Skip to main content
Download PDF

Systematic review of lifestyle interventions to improve weight, physical activity and diet among people with a mental health condition

Systematic Reviews volume 11, Article number: 198 (2022) Cite this article

Abstract

Background

People with a mental health condition experience an elevated risk of chronic disease and greater prevalence of health and behaviours. Lifestyle interventions aim to reduce this risk by modifying health behaviours such as physical activity and diet. Previous reviews exploring the efficacy of such interventions for this group have typically limited inclusion to individuals with severe mental illness (SMI), with a focus of impact on weight. This review assessed the efficacy of lifestyle interventions delivered in community or outpatient settings to people with any mental health condition, on weight, physical activity and diet.

Methods

Eligible studies were randomised or cluster-randomised controlled trials published between January 1999 and February 2019 aiming to improve weight, physical activity or diet, for people with any mental health condition. Two reviewers independently completed study screening, data extraction and assessment of methodological quality. Primary outcome measures were weight, physical activity and diet. Secondary outcome measures were body mass index (BMI), waist circumference, sedentary behaviour and mental health. Where possible, meta-analyses were conducted. Narrative synthesis using vote counting based on direction of effect was used where studies were not amenable to meta-analysis.

Results

Fifty-seven studies were included (49 SMI only), with 46 contributing to meta-analyses. Meta-analyses revealed significant (< 0.05) effect of interventions on mean weight loss (−1.42 kg), achieving 5% weight loss (OR 2.48), weight maintenance (−2.05 kg), physical activity (IPAQ MET minutes: 226.82) and daily vegetable serves (0.51), but not on fruit serves (0.01). Significant effects were also seen for secondary outcomes of BMI (−0.48 units) and waist circumference (−0.87cm), but not mental health (depression: SMD −0.03; anxiety: SMD −0.49; severity of psychological symptoms: SMD 0.72). Studies reporting sedentary behaviour were not able to be meta-analysed. Most trials had high risk of bias, quality of evidence for weight and physical activity were moderate, while quality of evidence for diet was low.

Conclusion

Lifestyle interventions delivered to people with a mental health condition made statistically significant improvements to weight, BMI, waist circumference, vegetable serves and physical activity. Further high-quality trials with greater consistency in measurement and reporting of outcomes are needed to better understand the impact of lifestyle interventions on physical activity, diet, sedentary behaviour and mental health and to understand impact on subgroups.

Systematic review registration

PROSPERO CRD42019137197

Peer Review reports

Introduction

It is estimated that 17% of the population will experience a mental health condition, encapsulating more commonly encountered conditions such as depression and anxiety, as well as less common potentially severe conditions such as schizophrenia and psychotic disorders [1]. People with mental health conditions experience a significant reduction in life expectancy, which has been largely attributed to elevated risk of chronic conditions such as cardiovascular disease and diabetes [2]. These conditions result from health risks such as overweight and obesity, poor nutrition and physical inactivity [3, 4], which have been reported to have a higher prevalence among this group [5,6,7,8,9,10]. There is a need for evidence of effective interventions to address these health risks for people with a mental health condition [2, 11,12,13].

Lifestyle interventions are one means of supporting changes to physical health by promoting improvements in weight, physical activity and diet. Such interventions include programmes based on a variety of approaches including provision of health education, and cognitive behavioural therapy (CBT), and may also include practical components such as participation in physical activity. Lifestyle interventions can be delivered in individual or group settings across a range of modalities including face to face, telephone or via web-based methods. Systematic review evidence has shown that among general population samples, lifestyle interventions are an effective means to achieve significant improvements in anthropometric measures including reductions in body weight, body mass index (BMI) and waist circumference [14], as well as improvements to physical activity [15] and dietary outcomes including fruit and vegetable consumption [16]. Lifestyle interventions have also been associated with reduced risk for chronic health conditions such as cardiovascular disease [17], type 2 diabetes and metabolic syndrome [18], as well as all-cause mortality [19].

For the priority population group of people with a mental health condition, systematic review evidence suggests that lifestyle interventions can lead to improvements in anthropometric measures. For example, meta-analyses have indicated that lifestyle interventions for people with severe mental illness (SMI) resulted in significant reductions of up to 2 kg in weight [20,21,22,23], 1.2 BMI units [20, 24,25,26] and 2.5 cm in waist circumference [23, 25] when compared to control conditions. A systematic review using narrative synthesis to assess the impact of lifestyle interventions on physical activity among people with SMI in both controlled and uncontrolled trials found low-quality evidence for both types of trials [27]. Of 16 controlled trials, seven reported significant improvements in physical activity comparative to controls, while 3 of 16 uncontrolled trials reported improvement. However, no systematic reviews could be located that use meta-analyses to synthesise the impact of lifestyle interventions on physical activity among people with a mental health condition. Similarly, no reviews with or without meta-analysis could be located examining the efficacy of lifestyle intervention on improvements in diet among people with a mental health condition. Additionally, previous reviews are limited by typically including only individuals with SMI (for example schizophrenia), who make up a small proportion of the population with mental health conditions [28, 29]. Some reviews include studies across both inpatient and community settings [20, 21, 23, 25], with the possibility of differences in wellness, or participant autonomy with respect to diet or physical activity, potentially impacting results.

To address these gaps in the literature, the aim of the current systematic review was therefore to evaluate the effectiveness of lifestyle interventions delivered in a community or outpatient settings to people with any mental health condition, on weight, physical activity and diet. The review also included secondary outcomes of the impact of interventions on BMI, waist circumference, sedentary behaviour and mental health.

Methods

Search methods

A systematic review was reported following the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) statement [30] and prospectively registered with PROSPERO (CRD42019137197). Seven electronic databases were searched from January 1999 to February 2019: PsycINFO, MEDLINE, Excerpta Medica database (EMBASE), Psychology and Behavioural Sciences Collection, Scopus, Cochrane Central Register of Controlled Trials (CENTRAL) and Cumulative Index to Nursing and Allied Health Literature (CINAHL) (Supplementary Table 1. Example search strategy for PsycINFO). This time frame was chosen in order to collect the most recent 20 years of studies prior to being impacted by COVID-19. The search included terms relating to mental health conditions, the three primary outcome measures (weight, physical activity and diet), study designs and intervention types. Authors of included protocol papers or registrations were contacted for any publication of outcomes, and reference lists of included studies and related systematic reviews were hand-searched for potentially eligible studies.

Study inclusion criteria

Study design

Randomised and cluster-randomised controlled trials were eligible for inclusion. Control groups included treatment as usual, brief advice or minimal intervention. Studies with multiple intervention arms were included.

Participants

Eligible studies included people with a mental health condition (with the exception of eating-related disorders or neurodegenerative disorders) at the time of recruitment into the trial, indicated via clinician or client reported diagnosis or inferred through current treatment for a mental health condition. Studies in which the mean age of participants was less than 18 years, or in which results were not reported separately for participants over 18 years, were excluded.

Interventions

Interventions which promoted and/or supported weight loss/management and/or changes in physical activity and/or diet for individuals, were delivered by any mode (face to face, telephone, digital), delivered to groups or individuals and based on any framework or approach (e.g. education, skills training, CBT, facilitation of behaviours), were included. Interventions which included any pharmacological component other than those for the management of an existing mental health condition (e.g. interventions trialling weight loss drugs) were excluded.

Setting

Studies were included if interventions were delivered in community-based settings, such as outpatient services, community managed organisations, shared housing, online or other areas in the general public. Interventions delivered in inpatient settings were excluded.

Study outcome measures

Studies were included if they quantitatively assessed at least one of the primary review outcomes: weight, physical activity or diet. Eligible weight measures included weight (kilograms (kg) or pounds (lb)) and assessed via self-report or objective measurement. Studies measuring changes in weight were separated by intervention aim as follows: (1) to reduce the weight of participants in the intervention group (weight loss) or (2) to minimise potential weight gain, for example amongst individuals taking antipsychotic medication known to result in weight gain (weight maintenance). Eligible physical activity measurements included self-report or objective measurement tools (e.g. accelerometer), expressed as any unit of measurement (e.g. number of sessions, number of minutes, number of steps per day/week) and any intensity (e.g. light, moderate, vigorous). Eligible diet measures included an individual’s consumption of any food or beverages over any period of time (mean serves, number of times consumed per day/week, meeting recommendations for food groups) and assessed via tools such as food frequency questionnaires, diaries, records or surveys.

Secondary review outcomes were as follows: body mass index (BMI) [31] based on objective or reported height and weight measures; waist circumference, measured in centimetres or inches based on objective measurement or self-report; sedentary behaviour, as indicated by any measurement of time (e.g. minutes per day, sessions per day, total per week, sitting time); and mental health (any validated measure of mental health).

Study selection process

Two reviewers independently assessed titles and abstracts of identified studies for eligibility based on predetermined inclusion/exclusion criteria. The full texts of studies that met inclusion criteria were then independently assessed by two reviewers for final inclusion. Consensus was first attempted to resolve any disagreement between the two reviewers regarding study eligibility or, if required, resolved via a third reviewer. Where necessary, corresponding authors were contacted for further details to determine study eligibility.

Data extraction

Data was extracted for all measures of each review outcome. Two reviewers independently extracted data for each included study using a standardised Word document form, modelled from the Cochrane data extraction template [32]. Disagreements regarding data extraction were resolved through consensus between the two reviewers. Where possible, outcome data were entered into RevMan software to complete meta-analyses [33]. Where outcome data were reported in a format amenable to meta-analysis but necessary data were missing, corresponding authors were contacted for further details.

The following information was extracted:

  • Author and year of publication, country, study design, number of trial arms, sample size and percentage female, mean age and mental health condition

  • Characteristics of the intervention including the following: health behaviours promoted, intervention and comparison group conditions, duration and method of delivery (e.g. face to face, telephone, multiple)

  • All data pertaining to primary and secondary outcomes including data measurement tools, effect summary statistics and measures of outcome variability

Data analysis and synthesis

Meta-analysis

Studies were first examined for outcomes reported in a manner suitable for inclusion in meta-analyses. Random effect meta-analyses were conducted where at least three studies measured an outcome using the same or comparable measures or format. Intervention effect sizes and 95% confidence intervals were calculated. If a study had multiple measures for the same review outcome, one data source was selected according to the following hierarchy: (1) a score for a full tool (e.g. global score) was used rather than subscale; (2) where two tools measured the same outcome, the tool with greater validity was used; (3) where outcome measures were identified as primary or secondary by the study authors, the primary outcome was chosen; and (4) where no outcome was explicitly identified as primary, the measure consistently described first in the measures and/or results tables was used.

Random effects meta-analysis models were used with the RevMan 5 software [33] to calculate study effect size for mean difference, odds ratios and standardised mean differences. Where a study had multiple trial arms, the most comprehensive intervention (e.g. with greatest frequency of contact) was compared to the control condition. Where a study provided data for more than one follow-up point, the time point closest to the end of the intervention was used. When studies did not provide mean differences and their standard deviations for intervention and control groups, a range of approaches were used to derive the required information from what study authors provided [34]. One set of approaches involved imputing the size of the correlation coefficient between pre and post scores for the calculation of the standard deviation of the mean difference. For meta-analyses in which the conservative estimate of 0 for the correlation coefficient was not used (weight, waist circumference, BMI), a sensitivity analysis was carried out to determine the effect of the choice of correlation coefficient on the overall meta-analysis study effect size. See Supplementary Table 2 for details on approaches employed during meta-analyses and the sensitivity analyses.

Due to an insufficient number of studies [35] or insufficient detail of intervention approach, subgroup analyses based on mental health condition, delivery method and health behaviours targeted by the intervention specified a priori were not undertaken (PROSPERO ID: CRD42019137197).

Narrative synthesis

A narrative synthesis using vote counting for direction of effect was used to summarise evidence of effect and supplement the meta-analytic findings [34] where studies are as follows:

  1. 1.

    Presented an outcome in a format that was not conducive to meta-analysis (e.g. in a manner not comparable to other studies or insufficient studies measuring in the same format to form a meta-analysis)

  2. 2.

    Insufficient data was able to be received from authors for inclusion in a meta-analyses.

If a study presented data in multiple formats corresponding with more than one ‘measure’ under the one review outcome (e.g. weight change in kg, proportion of sample achieving 5% weight loss), data from the study could be included in a meta-analysis for one measure and in narrative synthesis for the other measure.

Assessment of risk of bias and quality of cumulative evidence

Risk of bias for each included study was assessed independently by two reviewers against the revised Cochrane risk-of-bias tool [36]. Study characteristics including selection bias (sequence generation and allocation concealment), performance bias (blinding of participants and personnel), detection bias (blinding of outcome assessment), attrition bias (no incomplete outcome data), reporting bias (no selective reporting) and other potential sources of bias were assessed [34]. Risk of bias for cluster-randomised trials was assessed against additional criteria, including recruitment to cluster, baseline imbalance, loss of clusters and incorrect analysis [34]. Grading of Recommendations Assessment, Development and Evaluation (GRADE) approach was used to assess confidence in cumulative evidence for each primary review outcome [37,38,39].

Results

Study selection

A total of 14,293 studies were collected via search strategies. Following the removal of duplicates, the search identified 9012 records, with 8739 studies excluded at title and abstract screening and a further 216 excluded during full-text review (Fig. 1). A total of 57 studies (52 randomised controlled trials and 5 cluster-randomised controlled trials) were included in the review.

Fig. 1
figure 1

Selection of studies. NB, studies may contribute to both quantitative and narrative synthesis for different variables

Full size image

Characteristics of included studies

Included studies were published between January 2003 and February 2019 and conducted across 13 countries, with the largest number conducted in USA (n = 23), followed by UK (n = 11) (Table 1). Studies included participants with a range of mental health conditions, with the most commonly reported conditions being schizophrenia and schizoaffective disorder and depression. Due to variability in the inclusion criteria of diagnoses considered be SMI, a broad classification was used guided by classifications used by previous systematic reviews [20, 25]. In addition, any study which identified that it considered its participants to have an SMI, or that included only participants who were taking antipsychotic medication, were classified as SMI studies. Of the 57 included studies, 49 included only participants considered to have an SMI, 6 included only participants considered to not have an SMI, and 2 included participants both with and without an SMI in their sample. Intervention duration ranged from 1 week to 12 months, with the most common duration (n = 18) being 12 weeks and 48 having intervention of 12 weeks or longer. The majority of interventions were delivered in face-to-face format (n = 44), followed by mixed mode of face to face and phone (n = 9), web/computer (n = 3) and phone only (n = 1). A total of 37 studies had interventions that promoted healthy weight, 34 promoted physical activity, 14 promoted diet and 23 promoted more than one of these. Sixteen interventions also promoted additional health issues not captured in this review, including smoking (n = 7) and alcohol consumption (n = 4). A total of 36 studies reported changes in weight, with 31 measured as weight loss and 5 measured as weight maintenance (minimisation of weight gain while taking antipsychotic medication). Physical activity was measured in 35 studies and diet in 14. BMI was measured in 34 studies and waist circumference in 23. Sedentary behaviour was measured in three studies and mental health outcomes in 24.

Table 1 Characteristics of included studies
Full size table

Primary outcomes

Table 2 provides a summary of findings for meta-analyses and narrative syntheses. Forest plots for each meta-analysis can be found in supplementary Figs. 1–11. A detailed description of findings for narrative syntheses can be found in Supplementary Table 3.

Table 2 Summary of findings from meta-analyses and narrative syntheses
Full size table

Weight

Weight loss

Of the 31 studies that measured weight loss, 26 were included in meta-analysis (23 SMI only; 2 non-SMI; 1 mixed). Meta-analysis of data indicated a positive effect of interventions to reduce weight, with an average weight loss relative to control condition across studies of −1.42 kg (95% CI [−2.21 to −0.63]). Five studies measured proportions of participants who achieved at least 5% weight loss (all SMI only), with an odds ratio of 2.48 (1.74 to 3.55) when compared to control conditions. Of the nine studies that measured weight loss included within a narrative synthesis, 8 indicated a direction in favour of the intervention and 1 in neither direction.

Weight maintenance

Of the 5 studies that measured weight maintenance, 4 were included in the meta-analysis (all SMI only). Across these studies, intervention participants’ weight increased by 2.05 kg less (95% CI [−3.40 to −0.70]) than participants in control conditions. One study was synthesised narratively and indicated a direction in favour of the intervention.

Physical activity

Of the 36 studies measuring changes in physical activity levels, 11 studies that used the same tool (IPAQ total MET minutes/week) were included in a meta-analysis (10 SMI only; 1 non-SMI). Meta-analysis indicated interventions had a positive effect, an increase of 226.82 (95% CI [22.03 to 431.61]) metabolic minutes per week at the end of intervention when compared to control groups. Of the 25 studies in the narrative synthesis that examined physical activity using other outcome measures, 18 studies indicated a direction in favour of the intervention, 5 in favour of control and 2 in neither direction.

Diet

Of the 14 studies measuring changes in diet, 3 were included in a meta-analysis for the measure of fruit serves (all SMI only). This analysis did not indicate evidence of an effect, with intervention participants increasing consumption by 0.01 (95% CI [−0.29 to 0.31]) serves per day compared to control conditions. Three studies were included in a meta-analysis for the measure of vegetable serves (all SMI only), which found interventions had a positive effect, with intervention participants increasing consumption by 0.51 (95% CI [0.11 to 0.92]) serves per day compared to control conditions. Of the 13 studies synthesised narratively across other diet measures, 11 studies indicated a direction in favour of the intervention and 1 in favour of control and 1 in neither direction.

Secondary outcomes

BMI

Of the 34 studies that measured change in BMI, 33 were included in meta-analysis (30 SMI only; 2 non-SMI; 1 mixed). Meta-analysis of data indicated a positive effect of interventions to reduce BMI, with average BMI reduction across studies −0.48 units (95% CI [−0.70 to −0.26]) when compared to control conditions. One study was synthesised narratively and indicated a direction in favour of the intervention.

Waist circumference

Of the 23 studies that measured change in waist circumference, 19 were included in a meta-analysis (all SMI only). Meta-analysis indicated a positive effect of interventions, with average waist circumference reduction across studies −0.87cms (95% CI [−1.60 to −0.14]) when compared to control conditions. Of the 4 studies synthesised narratively, 2 studies indicated a direction in favour of the intervention and 2 in neither direction.

Sedentary behaviour

The 3 studies that measured change in sedentary behaviour were not amenable to meta-analysis, and all were included as narrative synthesis. Two studies indicated a direction in favour of the control group and 1 in neither direction for the sedentary behaviour outcomes examined.

Mental health

Standardised mean differences (SMDs) were used to pool data across studies using different measurement tools for mental health outcomes (supplementary Table 4). Of the 25 studies measuring changes in mental health, 14 were included in meta-analysis for the outcomes of depression, anxiety and/or severity of psychological symptoms, and 18 were included in the narrative syntheses for other mental health measures.

Depression

Twelve studies measuring depression (using 6 comparable depression scales/tools) were included in meta-analysis (8 SMI only; 4 non-SMI). The analysis did not indicate evidence of an effect. The pooled effect of interventions on depression as a standardised mean difference (SMD) was −0.03 (95% CI −0.14 to 0.08) when compared to control conditions. Two studies were synthesised narratively, and both indicated a direction in favour of the intervention.

Anxiety

Five studies measuring anxiety (using 3 comparable anxiety scales/tools) were included in meta-analysis (3 SMI only; 2 non-SMI). The analysis did not indicate evidence of an effect. The pooled effect of interventions on anxiety as a standardised mean difference (SMD) was −0.49 (95% CI −1.15 to 0.16) when compared to control conditions. Two studies were synthesised narratively, and both indicated a direction in favour of the intervention.

Severity of psychological symptoms

Four studies measuring severity of psychological symptoms (using 2 comparable scales/tools) were included in meta-analysis (3 SMI only; 1 non-SMI). The analysis did not indicate evidence of an effect. The pooled effect of interventions on severity of psychological symptoms as a standardised mean difference (SMD) was 0.72 (95% CI −0.05 to 1.50) when compared to control conditions.

Other mental health measures/variables

Of the remaining 14 studies synthesised narratively, 9 indicated a direction in favour of the intervention and 5 in favour of control for the mental health outcomes examined.

Assessment of methodological quality

Risk of bias in included studies and quality of evidence

Assessment of risk of bias is shown in Fig. 2. Of the 52 individually randomised controlled studies, 32 (62%) were rated as high risk for bias overall, while 3 of 5 cluster-randomised studies were rated as high overall. The quality of evidence (GRADE) for weight outcomes was downgraded to “moderate” due to considerable statistical heterogeneity, the quality of evidence for physical activity was downgraded to “moderate” due to lack of blinding of participants, and the quality of evidence for diet was downgraded to “low” due to lack of blinding of participants and imprecise results.

Fig. 2
figure 2

Risk of bias in included studies

Full size image

Discussion

This is the first review to synthesise evidence from randomised controlled trials on the effectiveness of lifestyle interventions delivered in a community or outpatient setting for people with a mental health condition to improve weight, physical activity and/or diet. The review represents a thorough consideration of evidence across a comprehensive range of anthropometric, physical activity and diet-related outcomes. Meta-analyses revealed statistically significant improvements in primary outcomes of weight; physical activity, as measured by IPAQ MET minutes; and diet, in the form of increased vegetable consumption but no significant improvement for fruit consumption. Narrative synthesis through vote counting for studies not included in meta-analyses for the primary outcomes indicated a greater number of studies reporting improvements in the intervention group than for the control group or neither group. For secondary review outcomes, meta-analyses indicated statistically significant improvements in BMI and waist circumference, but not for anxiety, depression or severity of psychological symptoms. Narrative synthesis for sedentary behaviour did not support an effect. The majority of studies included only participants with SMI. Risk-of-bias assessment found the majority of studies were high risk or had some concerns overall, with bias most commonly pertaining to missing outcome data and deviations from interventions. Quality of evidence for weight and physical activity was moderate, while quality of evidence for diet was low

Anthropometric findings from the current review show some consistency with meta-analysis findings from previous systematic reviews of lifestyle interventions in mental health samples with SMI, concluding modest but significant effects on weight [20,21,22,23], BMI [20, 24,25,26] and waist circumference [23, 25]. In general, the magnitude of changes in the anthropometric variables was smaller in the current review than in other recent reviews focussing on people with mental health conditions. For example, the mean weight loss of 1.42 kg found in the present review is slightly less than the 2.01 kg mean loss reported in a recent review in which weight outcomes were reported in a similar manner [20]. Our review inclusion criteria, which encompassed a broader range of mental health conditions beyond those considered to be SMI, contributed very few studies to the meta-analyses of anthropometric outcomes — the results largely represent those contributed by studies of SMI participants. It is important to acknowledge that additional difficulties in achieving changes to anthropometric measures may be experienced by people with a mental health condition who are taking psychoactive medications, which often have weight gain as a side effect [117, 118]. Our meta-analysis based on studies that included only those on such medications, with a focus on weight maintenance, showed that intervention participants increased by 2.05 kg less than participants in control conditions suggesting interventions can be of value for these groups. Future research should consider whether lifestyle interventions are equally as effective for those taking such medications compared to those not and, if not, how the impact of such medications may best be minimised to reduce the impact on physical health [2].

This is the first review incorporating meta-analysis to examine the effects of lifestyle interventions for people with a mental health condition on physical activity. While a majority of included studies (n = 34) reported on a physical activity outcome variable, the diversity in measurement tools used, including several instances of a tool being used in only one study, meant that more than half of these were not included in meta-analyses, and only one of the included studies was not only participants with SMI [119, 120]. Based on studies using IPAQ MET minutes, findings suggest that lifestyle interventions lead to significant improvements in number of MET minutes achieved per week among intervention participants, with average increase in physical activity of 266 MET minutes aligning with more than half the recommended MET minutes per week for physical activity [121]. The narrative vote counting based on direction of effect of studies measuring physical activity in other formats also supports the finding of a positive effect. The current review reports limited evidence on sedentary behaviour with no evidence of intervention effect for this outcome. Our review adds to the evidence base on the impact of lifestyle interventions on physical activity and sedentary behaviour for those with a mental health condition, previously summarised in a narrative review of studies involving those with SMI, which concluded there was inconsistent evidence to show interventions can be effective in changing these outcomes for this group, and noted the lack of studies focussed on sedentary behaviour [27].

This is the first review to synthesise evidence for the impact of lifestyle interventions for people with a mental health condition on diet. Fourteen studies assessed improvements in diet, with the most commonly measured dietary outcomes relating to fruit and vegetable intake. Three studies contributed to meta-analyses for both fruit serves (showing no effect) and vegetable serves (showing a small effect of about half a serve daily). Of the remaining studies which contributed to narrative synthesis, the majority incorporated other validated measures of dietary variables. The seven studies that reported other fruit and/or vegetable variables, and the six studies reporting other dietary variables (e.g. adherence to a Mediterranean diet), indicated a direction of effect favourable to the intervention groups. Variability in measurement of dietary variables may be partly attributable to differences in what the lifestyle programmes were aiming to achieve and perhaps to global diversity in diets. Consistent measurement of variables including fruit and vegetable intake would assist in future syntheses. Trials amongst the general population suggest combined fruit and vegetable intake may be increased by up to 1.18 serves following the receipt of dietary advice, a larger effect than suggested in the current review [16]. Such findings and the small number of studies in our review suitable for meta-analysis highlight the need for further studies assessing the potential for lifestyle interventions to facilitate improvements in diet amongst people with a mental health condition.

Results regarding the effect of lifestyle interventions on measures of mental health were mixed. Meta-analysis for specific mental health outcome variables was possible only for anxiety and depression. No significant effects were found for either depression or anxiety nor for severity of psychological symptoms. Narrative synthesis across a range of other mental health measures indicated variable findings. It is possible that the inclusion of participants with more SMI (such as schizophrenia) in a majority of studies, for whom change in the lifestyle factors examined may be especially challenging, could have contributed to the variability in findings.

As noted above, it is important to acknowledge that the majority of studies in this review included only participants considered to have an SMI. While this review was designed to be inclusive of all mental health conditions and highlight the current research landscape of lifestyle interventions for this population, the findings cannot be considered reflective of all mental health conditions due to the limited number of trials in non-SMI groups. Given that SMI makes up a small proportion of people with mental health conditions, it is recommended that additional research into lifestyle interventions for people with mental health conditions other than SMI is conducted. The clinical significance of changes achieved through lifestyle interventions varies by outcome measure. It has been suggested that the scale of changes in outcomes such as weight and BMI found in the current review and previous reviews may be of questionable clinical significance [20, 26]. While many studies reported weight loss or reduction in BMI, few studies reported the proportion of participants achieving 5% weight loss, an amount deemed clinically significant for reducing health risks [122], which did show significant effect in the current review. While it has been suggested that even small improvements to physical activity are associated with a reduction in health risk in the general population [123], the increase in fruit and vegetable consumption required to lead to meaningful change is unknown. Further research providing a benchmark for clinically significant change across health measures in this population would be helpful in the evaluation of future interventions.

Other limitations to the evidence base and review findings should also be noted. Planned subgroup analyses, by intervention delivery mode, intervention topic focus and participant mental health condition or groupings of condition (e.g. SMI vs other), were not able to be conducted due to insufficient studies or insufficient study detail required for grouping. Few studies explored interventions delivered via modalities other than face to face such as online, or via telephone, which some research has reported as being feasible within this population [91, 124, 125]. Across all outcome measures, there was a high risk of bias across the majority of included studies. Heterogeneity within meta-analyses for all continuous anthropometric outcomes was high. Analyses do not account for variability in intervention length, which ranged from 1 week to 12 months; however, 48 of the 57 interventions included in this review were of at least 12-week duration. The present analyses do not allow examination of maintenance effects. Analyses are based on immediate post-intervention outcomes to maximise the chance of capturing intervention effects and as many studies reported only baseline and immediate end of intervention outcome measures.

Conclusion

This review synthesised evidence from randomised controlled trials on efficacy of lifestyle interventions in improving several health measures and behaviours among people with a mental health condition. Findings based on moderate or low-quality evidence suggest that such interventions are effective in creating statistically significant but small positive changes to weight, BMI, waist circumference, physical activity and vegetable consumption, but not fruit consumption. Variability in measurement tools or insufficient reported data impacted capacity to meta-analyse some outcomes. Vote counting indicated a direction of effect in favour of intervention groups for studies assessing physical activity and diet that were not included in meta- analyses but did not support an effect for sedentary behaviour or mental health measures. The findings support the value of lifestyle interventions to improve health risks in people with a mental health condition but point to the need for further high-quality trials and a consideration of the clinical significance of findings. Improving consistency in data collection and reporting across intervention trials may contribute to higher quality evidence and assist in determining factors that contribute to intervention effectiveness. Furthermore, while the current review extends on previous research by including client samples beyond SMI, this extension did not contribute a large number of studies. Research which allows for examination of the efficacy of lifestyle interventions for specific mental health conditions would advance the field.

Availability of data and materials

All data generated or analysed during this study are included in this published article.

References

  1. Steel Z, Marnane C, Iranpour C, et al. The global prevalence of common mental disorders: a systematic review and meta-analysis 1980–2013. Int J Epidemiol. 2014;43(2):476–93.

    Article  PubMed  PubMed Central  Google Scholar 

  2. Firth J, Siddiqi N, Koyanagi A, et al. The lancet psychiatry commission: a blueprint for protecting physical health in people with mental illness. Lancet Psychiatry. 2019;6(8):675–712.

    Article  PubMed  Google Scholar 

  3. Stanley S, Laugharne J. The impact of lifestyle factors on the physical health of people with a mental illness: a brief review. Int J Behavior Med. 2014;21(2):275–81.

    Article  Google Scholar 

  4. Scott D, Happell B. The high prevalence of poor physical health and unhealthy lifestyle behaviours in individuals with severe mental illness. Issues Ment Health Nurs. 2011;32(9):589–97.

    Article  PubMed  Google Scholar 

  5. Win S, Parakh K, Eze-Nliam CM, Gottdiener JS, Kop WJ, Ziegelstein RC. Depressive symptoms, physical inactivity and risk of cardiovascular mortality in older adults: the cardiovascular health study. Heart. 2011;97(6):500–5.

    Article  PubMed  Google Scholar 

  6. Kamphuis MH, Geerlings MI, Tijhuis MA, et al. Physical inactivity, depression, and risk of cardiovascular mortality. Med Sci Sports Exerc. 2007;39(10):1693–9.

    Article  PubMed  Google Scholar 

  7. Bonnet F, Irving K, Terra J-L, Nony P, Berthezène F, Moulin P. Anxiety and depression are associated with unhealthy lifestyle in patients at risk of cardiovascular disease. Atherosclerosis. 2005;178(2):339–44.

    Article  CAS  PubMed  Google Scholar 

  8. Avila C, Holloway AC, Hahn MK, et al. An overview of links between obesity and mental health. Curr Obes Rep. 2015;4(3):303–10.

    Article  PubMed  Google Scholar 

  9. Rajan T, Menon V. Psychiatric disorders and obesity: a review of association studies. J Postgrad Med. 2017;63(3):182.

    Article  CAS  PubMed  PubMed Central  Google Scholar 

  10. Roick C, Fritz-Wieacker A, Matschinger H, et al. Health habits of patients with schizophrenia. Soc Psychiatry Psychiatr Epidemiol. 2007;42(4):268–76.

    Article  PubMed  Google Scholar 

  11. National Mental Health Commision. Equally well consensus statement: improving the physical health and wellbeing of people living with mental illness in Australia. Sydney: NMHC; 2016.

    Google Scholar 

  12. Department of Health. The fifth National Mental Health and suicide prevention plan: Commonwealth of Australia Canberra, ACT; 2017. https://www.mentalhealthcommission.gov.au/getmedia/0209d27b-1873-4245-b6e5-49e770084b81/Fifth-National-Mental-Health-and-Suicide-Prevention-Plan.pdf.

  13. World Health Organization. Management of physical health conditions in adults with severe mental disorders: WHO guidelines; 2018.

    Google Scholar 

  14. Galani C, Schneider H. Prevention and treatment of obesity with lifestyle interventions: review and meta-analysis. Int J Public Health. 2007;52(6):348–59.

    Article  PubMed  Google Scholar 

  15. Foster C, Hillsdon M, Thorogood M, Kaur A, Wedatilake T. Interventions for promoting physical activity. Cochrane Database Syst Rev. 2005;(1). https://doi.org/10.1002/14651858.CD003180.pub2.

  16. Rees K, Dyakova M, Ward K, Thorogood M, Brunner E. Dietary advice for reducing cardiovascular risk. Cochrane Database Syst Rev. 2013;(3). https://doi.org/10.1002/14651858.CD002128.pub5.

  17. Ma C, Avenell A, Bolland M, et al. Effects of weight loss interventions for adults who are obese on mortality, cardiovascular disease, and cancer: systematic review and meta-analysis. BMJ. 2017;359:j4849.

    Article  PubMed  PubMed Central  Google Scholar 

  18. Brown T, Avenell A, Edmunds LD, et al. Systematic review of long-term lifestyle interventions to prevent weight gain and morbidity in adults. Obes Rev. 2009;10(6):627–38.

    Article  CAS  PubMed  Google Scholar 

  19. Kritchevsky SB, Beavers KM, Miller ME, et al. Intentional weight loss and all-cause mortality: a meta-analysis of randomized clinical trials. PLoS One. 2015;10(3). https://doi.org/10.1371/journal.pone.0121993.

  20. Olker SJ, Parrott JS, Swarbrick MA, Spagnolo AB. Weight management interventions in adults with a serious mental illness: a meta-analytic review. Am J Psychiatr Rehabil. 2016;19(4):370–93.

    Article  Google Scholar 

  21. Naslund JA, Whiteman KL, McHugo GJ, Aschbrenner KA, Marsch LA, Bartels SJ. Lifestyle interventions for weight loss among overweight and obese adults with serious mental illness: a systematic review and meta-analysis. Gen Hosp Psychiatry. 2017;47:83–102.

    Article  PubMed  PubMed Central  Google Scholar 

  22. Brown C, Geiszler LC, Lewis KJ, Arbesman M. Effectiveness of interventions for weight loss for people with serious mental illness: a systematic review and meta-analysis. Am J Occup Ther. 2018;72(5):7205190030p1–9.

    Article  PubMed  Google Scholar 

  23. Singh VK, Karmani S, Malo PK, et al. Impact of lifestyle modification on some components of metabolic syndrome in persons with severe mental disorders: a meta-analysis. Schizophr Res. 2018;202:17–25.

    Article  PubMed  Google Scholar 

  24. Bonfioli E, Berti L, Goss C, Muraro F, Burti L. Health promotion lifestyle interventions for weight management in psychosis: a systematic review and meta-analysis of randomised controlled trials. BMC Psych. 2012;12(1):78.

    Article  Google Scholar 

  25. Fernández-San-Martín MI, Martín-López LM, Masa-Font R, et al. The effectiveness of lifestyle interventions to reduce cardiovascular risk in patients with severe mental disorders: meta-analysis of intervention studies. Community Ment Health J. 2014;50(1):81–95.

    Article  PubMed  Google Scholar 

  26. Speyer H, Jakobsen AS, Westergaard C, et al. Lifestyle interventions for weight management in people with serious mental illness: a systematic review with meta-analysis, trial sequential analysis, and meta-regression analysis exploring the mediators and moderators of treatment effects. Psychother Psychosom. 2019;88(6):350–62.

    Article  PubMed  Google Scholar 

  27. Ashdown-Franks G, Williams J, Vancampfort D, et al. Is it possible for people with severe mental illness to sit less and move more? A systematic review of interventions to increase physical activity or reduce sedentary behaviour. Schizophr Res. 2018;202:3–16.

    Article  PubMed  Google Scholar 

  28. Australian Institute of Health and Welfare. Australia’s health 2014, cat. No. AUS 178. Canberra: AIHW; 2014.

    Google Scholar 

  29. Substance Abuse and Mental Health Services Administration. Key substance use and mental health indicators in the United States: results from the 2019 National Survey on drug use and health (HHS publication no. PEP20-07-01-001, NSDUH series H-55). Rockville: Center for Behavioral Health Statistics and Quality, Substance Abuse and Mental Health Services Administration; 2020.

    Google Scholar 

  30. Moher D, Liberati A, Tetzlaff J, Altman DG, Group P. Preferred reporting items for systematic reviews and meta-analyses: the PRISMA statement. PLoS Med. 2009;6(7):e1000097.

    Article  PubMed  PubMed Central  Google Scholar 

  31. World Health Organization. Obesity: preventing and managing the global epidemic (2000). Report of a WHO consultation. WHO technical report series 894. Geneva; 2000.

  32. Cochrane Effective Practice and Organisation of Care (EPOC). Data collection form. EPOC Resources for review authors ecore-s-r-r-aa; 2013.

  33. Review Manager (RevMan) [Computer program]. Version 5.3. Copenhagen: the Nordic Cochrane Centre, The Cochrane Collaboration, 2014.

  34. Higgins JP, Thomas J, Chandler J, et al. Cochrane handbook for systematic reviews of interventions: Wiley; 2019. https://training.cochrane.org/handbook.

  35. Ryan R; Cochrane Consumers and Communication Review Group. ‘Cochrane Consumers and Communication Group: meta-analysis. http://cccrg.cochrane.org, December 2016 (Accessed 12.07.2021).

  36. Sterne JA, Savović J, Page MJ, et al. RoB 2: a revised tool for assessing risk of bias in randomised trials. BMJ. 2019;366. https://doi.org/10.1136/bmj.l4898.

  37. Guyatt GH, Oxman AD, Kunz R, Vist GE, Falck-Ytter Y, Schünemann HJ. What is “quality of evidence” and why is it important to clinicians? Bmj. 2008;336(7651):995–8.

    Article  PubMed  PubMed Central  Google Scholar 

  38. Guyatt GH, Oxman AD, Vist GE, et al. GRADE: an emerging consensus on rating quality of evidence and strength of recommendations. Bmj. 2008;336(7650):924–6.

    Article  PubMed  PubMed Central  Google Scholar 

  39. Group GW. Grading quality of evidence and strength of recommendations. Bmj. 2004;328(7454):1490.

    Article  Google Scholar 

  40. Abrantes AM, McLaughlin N, Greenberg BD, et al. Design and rationale for a randomized controlled trial testing the efficacy of aerobic exercise for patients with obsessive-compulsive disorder. Ment Health Phys Act. 2012;5(2):155–65.

    Article  PubMed  PubMed Central  Google Scholar 

  41. Abrantes AM, Brown RA, Strong DR, et al. A pilot randomized controlled trial of aerobic exercise as an adjunct to OCD treatment. Gen Hosp Psychiatry. 2017;49:51–5.

    Article  PubMed  PubMed Central  Google Scholar 

  42. Álvarez-Jiménez M, González-Blanch C, Vázquez-Barquero JL, et al. Attenuation of antipsychotic-induced weight gain with early behavioral intervention in drug-naive first-episode psychosis patients: a randomized controlled trial. J Clin Psych. 2006;67(8):1253–60.

    Article  Google Scholar 

  43. Attux C, Martini LC, Elkis H, et al. A 6-month randomized controlled trial to test the efficacy of a lifestyle intervention for weight gain management in schizophrenia. BMC Psych. 2013;13(1):60.

    Article  Google Scholar 

  44. Baker AL, Richmond R, Kay-Lambkin FJ, et al. Randomised controlled trial of a healthy lifestyle intervention among smokers with psychotic disorders: outcomes to 36 months. Australian New Zealand J Psych. 2018;52(3):239–52.

    Article  Google Scholar 

  45. Baker AL, Richmond R, Kay-Lambkin FJ, et al. Randomized controlled trial of a healthy lifestyle intervention among smokers with psychotic disorders. Nicotine Tob Res. 2015;17(8):946–54.

    Article  PubMed  Google Scholar 

  46. Baker A, Kay-Lambkin FJ, Richmond R, et al. Study protocol: a randomised controlled trial investigating the effect of a healthy lifestyle intervention for people with severe mental disorders. BMC Public Health. 2011;11(1):10.

    Article  PubMed  PubMed Central  Google Scholar 

  47. Bartels SJ, Pratt SI, Aschbrenner KA, et al. Clinically significant improved fitness and weight loss among overweight persons with serious mental illness. Psychiatr Serv. 2013;64(8):729–36.

    Article  PubMed  PubMed Central  Google Scholar 

  48. Bartels SJ, Pratt SI, Aschbrenner KA, et al. Pragmatic replication trial of health promotion coaching for obesity in serious mental illness and maintenance of outcomes. Am J Psychiatr. 2015;172(4):344–52.

    Article  PubMed  Google Scholar 

  49. Battaglia G, Alesi M, Inguglia M, et al. Soccer practice as an add-on treatment in the management of individuals with a diagnosis of schizophrenia. Neuropsychiatr Dis Treat. 2013;9:595.

    Article  PubMed  PubMed Central  Google Scholar 

  50. Beebe LH, Tian L, Morris N, Goodwin A, Allen SS, Kuldau J. Effects of exercise on mental and physical health parameters of persons with schizophrenia. Issues Ment Health Nurs. 2005;26(6):661–76.

    Article  PubMed  Google Scholar 

  51. Bersani FS, Biondi M, Coviello M, et al. Psychoeducational intervention focused on healthy living improves psychopathological severity and lifestyle quality in psychiatric patients: preliminary findings from a controlled study. J Ment Health. 2017;26(3):271–5.

    Article  PubMed  Google Scholar 

  52. Bonfioli E, Mazzi MA, Berti L, Burti L. Physical health promotion in patients with functional psychoses receiving community psychiatric services: results of the PHYSICO-DSM-VR study. Schizophr Res. 2018;193:406–11.

    Article  PubMed  Google Scholar 

  53. Brown S, Chan K. A randomized controlled trial of a brief health promotion intervention in a population with serious mental illness. J Ment Health. 2006;15(5):543–9.

    Article  Google Scholar 

  54. Brown S, Smith E. Can a brief health promotion intervention delivered by mental health key workers improve clients' physical health: a randomized controlled trial. J Ment Health. 2009;18(5):372–8.

    Article  Google Scholar 

  55. Brown C, Goetz J, Hamera E. Weight loss intervention for people with serious mental illness: a randomized controlled trial of the RENEW program. Psychiatr Serv. 2011;62(7):800–2.

    Article  PubMed  PubMed Central  Google Scholar 

  56. Haase AM, Taylor AH, Fox KR, Thorp H, Lewis G. Rationale and development of the physical activity counselling intervention for a pragmatic TRial of exercise and depression in the UK (TREAD-UK). Ment Health Phys Act. 2010;3(2):85–91.

    Article  Google Scholar 

  57. Chalder M, Wiles NJ, Campbell J, et al. Facilitated physical activity as a treatment for depressed adults: randomised controlled trial. Bmj. 2012;344. https://doi.org/10.1136/bmj.e2758.

  58. Chao PJ. A group randomized trial to examine the feasibility and effects of pedometer use and self-monitoring of daily walking in people with severe and persistent mental illnesses. Honolulu: University of Hawaii at Manoa; 2010.

    Google Scholar 

  59. Daley AJ, Winter H, Grimmett C, McGuinness M, McManus R, MacArthur C. Feasibility of an exercise intervention for women with postnatal depression: a pilot randomised controlled trial. Br J Gen Pract. 2008;58(548):178–83.

    Article  PubMed  PubMed Central  Google Scholar 

  60. Daley AJ, Blamey RV, Jolly K, et al. A pragmatic randomized controlled trial to evaluate the effectiveness of a facilitated exercise intervention as a treatment for postnatal depression: the PAM-PeRS trial. Psychol Med. 2015;45(11):2413–25.

    Article  CAS  PubMed  Google Scholar 

  61. Daley AJ, Jolly K, Sharp DJ, et al. The effectiveness of exercise as a treatment for postnatal depression: study protocol. BMC Pregnancy Childbirth. 2012;12(1):1–8.

    Article  Google Scholar 

  62. Daumit GL, Dickerson FB, Wang N-Y, et al. A behavioral weight-loss intervention in persons with serious mental illness. N Engl J Med. 2013;368(17):1594–602.

    Article  CAS  PubMed  PubMed Central  Google Scholar 

  63. Druss BG, Zhao L, Silke A, et al. The health and recovery peer (HARP) program: a peer-led intervention to improve medical self-management for persons with serious mental illness. Schizophr Res. 2010;118(1-3):264–70.

    Article  PubMed  PubMed Central  Google Scholar 

  64. Druss BG, Singh M, von Esenwein SA, et al. Peer-led self-management of general medical conditions for patients with serious mental illnesses: a randomized trial. Psychiatr Serv. 2018;69(5):529–35.

    Article  PubMed  PubMed Central  Google Scholar 

  65. Erickson ZD, Mena SJ, Pierre JM, et al. Behavioral interventions for antipsychotic medication–associated obesity: a randomized, controlled clinical trial. J Clin Psych. 2016;77(2):183–9.

    Article  Google Scholar 

  66. Erickson ZD, Kwan CL, Gelberg HA, et al. A randomized, controlled multisite study of behavioral interventions for veterans with mental illness and antipsychotic medication-associated obesity. J Gen Intern Med. 2017;32(1):32–9.

    Article  PubMed  PubMed Central  Google Scholar 

  67. Evans S, Newton R, Higgins S. Nutritional intervention to prevent weight gain in patients commenced on olanzapine: a randomizedcontrolled trial. Australian New Zealand J Psych. 2005;39(6):479–86.

    Google Scholar 

  68. Forsberg KA, Björkman T, Sandman PO, Sandlund M. Physical health—a cluster randomized controlled lifestyle intervention among persons with a psychiatric disability and their staff. Nordic J Psychiatry. 2008;62(6):486–95.

    Article  Google Scholar 

  69. Forsyth A, Deane FP, Williams P. A lifestyle intervention for primary care patients with depression and anxiety: a randomised controlled trial. Psychiatry Res. 2015;230(2):537–44.

    Article  PubMed  Google Scholar 

  70. Gaughran F, Stahl D, Ismail K, et al. Improving physical health and reducing substance use in psychosis–randomised control trial (IMPACT RCT): study protocol for a cluster randomised controlled trial. BMC Psych. 2013;13(1):263.

    Article  Google Scholar 

  71. Gaughran F, Stahl D, Ismail K, et al. Randomised control trial of the effectiveness of an integrated psychosocial health promotion intervention aimed at improving health and reducing substance use in established psychosis (IMPaCT). BMC Psych. 2017;17(1):413.

    Article  Google Scholar 

  72. Gillhoff K, Gaab J, Emini L, Maroni C, Tholuck J, Greil W. Effects of a multimodal lifestyle intervention on body mass index in patients with bipolar disorder: a randomized controlled trial. Prim Care Companion J Clin Psych. 2010;12(5). https://doi.org/10.4088/PCC.09m00906yel.

  73. Goldberg RW, Reeves G, Tapscott S, et al. “MOVE!”: outcomes of a weight loss program modified for veterans with serious mental illness. Psychiatr Serv. 2013;64(8):737–44.

    Article  PubMed  PubMed Central  Google Scholar 

  74. Goracci A, Rucci P, Forgione R, et al. Development, acceptability and efficacy of a standardized healthy lifestyle intervention in recurrent depression. J Affect Disord. 2016;196:20–31.

    Article  CAS  PubMed  Google Scholar 

  75. Green CA, Janoff SL, Yarborough BJH, Yarborough MT. A 12-week weight reduction intervention for overweight individuals taking antipsychotic medications. Community Ment Health J. 2014;50(8):974–80.

    Article  PubMed  Google Scholar 

  76. Yarborough BJH, Stumbo SP, Yarborough MT, Young TJ, Green CA. Improving lifestyle interventions for people with serious mental illnesses: qualitative results from the STRIDE study. Psychiatric Rehabil J. 2016;39(1):33.

    Article  Google Scholar 

  77. Green CA, Yarborough BJH, Leo MC, et al. The STRIDE weight loss and lifestyle intervention for individuals taking antipsychotic medications: a randomized trial. Am J Psychiatr. 2014;172(1):71–81.

    Article  PubMed  Google Scholar 

  78. Green CA, Yarborough BJH, Leo MC, et al. Weight maintenance following the STRIDE lifestyle intervention for individuals taking antipsychotic medications. Obesity. 2015;23(10):1995–2001.

    Article  CAS  PubMed  Google Scholar 

  79. Meenan RT, Stumbo SP, Yarborough MT, Leo MC, Yarborough BJH, Green CA. An economic evaluation of a weight loss intervention program for people with serious mental illnesses taking antipsychotic medications. Adm Policy Ment Health Ment Health Serv Res. 2016;43(4):604–15.

    Article  Google Scholar 

  80. Gyllensten AL, Forsberg K-A. Computerized physical activity training for persons with severe mental illness-experiences from a communal supported housing project. Disabil Rehabil Assist Technol. 2017;12(8):780–8.

    Article  PubMed  Google Scholar 

  81. Gossage-Worrall R, Holt RI, Barnard K, et al. STEPWISE–STructured lifestyle education for people WIth SchizophrEnia: a study protocol for a randomised controlled trial. Trials. 2016;17(1):1–12.

    Article  Google Scholar 

  82. Holt RI, Gossage-Worrall R, Hind D, et al. Structured lifestyle education for people with schizophrenia, schizoaffective disorder and first-episode psychosis (STEPWISE): randomised controlled trial. Br J Psychiatry. 2019;214(2):63–73.

    Article  PubMed  PubMed Central  Google Scholar 

  83. Iglesias-García C, Toimil-Iglesias A, Alonso-Villa M. Pilot study of the efficacy of an educational programme to reduce weight, on overweight and obese patients with chronic stable schizophrenia. J Psychiatr Ment Health Nurs. 2010;17(9):849–51.

    Article  PubMed  Google Scholar 

  84. O’Neil A, Berk M, Itsiopoulos C, et al. A randomised, controlled trial of a dietary intervention for adults with major depression (the “SMILES” trial): study protocol. BMC Psych. 2013;13(1):1–7.

    Google Scholar 

  85. Jacka FN, O’Neil A, Opie R, et al. A randomised controlled trial of dietary improvement for adults with major depression (the ‘SMILES’trial). BMC Med. 2017;15(1):1–13.

    Article  Google Scholar 

  86. Jean-Baptiste M, Tek C, Liskov E, et al. A pilot study of a weight management program with food provision in schizophrenia. Schizophr Res. 2007;96(1-3):198–205.

    Article  PubMed  Google Scholar 

  87. Khazaal Y, Fresard E, Rabia S, et al. Cognitive behavioural therapy for weight gain associated with antipsychotic drugs. Schizophr Res. 2007;91(1-3):169–77.

    Article  PubMed  Google Scholar 

  88. Kilbourne AM, Barbaresso MM, Lai Z, et al. Improving physical health in patients with chronic mental disorders: 12-month results from a randomized controlled collaborative care trial. J Clin Psych. 2017;78(1):129.

    Article  Google Scholar 

  89. Kilbourne AM, Bramlet M, Barbaresso MM, et al. SMI life goals: description of a randomized trial of a collaborative care model to improve outcomes for persons with serious mental illness. Contemp Clin Trials. 2014;39(1):74–85.

    Article  PubMed  PubMed Central  Google Scholar 

  90. Kwon JS, Choi J-S, Bahk W-M, et al. Weight management program for treatment-emergent weight gain in olanzapine-treated patients with schizophrenia or schizoaffective disorder: a 12-week randomized controlled clinical trial. J Clin Psychiatry. 2006;67(4):547–53.

    Article  PubMed  Google Scholar 

  91. Lee H, Kane I, Brar J, Sereika S. Telephone-delivered physical activity intervention for individuals with serious mental illness: a feasibility study. J Am Psych Nurses Assoc. 2014;20(6):389–97.

    Article  Google Scholar 

  92. Littrell KH, Hilligoss NM, Kirshner CD, Petty RG, Johnson CG. The effects of an educational intervention on antipsychotic-induced weight gain. J Nurs Scholarsh. 2003;35(3):237–41.

    Article  PubMed  Google Scholar 

  93. Lovell K, Wearden A, Bradshaw T, et al. An exploratory randomized controlled study of a healthy living intervention in early intervention services for psychosis: the INTERvention to encourage ACTivity, improve diet, and reduce weight gain (INTERACT) study. J Clin Psychiatry. 2014;75(5):498–505.

    Article  PubMed  Google Scholar 

  94. Marzolini S, Jensen B, Melville P. Feasibility and effects of a group-based resistance and aerobic exercise program for individuals with severe schizophrenia: a multidisciplinary approach. Ment Health Phys Act. 2009;2(1):29–36.

    Article  Google Scholar 

  95. Masa-Font R, Fernández-San-Martín M, López LM, et al. The effectiveness of a program of physical activity and diet to modify cardiovascular risk factors in patients with severe mental illness after 3-month follow-up: CAPiCOR randomized clinical trial. European Psychiatry. 2015;30(8):1028–36.

    Article  CAS  PubMed  Google Scholar 

  96. Masa-Font R, Sanmartín MIF, López LMM, et al. The effectiveness of a program of physical activity and diet to modify cardiovascular risk factors in patients with severe mental illness (CAPiCOR study). Int Arch Med. 2015;8. https://doi.org/10.1016/j.eurpsy.2015.09.006.

  97. Mauri M, Simoncini M, Castrogiovanni S, et al. A psychoeducational program for weight loss in patients who have experienced weight gain during antipsychotic treatment with olanzapine. Pharmacopsychiatry. 2008;41(01):17–23.

    Article  CAS  PubMed  Google Scholar 

  98. McCreadie RG, Kelly C, Connolly M, et al. Dietary improvement in people with schizophrenia: randomised controlled trial. Br J Psychiatry. 2005;187(4):346–51.

    Article  PubMed  Google Scholar 

  99. McKibbin CL, Golshan S, Griver K, Kitchen K, Wykes TL. A healthy lifestyle intervention for middle-aged and older schizophrenia patients with diabetes mellitus: a 6-month follow-up analysis. Schizophr Res. 2010;121(1-3):203–6.

    Article  PubMed  Google Scholar 

  100. McKibbin CL, Patterson TL, Norman G, et al. A lifestyle intervention for older schizophrenia patients with diabetes mellitus: a randomized controlled trial. Schizophr Res. 2006;86(1-3):36–44.

    Article  PubMed  Google Scholar 

  101. Muralidharan A, Niv N, Brown CH, et al. Impact of online weight management with peer coaching on physical activity levels of adults with serious mental illness. Psychiatr Serv. 2018;69(10):1062–8.

    Article  PubMed  PubMed Central  Google Scholar 

  102. Young AS, Cohen AN, Goldberg R, et al. Improving weight in people with serious mental illness: the effectiveness of computerized services with peer coaches. J Gen Intern Med. 2017;32(1):48–55.

    Article  PubMed  PubMed Central  Google Scholar 

  103. Osborn D, Burton A, Walters K, et al. Evaluating the clinical and cost effectiveness of a behaviour change intervention for lowering cardiovascular disease risk for people with severe mental illnesses in primary care (PRIMROSE study): study protocol for a cluster randomised controlled trial. Trials. 2016;17(1):1–12.

    Article  CAS  Google Scholar 

  104. Osborn D, Burton A, Hunter R, et al. Clinical and cost-effectiveness of an intervention for reducing cholesterol and cardiovascular risk for people with severe mental illness in English primary care: a cluster randomised controlled trial. Lancet Psychiatry. 2018;5(2):145–54.

    Article  PubMed  Google Scholar 

  105. Farrand P, Pentecost C, Greaves C, et al. A written self-help intervention for depressed adults comparing behavioural activation combined with physical activity promotion with a self-help intervention based upon behavioural activation alone: study protocol for a parallel group pilot randomised controlled trial (BAcPAc). Trials. 2014;15(1):1–12.

    Article  Google Scholar 

  106. Pentecost C, Farrand P, Greaves CJ, et al. Combining behavioural activation with physical activity promotion for adults with depression: findings of a parallel-group pilot randomised controlled trial (BAcPAc). Trials. 2015;16(1):367.

    Article  PubMed  PubMed Central  Google Scholar 

  107. Petzold MB, Mumm JLM, Bischoff S, et al. Increasing physical activity and healthy diet in outpatients with mental disorders: a randomized-controlled evaluation of two psychological interventions. Eur Arch Psychiatry Clin Neurosci. 2019;269(5):529–42.

    Article  PubMed  Google Scholar 

  108. Ratliff JC, Palmese LB, Tonizzo KM, Chwastiak L, Tek C. Contingency management for the treatment of antipsychotic-induced weight gain: a randomized controlled pilot study. Obes Facts. 2012;5(6):919–27.

    Article  CAS  PubMed  PubMed Central  Google Scholar 

  109. Skrinar GS, Huxley NA, Hutchinson DS, Menninger E, Glew P. The role of a fitness intervention on people with serious psychiatric disabilities. Psych Rehabil J. 2005;29(2):122.

    Article  Google Scholar 

  110. Speyer H, Nørgaard HCB, Hjorthøj C, et al. Protocol for CHANGE: a randomized clinical trial assessing lifestyle coaching plus care coordination versus care coordination alone versus treatment as usual to reduce risks of cardiovascular disease in adults with schizophrenia and abdominal obesity. BMC Psych. 2015;15(1):119.

    Article  Google Scholar 

  111. Jakobsen AS, Speyer H, Nørgaard HCB, et al. Effect of lifestyle coaching versus care coordination versus treatment as usual in people with severe mental illness and overweight: two-years follow-up of the randomized CHANGE trial. PLoS One. 2017;12(10):e0185881.

    Article  PubMed  PubMed Central  CAS  Google Scholar 

  112. Speyer H, Christian Brix Nørgaard H, Birk M, et al. The CHANGE trial: no superiority of lifestyle coaching plus care coordination plus treatment as usual compared to treatment as usual alone in reducing risk of cardiovascular disease in adults with schizophrenia spectrum disorders and abdominal obesity. World Psychiatry. 2016;15(2):155–65.

    Article  PubMed  PubMed Central  Google Scholar 

  113. Ström M, Uckelstam C-J, Andersson G, Hassmén P, Umefjord G, Carlbring P. Internet-delivered therapist-guided physical activity for mild to moderate depression: a randomized controlled trial. PeerJ. 2013;1:e178.

    Article  PubMed  PubMed Central  Google Scholar 

  114. Park T, Usher K, Foster K. Description of a healthy lifestyle intervention for people with serious mental illness taking second-generation antipsychotics. Int J Ment Health Nurs. 2011;20(6):428–37.

    Article  PubMed  Google Scholar 

  115. Usher K, Park T, Foster K, Buettner P. A randomized controlled trial undertaken to test a nurse-led weight management and exercise intervention designed for people with serious mental illness who take second generation antipsychotics. J Adv Nurs. 2013;69(7):1539–48.

    Article  PubMed  Google Scholar 

  116. Weber M, Wyne K. A cognitive/behavioral group intervention for weight loss in patients treated with atypical antipsychotics. Schizophr Res. 2006;83(1):95–101.

    Article  PubMed  Google Scholar 

  117. Kivimäki M, Hamer M, Batty GD, et al. Antidepressant medication use, weight gain, and risk of type 2 diabetes: a population-based study. Diabetes Care. 2010;33(12):2611–6.

    Article  PubMed  PubMed Central  Google Scholar 

  118. Tschoner A, Engl J, Laimer M, et al. Metabolic side effects of antipsychotic medication. Int J Clin Pract. 2007;61(8):1356–70.

    Article  CAS  PubMed  Google Scholar 

  119. van Hasselt FM (2013). Improving the physical health of people with severe mental illness: the need for tailor made care and uniform evaluation of interventions Groningen: s.n.

  120. Van Hasselt F, Krabbe P, Van Ittersum D, Postma M, Loonen A. Evaluating interventions to improve somatic health in severe mental illness: a systematic review. Acta Psychiatr Scand. 2013;128(4):251–60.

    PubMed  Google Scholar 

  121. Omni Calculator. MET minutes calculator. Accessed: 2 Aug 2021.

  122. Pasanisi F, Contaldo F, de Simone G, Mancini M. Benefits of sustained moderate weight loss in obesity. Nutr Metab Cardiovasc Dis. 2001;11(6):401.

    CAS  PubMed  Google Scholar 

  123. Warburton DE, Nicol CW, Bredin SS. Health benefits of physical activity: the evidence. Cmaj. 2006;174(6):801–9.

    Article  PubMed  PubMed Central  Google Scholar 

  124. Baker AL, Turner A, Kelly PJ, et al. ‘Better health choices’ by telephone: a feasibility trial of improving diet and physical activity in people diagnosed with psychotic disorders. Psychiatry Res. 2014;220(1):63–70.

    Article  PubMed  Google Scholar 

  125. Temmingh H, Claassen A, van Zyl S, et al. The evaluation of a telephonic wellness coaching intervention for weight reduction and wellness improvement in a community-based cohort of persons with serious mental illness. J Nerv Ment Dis. 2013;201(11):977–86.

    Article  PubMed  Google Scholar 

Download references

Acknowledgements

The authors would like to thank Debbie Booth for her assistance in developing the search strategy for the present review, as well as Simone Lodge for her contribution to review tasks and formatting of the manuscript.

Funding

Not applicable

Author information

Authors and Affiliations

  1. University of Newcastle, University Drive, Callaghan, NSW, 2308, Australia

    Tegan Bradley, Julia Dray, Kate Bartlem, Paula Wye, Grace Hanly, Lauren Gibson, Caitlin Fehily, Jacqueline Bailey, Olivia Wynne, Kim Colyvas & Jenny Bowman

  2. Hunter Medical Research Institute, Lot 1, Kookaburra Cct, New Lambton Heights, NSW, 2305, Australia

    Tegan Bradley, Julia Dray, Kate Bartlem, Grace Hanly, Lauren Gibson, Caitlin Fehily & Jenny Bowman

  3. Hunter New England Population Health, Locked Bag 10, Wallsend, NSW, 2287, Australia

    Elizabeth Campbell

Authors
  1. Tegan Bradley
    View author publications

    You can also search for this author in PubMed Google Scholar

  2. Elizabeth Campbell
    View author publications

    You can also search for this author in PubMed Google Scholar

  3. Julia Dray
    View author publications

    You can also search for this author in PubMed Google Scholar

  4. Kate Bartlem
    View author publications

    You can also search for this author in PubMed Google Scholar

  5. Paula Wye
    View author publications

    You can also search for this author in PubMed Google Scholar

  6. Grace Hanly
    View author publications

    You can also search for this author in PubMed Google Scholar

  7. Lauren Gibson
    View author publications

    You can also search for this author in PubMed Google Scholar

  8. Caitlin Fehily
    View author publications

    You can also search for this author in PubMed Google Scholar

  9. Jacqueline Bailey
    View author publications

    You can also search for this author in PubMed Google Scholar

  10. Olivia Wynne
    View author publications

    You can also search for this author in PubMed Google Scholar

  11. Kim Colyvas
    View author publications

    You can also search for this author in PubMed Google Scholar

  12. Jenny Bowman
    View author publications

    You can also search for this author in PubMed Google Scholar

Contributions

Conception and design, TB, EC, KB and PW. Collection and assembly of data, TB, EC, JD, KB, GH, LG, CF, JBa and OW. Data analysis and interpretation, TB, EC, JD and KC. Manuscript writing, TB, EC, PW and JBo. Revised the article, all authors. Final approval of manuscript, all authors. The authors read and approved the final manuscript.

Corresponding author

Correspondence to Tegan Bradley.

Ethics declarations

Ethics approval and consent to participate

This work used published data; therefore, ethical approval was not required.

Consent for publication

Not applicable.

Competing interests

The authors declare that they have no competing interests.

Additional information

Publisher’s Note

Springer Nature remains neutral with regard to jurisdictional claims in published maps and institutional affiliations.

Supplementary Information

Additional file 1: Supplementary Table 1.

Search Strategy (PSYCINFO). Supplementary Table 2. Approaches to calculate required data for meta-analyses when not presented in published studies. Supplementary Table 3. Summary of narrative synthesis. Supplementary Figure 1. Meta-analysis for weight loss (kgs). Supplementary Figure 2. Meta-analysis for weight loss (5% body weight loss). Supplementary Figure 3. Meta-analysis for weight maintenance (kgs). Supplementary Figure 4. Meta-analysis for physical activity (IPAQ - Met Minutes). Supplementary Figure 5. Meta-analysis for diet (fruit serves daily). Supplementary Figure 6. Meta-analysis for diet (vegetable serves daily). Supplementary Figure 7. Meta-analysis for BMI. Supplementary Figure 8. Meta-analysis for waist circumference (cms). Supplementary Table 4. Pooled measures for mental health. Supplementary Figure 9. Meta-analysis for Depression (SMD). Supplementary Figure 10. Meta-analysis for Anxiety (SMD). Supplementary Figure 11. Meta-analysis for Severity of Psychological Symptoms (SMD).

Rights and permissions

Open Access This article is licensed under a Creative Commons Attribution 4.0 International License, which permits use, sharing, adaptation, distribution and reproduction in any medium or format, as long as you give appropriate credit to the original author(s) and the source, provide a link to the Creative Commons licence, and indicate if changes were made. The images or other third party material in this article are included in the article's Creative Commons licence, unless indicated otherwise in a credit line to the material. If material is not included in the article's Creative Commons licence and your intended use is not permitted by statutory regulation or exceeds the permitted use, you will need to obtain permission directly from the copyright holder. To view a copy of this licence, visit http://creativecommons.org/licenses/by/4.0/. The Creative Commons Public Domain Dedication waiver (http://creativecommons.org/publicdomain/zero/1.0/) applies to the data made available in this article, unless otherwise stated in a credit line to the data.

Reprints and permissions

About this article

Check for updates. Verify currency and authenticity via CrossMark

Cite this article

Bradley, T., Campbell, E., Dray, J. et al. Systematic review of lifestyle interventions to improve weight, physical activity and diet among people with a mental health condition. Syst Rev 11, 198 (2022). https://doi.org/10.1186/s13643-022-02067-3

Download citation

  • Received:

  • Accepted:

  • Published:

  • DOI: https://doi.org/10.1186/s13643-022-02067-3

Keywords

Systematic Reviews

ISSN: 2046-4053