of the dietitian-led model of care. RESULTS: In the traditional model, a lack of quality evidence to guide micronutrient management, and a tension in trust between surgeons and patients related to adherence to micronutrient prescriptions were described as challenges in current practice. The dietitian-led model was seen to overcome some of these challenges, increasing collaborative, and coordinated, consistent and personalised patient care that led to increased testing for and detection of micronutrient deficiencies. Barriers to sustainability of the dietitian-led model included a lack of workforce succession planning, and no clearly defined delegation for some aspects of care. CONCLUSION: An extended scope dietitian-led model of care for micronutrient management after bariatric surgery improves clinical care. Challenges such as succession planning must be considered in design of extended scope services.

Monitoring for micronutrient deficiency after bariatric surgery-what is the risk?

BACKGROUND: Bariatric surgery may increase the risk of micronutrient deficiencies; however, confounders including preoperative deficiency, supplementation and inflammation are rarely considered. OBJECTIVE: To examine the impact of bariatric surgeries, supplementation and inflammation on micronutrient deficiency. SETTING: Two public hospitals, Australia. METHODS: Participants were recruited to an observational study monitoring biochemical micronutrient outcomes, supplementation dose, inflammation and glycaemic control, pre-operatively and at 1-3, 6 and 12 months after gastric bypass (GB; Roux-en-Y Gastric Bypass and Single Anastomosis Gastric Bypass; N = 66) or sleeve gastrectomy (SG; N = 144). Participant retention at 12 months was 81%. RESULTS: Pre-operative micronutrient deficiency was common, for vitamin D (29-30%), iron (13-22%) and selenium (39% GB cohort). Supplement intake increased after surgery; however, dose was <50% of target for most nutrients. After SG, folate was vulnerable to deficiency at 6 months (OR 13 [95% CI 2, 84]; p = 0.007), with folic acid supplementation being independently associated with reduced risk. Within 1-3 months of GB, three nutrients had higher deficiency rates compared to pre-operative levels; vitamin B1 (21% vs. 6%, p < 0.01), vitamin A (21% vs. 3%, p < 0.01) and selenium (59% vs. 39%, p < 0.05). Vitamin B1 deficiency was independently associated with surgery and inflammation, selenium deficiency with improved glycaemic control after surgery and inflammation, whilst vitamin A deficiency was associated with inflammation only. CONCLUSION: In the setting of prophylactic post-surgical micronutrient prescription, few nutrients are at risk of de novo deficiency. Although micronutrient supplementation and monitoring remains important, rationalising high-frequency biochemical testing protocols in the first year after surgery may be warranted.

High-intensity Interval Training for the Management of Nonalcoholic Steatohepatitis: Participant Experiences and Perspectives.

Background and Aims: High-intensity interval training (HIIT) is a therapeutic option for people with nonalcoholic steatohepatitis (NASH). However, the perspectives and experiences of HIIT for people with NASH are unknown, limiting translation of research. We explored the experiences and perspectives of both professionally supervised and self-directed HIIT in people with NASH and evaluated participant-reported knowledge, barriers, and enablers to commencing and sustaining HIIT. Methods: Twelve participants with NASH underwent 12 weeks of supervised HIIT (3 days/week, 4×4 minutes at 85-95% maximal heart rate, interspersed with 3 minutes active recovery), followed by 12-weeks of self-directed (unsupervised) HIIT. One-on-one, semistructured participant interviews were conducted by exercise staff prior to HIIT and following both supervised and self-directed HIIT to explore prior knowledge, barriers, enablers, and outcomes at each stage. Interviews were audio-recorded, transcribed, coded, and thematically analyzed by two independent researchers. Results: Four dominant themes were identified: (1) no awareness of/experience with HIIT and ambivalence about exercise capabilities; (2) multiple medical and social barriers to commencing and continuing HIIT; (3) exercise specialist support was a highly valued enabler, and (4) HIIT was enjoyed and provided holistic benefits. Conclusions: People with NASH may lack knowledge of and confidence for HIIT, and experience multiple complex barriers to commencing and continuing HIIT. Exercise specialist support is a key enabler to sustained engagement. These factors need to be addressed in future clinical programs to augment the uptake and long-term sustainability of HIIT by people with NASH so they can experience the range of related benefits.

Physical Activity and Nonalcoholic Fatty Liver Disease: A Roundtable Statement from the American College of Sports Medicine.

ABSTRACT: Although physical activity (PA) is crucial in the prevention and clinical management of nonalcoholic fatty liver disease, most individuals with this chronic disease are inactive and do not achieve recommended amounts of PA. There is a robust and consistent body of evidence highlighting the benefit of participating in regular PA, including a reduction in liver fat and improvement in body composition, cardiorespiratory fitness, vascular biology, and health-related quality of life. Importantly, the benefits of regular PA can be seen without clinically significant weight loss. At least 150 min of moderate or 75 min of vigorous intensity PA are recommended weekly for all patients with nonalcoholic fatty liver disease, including those with compensated cirrhosis. If a formal exercise training program is prescribed, aerobic exercise with the addition of resistance training is preferred. In this roundtable document, the benefits of PA are discussed, along with recommendations for 1) PA assessment and screening; 2) how best to advise, counsel, and prescribe regular PA; and 3) when to refer to an exercise specialist.

Cost-effectiveness of telehealth-delivered nutrition interventions: a systematic review of randomized controlled trials.

CONTEXT: Telehealth-delivered nutrition interventions are effective in practice; however, limited evidence exists regarding their cost-effectiveness. OBJECTIVE: To evaluate the cost-effectiveness of telehealth-delivered nutrition interventions for improving health outcomes in adults with chronic disease. DATA SOURCES: PubMed, CENTRAL, CINAHL, and Embase databases were systematically searched from database inception to November 2021. Included studies were randomized controlled trials delivering a telehealth-delivered diet intervention conducted with adults with a chronic disease and that reported on cost-effectiveness or cost-utility analysis outcomes. DATA EXTRACTION: All studies were independently screened and extracted, and quality was appraised using the Consolidated Health Economic Evaluation Reporting Standards (CHEERS) checklist. DATA ANALYSIS: All extracted data were grouped into subcategories according to their telehealth modality and payer perspective, and were analyzed narratively. RESULTS: Twelve randomized controlled trials comprising 5 phone-only interventions, 3 mobile health (mHealth), 2 online, and 1 each using a combination of phone-online or phone-mHealth interventions, were included in this review. mHealth interventions were the most cost-effective intervention in all studies. Across all telehealth interventions and cost analyses from health service perspectives, 60% of studies were cost-effective. From a societal perspective, however, 33% of studies reported that the interventions were cost-effective. Of the 10 studies using cost-utility analyses, 3 were cost saving and more effective, making the intervention dominant, 1 study reported no difference in costs or effectiveness, and the remaining 6 studies reported increased cost and effectiveness, meaning payers must decide whether this falls within an acceptable willingness-to-pay threshold for them. Quality of study reporting varied with between 63% to 92%, with an average of 77% of CHEERS items reported. CONCLUSION: Telehealth-delivered nutrition interventions in chronic disease populations appear to be cost-effective from a health perspective, and particularly mHealth modalities. These findings support telehealth-delivered nutrition care as a clinically beneficial, cost-effective intervention delivery modality.

Developing a knowledge translation program for health practitioners: Allied Health Translating Research into Practice.

Background: Front-line health practitioners lack confidence in knowledge translation, yet they are often required to undertake projects to bridge the knowledge-practice gap. There are few initiatives focused on building the capacity of the health practitioner workforce to undertake knowledge translation, with most programs focusing on developing the skills of researchers. This paper reports the development and evaluation of a knowledge translation capacity building program for allied health practitioners located over geographically dispersed locations in Queensland, Australia. Methods: Allied Health Translating Research into Practice (AH-TRIP) was developed over five years with consideration of theory, research evidence and local needs assessment. AH-TRIP includes five components: training and education; support and networks (including champions and mentoring); showcase and recognition; TRIP projects and implementation; evaluation. The RE-AIM framework (Reach, Effectiveness, Adoption, Implementation Maintenance) guided the evaluation plan, with this paper reporting on the reach (number, discipline, geographical location), adoption by health services, and participant satisfaction between 2019 and 2021. Results: A total of 986 allied health practitioners participated in at least one component of AH-TRIP, with a quarter of participants located in regional areas of Queensland. Online training materials received an average of 944 unique page views each month. A total of 148 allied health practitioners have received mentoring to undertake their project, including a range of allied health disciplines and clinical areas. Very high satisfaction was reported by those receiving mentoring and attending the annual showcase event. Nine of sixteen public hospital and health service districts have adopted AH-TRIP. Conclusion: AH-TRIP is a low-cost knowledge translation capacity building initiative which can be delivered at scale to support allied health practitioners across geographically dispersed locations. Higher adoption in metropolitan areas suggests that further investment and targeted strategies are needed to reach health practitioners working in regional areas. Future evaluation should focus on exploring the impact on individual participants and the health service.

American College of Sports Medicine (ACSM) International Multidisciplinary Roundtable report on physical activity and nonalcoholic fatty liver disease.

BACKGROUND AND AIMS: We present findings from the inaugural American College of Sports Medicine (ACSM) International Multidisciplinary Roundtable, which was convened to evaluate the evidence for physical activity as a means of preventing or modifying the course of NAFLD. APPROACH AND RESULTS: A scoping review was conducted to map the scientific literature and identify key concepts, research gaps, and evidence available to inform clinical practice, policymaking, and research. The scientific evidence demonstrated regular physical activity is associated with decreased risk of NAFLD development. Low physical activity is associated with a greater risk for disease progression and extrahepatic cancer. During routine health care visits, all patients with NAFLD should be screened for and counseled about physical activity benefits, including reduction in liver fat and improvement in body composition, fitness, and quality of life. While most physical activity benefits occur without clinically significant weight loss, evidence remains limited regarding the association between physical activity and liver fibrosis. At least 150 min/wk of moderate or 75 min/wk of vigorous-intensity physical activity are recommended for all patients with NAFLD. If a formal exercise training program is prescribed, aerobic exercise with the addition of resistance training is preferred. CONCLUSIONS: The panel found consistent and compelling evidence that regular physical activity plays an important role in preventing NAFLD and improving intermediate clinical outcomes. Health care, fitness, and public health professionals are strongly encouraged to disseminate the information in this report. Future research should prioritize determining optimal strategies for promoting physical activity among individuals at risk and in those already diagnosed with NAFLD.

Patient experiences with micronutrient and overall nutrition management after bariatric surgery: identifying facilitators and barriers to implementing care.

BACKGROUND: Adherence to perioperative guideline recommendations for prophylactic supplementation and regular biochemical monitoring is suboptimal. However, little is known about the patient perspective on this postoperative challenge. OBJECTIVES: To qualitatively explore patient experiences of postoperative micronutrient management and identify patient-reported barriers and facilitators to the provision of nutrition care. SETTING: Two tertiary public hospitals in Queensland, Australia. METHODS: Semi-structured interviews were conducted with 31 participants 12 months after bariatric surgery. Inductive analysis of interview transcripts was performed using applied thematic analysis, and deductive analysis was performed by aligning interview themes against the Theoretical Domains Framework and the Capability, Motivation, and Opportunity Behavior Change Wheel Framework. RESULTS: Participants' perceptions of engagement with the bariatric surgery multidisciplinary team greatly influenced their experience with overall nutrition care, including but not exclusive to micronutrient care. At times, this engagement negatively impacted patients' experiences with their nutrition care and related to varied acceptance of healthcare advice from the team or, at times, an unmet desire for person-centered communication styles. Engaging person-centered care techniques had a positive influence on patient experience with micronutrient and overall nutrition care. Micronutrient management (taking supplements and having regular blood tests) was broadly accepted and enabled by the presence of established medication and blood test routines preoperatively. However, challenges did exist and were practical in nature. Incorporating education on habit-forming techniques was identified as a facilitator to assist with micronutrient management. CONCLUSION: Although participants mostly accept embedding micronutrient management into their life, developing interventions that focus on habit-forming skills and that enable multidisciplinary teams to provide person-centered care is recommended to enhance care after surgery.

Effectiveness of dietary interventions delivered by digital health to adults with chronic conditions: Systematic review and meta-analysis.

BACKGROUND: Digital health interventions may facilitate management of chronic conditions; however, no reviews have systematically assessed the effectiveness of dietary interventions delivered by digital health platforms for improving dietary intake and clinical outcomes for adults with diet-related chronic conditions. METHODS: Databases CINAHL, CENTRAL, Embase and MEDLINE were searched from inception to April 2021 to identify controlled trials for dietary education delivered by digital health (mobile or electronic health) to adults with diet-related chronic conditions. Random effects analysis was performed for diet quality, food groups, nutrients and clinical outcomes. Screening, data extraction and quality checking were completed in duplicate. RESULTS: Thirty-nine studies were included involving 7333 participants. Significant changes were found for Mediterranean diet adherence score (standardised mean difference [SMD] = 0.79; 95% confidence interval [CI] = 0.18 to 1.40), overall fruit and vegetable intake (mean difference [MD]: 0.63 serves/day; 95% CI = 0.27-0.98), fruit intake alone (MD = 0.58 serves/day; 95% CI = 0.39 to 0.77) and sodium intake (SMD = -0.22; 95% CI = -0.44 to -0.01). Improvements were also found for waist circumference [MD = -2.24 centimetres; 95% CI = -4.14 to -0.33], body weight (MD = -1.94 kg; 95% CI = -2.63 to -1.24) and haemoglobin A1c (MD = -0.17%; 95% CI = -0.29 to -0.04). Validity of digital assessment tools to measure dietary intake were not reported. The quality of evidence was considered to have low to moderate certainty. CONCLUSIONS: Modest improvements in diet and clinical outcomes may result from intervention via digital health for those with diet-related chronic conditions. However, additional robust trials with better reporting of digital dietary assessment tools are needed to support implementation within clinical practice.

'We work in silos': Exploring clinicians' perspectives on the dietary management of coronary heart disease and type 2 diabetes in an Australian public hospital and community health service.

AIMS: This study explored clinicians' perspectives on roles, practices and service delivery in the dietary management of coronary heart disease and type 2 diabetes in a public health service. METHODS: Semi-structured individual interviews were conducted with 57 clinicians (21 nurses, 19 doctors, 13 dietitians and 4 physiotherapists) involved in the care of relevant patients across hospital and post-acute community settings in a metropolitan health service in Australia. Interviews were audio-recorded, transcribed verbatim and analysed using inductive thematic analysis. RESULTS: A total of 3 themes with 10 subthemes were identified. (a) 'Treatment prioritisation': important role of nutrition in risk factor management; competing priorities with complex patients; weight loss as a priority; and dietitians individualise. (b) 'Diverse roles in providing diet advice': a tension between nutrients, restrictions and diet quality; patients seek and trust advice from non-dietitians; and providing nutrition information materials crosses professions. (c) 'Dietitian access': variable integration and resourcing; access governed by clinician discretion and perceived patient interest; and bespoke application of referral pathways. CONCLUSIONS: Time and resource constraints, variable access and referral to dietitians, and inconsistent advice were key challenges in the dietary management of coronary heart disease and type 2 diabetes. Models of care may be improved with greater investment and integration of dietitians, including to provide professional support across disciplines and disease specialties.

High-Intensity Interval Training is Safe, Feasible and Efficacious in Nonalcoholic Steatohepatitis: A Randomized Controlled Trial.

BACKGROUND: High-Intensity Interval Training (HIIT) involves bursts of high-intensity exercise interspersed with lower-intensity exercise recovery. HIIT may benefit cardiometabolic health in people with nonalcoholic steatohepatitis (NASH). AIMS: We aimed to examine the safety, feasibility, and efficacy of 12-weeks of supervised HIIT compared with a sham-exercise control (CON) for improving aerobic fitness and peripheral insulin sensitivity in biopsy-proven NASH. METHODS: Participants based in the community [(n = 14, 56 ± 10 years, BMI 39.2 ± 6.7 kg/m2, 64% male), NAFLD Activity Score 5 (range 3-7)] were randomized to 12-weeks of supervised HIIT (n = 8, 4 × 4 min at 85-95% maximal heart rate, interspersed with 3 min active recovery; 3 days/week) or CON (n = 6, stretching; 3 days/week). Safety (adverse events) and feasibility determined as ≥ 70% program completion and ≥ 70% global adherence (including session attendance, interval intensity adherence, and duration adherence) were assessed. Changes in cardiorespiratory fitness (V̇O2peak), exercise capacity (time-on-test) and peripheral insulin sensitivity (euglycemic hyperinsulinemic clamp) were assessed. Data were analysed using ANCOVA with baseline value as the covariate. RESULTS: There were no HIIT-related adverse events and HIIT was globally feasible [program completion 75%, global adherence 100% (including adherence to session 95.4 ± 7.3%, interval intensity 95.3 ± 6.0% and duration 96.8 ± 2.4%)]. A large between-group effect was observed for exercise capacity [mean difference 134.2 s (95% CI 19.8, 248.6 s), ƞ2 0.44, p = 0.03], improving in HIIT (106.2 ± 97.5 s) but not CON (- 33.4 ± 43.3 s), and for peripheral insulin sensitivity [mean difference 3.4 mg/KgLegFFM/min (95% CI 0.9,6.8 mg/KgLegFFM/min), ƞ2 0.32, p = 0.046], improving in HIIT (1.0 ± 0.8 mg/KgLegFFM/min) but not CON (- 3.1 ± 1.2 mg/KgLegFFM/min). CONCLUSIONS: HIIT is safe, feasible and efficacious for improving exercise capacity and peripheral insulin sensitivity in people with NASH. CLINICAL TRIAL REGISTRATION NUMBER: Australian New Zealand Clinical Trial Registry (anzctr.org.au) identifier ACTRN12616000305426 (09/03/2016).

A longitudinal analysis of resting energy expenditure and body composition in people with spinal cord injury undergoing surgical repair of pressure injuries: a pilot study.

BACKGROUND: Data informing energy needs of people with spinal cord injury (SCI) and pressure injuries are scarce, the impact of surgical repair unknown, and the role of body composition in healing unexplored. The study aims were to investigate resting energy expenditure (REE) over the course of pressure injury surgical repair, compare with available energy prediction equations, and explore associations between body composition and wound healing. METHODS: Indirect calorimetry measured REE pre-surgery, post-surgery, at suture removal and hospital discharge. A clinically significant change was defined as +/-10% difference from pre-surgery. Eight SCI-specific energy prediction equations were compared to pre-surgery REE. Wound breakdown (Yes/No), weight, waist circumference (WC), and body composition (fat mass [FM], fat-free mass [FFM], bioimpedance spectroscopy) were measured. RESULTS: Twenty people underwent pressure injury surgical repair (95% male, mean age 56 ± 12 years, 70% paraplegia). Between pre-surgery and discharge, mean REE increased (+118 kcal/d, p = 0.005), but with <10% change at any timepoint. An energy prediction equation incorporating FFM showed greatest agreement (rc = 0.779, 95% CI: 0.437, 0.924). Those with wound breakdown (65%) had a higher weight (12.7 kg, 95% CI: -4.0, 29.3), WC (17.8 cm, 95% CI: -5.1, 40.7), and FM % (36.0% [IQR 31.8, 40.2] vs 26.0% [IQR 15.6, 41.3]) than those without wound breakdown, although statistical significance was not reached. CONCLUSION: The presence of pressure injuries and subsequent surgical repair did not impact REE and energy prediction equations incorporating FFM performed best. While not statistically significant, clinically important differences in body composition were observed in those with wound breakdown.

'It seems like common sense now': experiences of allied health clinicians participating in a knowledge translation telementoring program.

INTRODUCTION AND AIMS: Clinicians understanding and applying the skills of knowledge translation is essential for the delivery of high value, effective health care. However, many clinicians lack confidence and capacity to undertake knowledge translation. Our team recently piloted a group telementoring knowledge translation support service (KTSS) with allied health professionals (AHPs) undertaking knowledge translation in their practice. This article aims to investigate barriers and enablers to participants' participation and identify evidence-based strategies to improve future delivery of the initiative. METHODS: The evaluation utilized semistructured interviews with participants who completed the first KTSS. Interview transcripts were analysed to identify key themes and subthemes. Subthemes were also mapped to an implementation science framework and model (theoretical domains framework and behaviour change wheel) to guide evidence-based identification of effective strategies to address, overcome, or enhance issues raised. RESULTS: Six of the nine participants invited were interviewed. Five barriers and six enablers of KTSS participation, and five improvement ideas for a future KTSS program, were suggested. Barriers included knowledge gaps, competing time demands, and organizational expectations. Enablers included organizational support, motivation and preparation, and local champions. Additional strategies included additional preparation, an initial rapport building session, and strategies to meet the emotional needs of the participants. These were reinforced by the framework mapping results, with the further addition of a peer modelling strategy. CONCLUSION: Through a qualitative methodology we have examined and identified the experiences of AHPs who have participated in a knowledge translation telementoring program with clear strategies to enhance further programs offered.

The Effect of Diet and Exercise Interventions on Body Composition in Liver Cirrhosis: A Systematic Review.

Alterations in body composition, in particular sarcopenia and sarcopenic obesity, are complications of liver cirrhosis associated with adverse outcomes. This systematic review aimed to evaluate the effect of diet and/or exercise interventions on body composition (muscle or fat) in adults with cirrhosis. Five databases were searched from inception to November 2021. Controlled trials of diet and/or exercise reporting at least one body composition measure were included. Single-arm interventions were included if guideline-recommended measures were used (computed tomography/magnetic resonance imaging, dual-energy X-ray absorptiometry, bioelectrical impedance analysis, or ultrasound). A total of 22 controlled trials and 5 single-arm interventions were included. Study quality varied (moderate to high risk of bias), mainly due to lack of blinding. Generally, sample sizes were small (n = 6-120). Only one study targeted weight loss in an overweight population. When guideline-recommended measures of body composition were used, the largest improvements occurred with combined diet and exercise interventions. These mostly employed high protein diets with aerobic and or resistance exercises for at least 8 weeks. Benefits were also observed with supplementary branched-chain amino acids. While body composition in cirrhosis may improve with diet and exercise prescription, suitably powered RCTs of combined interventions, targeting overweight/obese populations, and using guideline-recommended body composition measures are needed to clarify if sarcopenia/sarcopenic obesity is modifiable in patients with cirrhosis.

Utilizing Technology for Diet and Exercise Change in Complex Chronic Conditions Across Diverse Environments (U-DECIDE): Protocol for a Randomized Controlled Trial.

BACKGROUND: The metabolic syndrome is common across many complex chronic disease groups. Advances in health technology have provided opportunities to support lifestyle interventions. OBJECTIVE: The purpose of this study is to test the feasibility of a health technology-assisted lifestyle intervention in a patient-led model of care. METHODS: The study is a single-center, 26-week, randomized controlled trial. The setting is specialist kidney and liver disease clinics at a large Australian tertiary hospital. The participants will be adults with a complex chronic condition who are referred for dietetic assessment and display at least one feature of the metabolic syndrome. All participants will receive an individualized assessment and advice on diet quality from a dietitian, a wearable activity monitor, and standard care. Participants randomized to the intervention group will receive access to a suite of health technologies from which to choose, including common base components (text messages) and optional components (online and mobile app-based nutrition information, an online home exercise program, and group-based videoconferencing). Exposure to the optional aspects of the intervention will be patient-led, with participants choosing their preferred level of engagement. The primary outcome will be the feasibility of delivering the program, determined by safety, recruitment rate, retention, exposure uptake, and telehealth adherence. Secondary outcomes will be clinical effectiveness, patient-led goal attainment, treatment fidelity, exposure demand, and participant perceptions. Primary outcome data will be assessed descriptively and secondary outcomes will be assessed using an analysis of covariance. This study will provide evidence on the feasibility of the intervention in a tertiary setting for patients with complex chronic disease exhibiting features of the metabolic syndrome. RESULTS: The study was funded in 2019. Enrollment has commenced and is expected to be completed by June 2022. Data collection and follow up are expected to be completed by December 2022. Results from the analyses based on primary outcomes are expected to be submitted for publication by June 2023. CONCLUSIONS: The study will test the implementation of a health technology-assisted lifestyle intervention in a tertiary outpatient setting for a diverse group of patients with complex chronic conditions. It is novel in that it embeds patient choice into intervention exposure and will inform health service decision-makers in regards to the feasibility of scale and spread of technology-assisted access to care for a broader reach of specialist services. TRIAL REGISTRATION: Australian New Zealand Clinical Trial Registry ACTRN12620001282976; https://www.anzctr.org.au/Trial/Registration/TrialReview.aspx?id=378337. INTERNATIONAL REGISTERED REPORT IDENTIFIER (IRRID): DERR1-10.2196/37556.