Impact of Online Weight Management With Peer Coaching on Physical Activity Levels of Adults With Serious Mental Illness

Adults with serious mental illness exhibit elevated rates of obesity and cardiovascular disease, both of which contribute to dramatically reduced life expectancy (1,2). The majority of adults with serious mental illness are also sedentary (3). Physical inactivity is a major cause of morbidity and mortality (4); however, little is known about how to increase physical activity levels in this group. Although weight management interventions include components to increase physical activity, randomized controlled trials (RCTs) of these interventions have focused on weight outcomes (5–8), and the only such RCT to report on physical activity outcomes reported a negative result (9).

Two RCTs have demonstrated that the provision of opportunities for supervised physical activity can increase general physical activity among adults with serious mental illness (10–13). However, there are many barriers to providing opportunities for supervised physical activity in routine mental health care, including safety concerns and lack of trained staff and facilities (14,15). Strategies to increase general physical activity among adults with serious mental illness outside supervised settings are needed.

Delivering behavioral interventions online may improve their effectiveness by providing access in participants’ own communities, allowing immediate application of the lessons taught in real-world settings. In addition, technology-based interventions can be enhanced by social connection to a peer facilitator, who can encourage practice and generalization (16,17). Whether online delivery of a behavioral intervention with peer coaching can increase general physical activity among adults with serious mental illness is unknown.

A recent RCT tested online delivery of a weight management program with adults with serious mental illness. A Web-based version of a weight management program used by the U.S. Department of Veterans Affairs (VA MOVE!) was compared with in-person delivery of the same program and with usual care. The Web-based version was tailored for adults with serious mental illness and was enhanced with peer coaching (WebMOVE). The online version was also tailored for adults with serious mental illness but did not include peer coaching (MOVE SMI).

Participation in WebMOVE was associated with significant weight loss among obese participants with serious mental illness, whereas the other conditions were not associated with significant weight loss (18). This study aimed to examine whether WebMOVE also led to increased general physical activity compared with MOVE SMI or usual care. Qualitative analysis examined barriers to and facilitators of participation in exercise in the active conditions.

Methods

Participants and Procedures

This study was a secondary analysis of data collected during a large RCT of a computerized weight management intervention for veterans with serious mental illness (18) at the Greater Los Angeles VA Medical Center. Participants were recruited via clinic patient lists and study flyers posted in clinic waiting areas. Inclusion criteria were ages 18 and older, serious mental illness diagnosis (schizophrenia spectrum disorders, affective psychoses, or posttraumatic stress disorder), and body mass index (BMI) above 30 or BMI over 28 with weight gain of at least 10 pounds in the past three months. Participants completed the Physical Activity Readiness Questionnaire (PAR-Q) (19), which provided information about whether they were healthy enough for exercise. Individuals with PAR-Q scores greater than 1 required approval by a physician. Participants were excluded for dementia, pregnancy or nursing, history of bariatric surgery, recent psychiatric hospitalization (past month), limited control over food preparation, and current attendance at weight loss programming.

All study procedures were approved by the appropriate institutional review board. Written informed consent was obtained from all participants. Eligible participants who provided consent completed baseline assessments, including questions about demographic information, weight, height, and self-reported physical activity as assessed by the International Physical Activity Questionnaire (IPAQ) (20). Following baseline assessment, participants (N=276) were randomly assigned to WebMOVE, MOVE SMI, or usual care, with stratified randomization based on the weight gain liability of prescribed antipsychotic medications. Assessments were repeated at three months and six months after randomization. Assessors were blind to participant intervention condition. [A CONSORT diagram is available as an online supplement to this article.]

Intervention Conditions

MOVE SMI is a manualized version of the VA MOVE! weight management program, tailored for adults with serious mental illness (9). MOVE SMI consists of eight in-person individual sessions and 16 in-person group sessions delivered by a mental health provider over a period of six months. Individual sessions include goal setting, review of diet and exercise habits, and consolidation of group session material. Group sessions include weekly weigh-ins, didactic information (e.g., exercise safety and emphasis on low to moderate physical activity, such as stretching or walking), goal setting, and review of progress and challenges.

WebMOVE is a computerized version of MOVE SMI with the same curriculum, delivered via 30 online interactive modules (15 on diet and 15 on physical activity). Modules include text and audio- or video-based information, tracking of activity and weight, and individualized goal setting. Each WebMOVE participant received a pedometer. Peer coaches with lived experience of serious mental illness conducted 25- to 30-minute coaching calls each week with each participant, providing individualized follow-up, positive reinforcement, motivational enhancement, specific physical activity suggestions, and problem-solving barriers—such as time constraints and mental health symptoms. Participants had access to the online system and the peer coaching support for six months.

Five peer coaches, two females and three males, who were paid VA employees and veterans, delivered the manualized intervention over the course of the study period. The coaches varied in their previous experiences with providing peer support and in their education backgrounds. The coaches received five months of training by master’s- and doctoral-level study staff. Each peer coach was provided with a detailed manual with specific instructions for each coaching call. Training included both didactic instruction from the manual and experiential training in coaching. The peer started experiential training by joining a master therapist for live coaching sessions and eventually led these sessions. When the master therapist considered the peer ready to coach independently, the peer began to deliver the curriculum to others. All peer coaches received weekly clinical supervision from the study’s co-principal investigator, a psychologist. Two of the peer coaches provided the majority of the peer support for the study, with the others having briefer tenure on the project. The hiring of peers for this project preceded the certification process for peer specialists in the VA.

Participants in usual care received a handout on the benefits of weight loss and had access to attend standard services available at the medical center, including the standard VA MOVE! weight management program.

Assessment of Physical Activity

The Short Form of the IPAQ measured self-reported physical activity in the past seven days. The IPAQ is a widely used questionnaire with acceptable psychometric properties and is considered reliable and valid for use with individuals with psychotic disorders (20,21). The IPAQ assesses the number of minutes spent walking, being moderately physically active, and being vigorously physically active while working, getting from place to place, engaging in home maintenance and caregiving activities, and during leisure time. A summary score of total physical activity can be produced by multiplying the minutes spent in each type of activity by the activity’s energy requirements, defined in metabolic-equivalent-expenditure (MET) minutes. METs are multiples of the resting metabolic rates; an average MET score has been derived for each type of physical activity (22). Outcome measures for the present analyses were MET minutes spent walking, doing moderate physical activity, and doing vigorous physical activity as well as total MET minutes.

Quantitative Data Analysis

For baseline demographic characteristics and BMI, descriptive statistics were calculated and global tests of differences between the three groups were performed. Because of a high number of zero values for MET minutes of moderate and vigorous activity, the percentage of persons engaging in any moderate or vigorous physical activity was calculated, and mean±SD minutes of activity were calculated only for persons with nonzero values.

Square root transformations were applied to MET minutes spent walking and total MET minutes to reduce skew prior to analysis. Linear mixed-effects models with group, time, and group × time interaction terms were used to examine differences between each active intervention and the usual care group in change in MET minutes spent walking and total MET minutes from baseline to the three-month and six-month time points.

Customary variable transformations for MET minutes spent doing moderate or vigorous physical activity were unsuccessful in eliminating discontinuity due to zero inflation; hence a mixed-distribution, mixed-effects model (also known as a two-part model) was used (SAS ‘mixcorr’ macro) (23). This model combined a submodel for the probability of occurrence of nonzero MET minutes (logistic regression model) and a submodel for the probability distribution of MET minutes conditional on an amount greater than zero (log normal regression model to account for positive skew). Group, time, and group × time interaction terms were included in each part of the two-part model, which allowed for comparisons to be made between each active intervention versus the usual care group.

Qualitative Procedures

A quota sampling approach was used to select a random sample of participants (N=48) in the active treatment groups (WebMOVE and MOVE SMI) to participate in a semistructured interview after completion of a six-month quantitative assessment. This interview assessed facilitators of and barriers to program participation, including the physical activity component of the interventions. The interviews were digitally recorded and transcribed for analysis. Atlas.ti was used to organize the data into thematic sections. Two members of the research team used an iterative process to code the data and to identify subthemes and overarching themes from the open codes. Any discrepancies in coding were reconciled prior to theme development.

Results

Quantitative Data

Participants’ demographic information and BMI are displayed in Table 1; there were no significant differences between groups on these variables. Intervention attendance did not differ significantly between groups. In both active conditions, a proportion of participants did not attend any sessions (MOVE SMI, N=17) or complete any modules (WebMOVE, N=22). Excluding those who attended no sessions, the mean±SD number of sessions attended by MOVE SMI participants was 9.7±6.2 out of 24 total sessions. WebMOVE participants who completed at least one module completed 14.7±12.2 of 30 total modules.

Results for the linear mixed-effects models for MET minutes spent walking and total MET minutes are displayed in Table 2. Comparing MET minutes spent walking among participants in MOVE SMI and usual care, there was a trend for significance in mean change at three months and a significant difference in mean change at six months. Comparing participants in WebMOVE and usual care, there was a trend for significance in mean change in MET minutes spent walking at six months. There were significant differences between participants in MOVE SMI and usual care in mean change in total MET minutes at three months and six months. There was also a significant difference between the WebMOVE and usual care groups in mean change in total MET minutes at six months. These differences reflected increases in physical activity among participants in the active conditions and declines in physical activity among participants in usual care.

Results for the first part of the two-part mixed-effects models (logistic regression), which focused on the percentage of participants engaged in any moderate or vigorous activity, are displayed in Table 3. At six months, the percentage of participants engaging in any moderate and vigorous physical activity decreased in the usual care group and increased in the MOVE SMI group, resulting in significant group × time interactions.

Results for the second part of the two-part mixed-effects models (log-normal regression), which focused on mean changes in moderate and vigorous physical activity among those with nonzero values, are displayed in Table 4. At six months, there was a significant group × time interaction for MET minutes spent doing vigorous physical activity. This finding reflected increases in vigorous activity by participants in both active conditions and a decrease in vigorous activity by participants in usual care.

Qualitative Data

Participants described three main exercise-related themes: types of exercise performed, exercise motivation, and barriers to exercise. Exemplary quotes for each of these themes are presented in Table 5. In the WebMOVE condition, participants also described their experiences with the peer coaches.

Types of exercise performed.

Overwhelmingly, participants in both the WebMOVE and MOVE SMI groups walked as their primary source of exercise. Participants with physical limitations, due to disabilities or weight, described walking as low impact and manageable. More able-bodied participants used walking as the foundation for additional exercise. Only MOVE SMI participants performed additional types of exercises, with strength training reported most frequently.

Motivation to exercise.

The social aspect of exercise was an important motivation for participants to begin and sustain physical activity. Participants in both active conditions described walking with friends, family, peers, or pets as helpful and motivating. Being accountable to others helped participants sustain physical activity. In WebMOVE, the peer coaches served this function. The WebMOVE group also described how the pedometers provided by the program helped them with goal setting and motivation for walking. Positive health outcomes (weight loss, changes in HbA1c and cholesterol, improved quality of life, and longevity) motivated participants in both treatment groups to exercise.

Barriers to exercise.

Lack of motivation and time were the primary barriers identified by participants. Veterans with physical limitations or disabilities described modifying recommended exercises. Chronic or acute pain was also a factor. To a lesser extent, participants described how mental health symptoms interfered with their intentions to exercise (e.g., symptoms of depression could negate well-intentioned plans to go walking). One participant lamented eating more as a result of exercising more—for this participant, the additional energy needed to exercise had resulted in an increase in calories consumed.

Role of the peer coach.

Participants’ remarks about peer coaches were primarily positive and involved the program in general, with only a few exercise-specific comments. Peer coaches played an important role in reviewing program content, keeping participants mindful of weekly goals, and offering accountability, motivation, and support. Coaches provided individualized recommendations for physical activity and technical support, such as help logging onto the program, using the pedometer, and tracking progress online.

Discussion

Among adults with serious mental illness, both in-person delivery of a tailored, manualized version of the VA MOVE! weight management program (MOVE SMI) and participation in a Web-based version with peer coaching support (WebMOVE) led to significant increases in total physical activity compared with usual care. MOVE SMI led to increases in physical activity across types (walking and moderate and vigorous activity), whereas WebMOVE led to increases primarily in walking behavior. Individuals in the usual care condition exhibited a decrease in total physical activity across the six-month intervention period, which may represent a waning of motivation to engage in health preservation behaviors without the support of a structured intervention.

These findings contrast with weight loss outcomes in a previous study, in which weight loss was associated with the WebMOVE condition but not with MOVE SMI (18). It is possible that weight loss outcomes were due to changes in diet rather than changes in physical activity. Notably, the weight loss analyses included only individuals who attended at least one intervention session, whereas this study used an intent-to-treat approach.

Participation in the MOVE SMI condition helped some individuals initiate moderate or vigorous physical activity. Whereas WebMOVE participants exclusively endorsed walking as their preferred form of physical activity, MOVE SMI participants reported engaging in weight and strength training as well. Attending in-person groups as part of MOVE SMI may have afforded opportunities for participants to exchange ideas, leading to greater variation in exercise behaviors. Alternatively, individuals who traveled outside their communities to attend the in-person MOVE SMI sessions may have felt more empowered to engage in moderate or vigorous activity outside the home (e.g., lifting weights at a fitness center). WebMOVE participants, although satisfied with the convenience offered by the Web-based program, suggested that the program be supplemented with in-person exercise groups. These findings indicate that face-to-face or group interventions may be particularly important for the promotion of moderate and vigorous exercise among adults with serious mental illness.

Participation in both active conditions was associated with a modest and gradual increase in walking behavior compared with usual care. Thus, to increase walking, especially via a Web-based intervention, the program should be prepared to provide support for gradual change over a longer time period.

One important observation of note was the low prevalence of any moderate or vigorous activity among the participants in this sample. Although any increase in physical activity is worth pursuing, recommendations indicate that a mix of exercise in terms of type and intensity is ideal (24). Helping adults with serious mental illness initiate moderate or vigorous activity is an important target for intervention and has potential for significant clinical impact. This study indicates that a face-to-face, group-based intervention was better able to promote initiation of more strenuous physical exercise than an online-delivered version of the same program. Thus WebMOVE, which was previously shown to be feasible and effective for weight loss (18), could be supplemented with an in-person exercise component.

Qualitative interviews indicated that WebMOVE participants were generally satisfied with the peer coaches, who were seen as a source of general support to promote engagement and facilitate use of the online modules. Few participants commented specifically about how the peers helped them with exercise. Thus the value of peer providers in health and wellness interventions may lie in their ability to enhance motivation for and navigation of this programming, as opposed to their ability to promote specific health preservation behaviors (25).

Qualitative findings also indicated that, in addition to time and motivation, the primary constraint on participants’ ability to exercise was a physical limitation or disability. To address this barrier, participants suggested that program content could be modified to include exercises for those with physical limitations, perhaps presented by a physical therapist, either in person or as a video module. This recommendation is particularly pertinent to the initiation of moderate or vigorous physical activity, which is more likely to pose a safety concern for individuals with physical limitations.

This study had a number of limitations. Although the IPAQ is a well-validated measure of general physical activity, it is based on self-report; future studies could use objective physical activity measures (e.g., pedometers). The study was conducted at a single site in an urban area, and it warrants replication in other geographical locations. The sample consisted of a majority male, veteran population and may not generalize to other adults with serious mental illness.

Conclusions

An RCT with adults with serious mental illness, a generally sedentary population with high medical illness burden and complex care needs, found that in-person delivery of weight management counseling increased total physical activity and led to initiation of moderate or vigorous physical activity. Computerized weight management counseling with peer support also affected total physical activity, but its effects took longer to emerge. Online weight management programs for adults with serious mental illness may need to be continued for longer than six months and be supplemented with an in-person physical activity component to maximize effects.