HEALTH PROMOTION 

RESOURCE GUIDE 

Choosing Evidence-Based Practices for Reducing 

Obesity and Improving Fitness for People with 

Serious Mental Illness 

SePteMbeR 2014 
SAMHSA-HRSA CenteR foR IntegRAted HeAltH SolutIonS 

The SAMHSA-HRSA Center for Integrated Health Solutions (CIHS) promotes the development of integrated primary and behavioral 

health services to better address the needs of individuals with mental health and substance use conditions, whether seen in 

specialty behavioral health or primary care provider settings. CIHS is the first “national home” for information, experts, and other 

resources dedicated to bidirectional integration of behavioral health and primary care. 

Jointly funded by the Substance Abuse and Mental Health Services Administration (SAMHSA) and the Health Resources and 

Services Administration (HRSA), and run by the National Council for Behavioral Health, CIHS provides training and technical assistance to community behavioral health organizations that received SAMHSA Primary and Behavioral Health Care Integration grants, 

as well as to community health centers and other primary care and behavioral health organizations. 

CIHS’s wide array of training and technical assistance helps improve the effectiveness, efficiency, and sustainability of integrated 

services, which ultimately improves the health and wellness of individuals living with behavioral health disorders. 

ACknowledgeMentS 

Special thanks to the following people for their generous assistance in the preparation of this white paper: 

8	 Stephen J. Bartels, M.D., M.S. & John A. Naslund, M.P.H. 

Dartmouth Centers for Health and Aging Geisel School of Medicine at Dartmouth and The Dartmouth Institute for Health Policy 

and Clinical Practice 

1701 K Street NW, Suite 400 

Washington, DC 20006 

202.684.7457 

integration@theNationalCouncil.org 

www.integration.samhsa.gov 

SAMHSA-HRSA CenteR foR IntegRAted HeAltH SolutIonS 

SAMHSA-HRSA CENTER FOR INTEGRATED HEALTH SOLUTIONS 2 
tAble of ContentS
 

HoW To USe THIS ReSoURCe GUIDe ......................................................................................3
 

SeCTIoN I: overview and Background................................................................................4
 

with Serious Mental Illness: What Works?
 

Adopt a Health Promotion Program for Persons with Serious Mental Illness
 

APPeNDICeS
 

SeCTIoN II: Weighing the evidence ...................................................................................4
 

SeCTIoN III: Selecting Programs Based on the evidence ........................................................5
 

SeCTIoN IV: What are Implementation-Ready Health Promotion Practices? .................................5
 

SeCTIoN V: evidence-Based Practices At-A-Glance ...............................................................6
 

SeCTIoN VI: evaluating Health Promotion Programs for Persons................................................9
 

SeCTIoN VII: A Checklist for evaluating Your organization’s Readiness to .................................. 11 


SeCTIoN VIII: Description of Different evidence-Based Implementation Ready Practices ............... 12
 

APPeNDIx I: Search Methods ........................................................................................ 18
 

APPeNDIx II: Search Results......................................................................................... 20
 

APPeNDIx III: evidence-Based Health Promotion Programs Not Available for Implementation ......... 20
 

RefeReNCeS ................................................................................................................. 21
 

SAMHSA-HRSA CenteR foR IntegRAted HeAltH SolutIonS 

SAMHSA-HRSA CENTER FOR INTEGRATED HEALTH SOLUTIONS 3 
How to uSe 

tHIS ReSouRCe guIde 

The purpose of this guide is to help behavioral 

health administrators, program directors, state 

agencies, clinicians, practitioners, families and 

consumers to select evidence-based practices. 

This Resource Guide provides a detailed overview 

of health promotion practices for reducing obesity and improving fitness among persons with serious mental illness that have been evaluated using 

rigorous scientific methods. each of the practices 

described in this guide have been implemented 

in diverse settings and have materials and manuals available for training purposes. The key results 


and additional information necessary for selection are provided for each evidence-based health promotion practice.
 

This guide is organized into the following eight sections:
 

I. Overview and Background: Evidence-Based Practices Aimed at Reducing Obesity and 

Improving Fitness for People with Serious Mental Illness 

II. Weighing the Evidence 

III. Selecting Programs Based on the Evidence 

IV. What are Implementation Ready Health Promotion Practices? 

V. Current Selected Evidence Practices – At-A-Glance 

VI. A Checklist for Evaluating Health Promotion Programs for Persons with Serious Mental 

Illness: What Works? 

VII. A Checklist for Evaluating Your Organization’s Readiness to Adopt a Health Promotion 

Program for Persons with Serious Mental Illness 

VIII. Description of Different Evidence-Based Implementation Ready Practices 

This guide is not intended to deliver training in any of these practices, but rather it is designed to inform others about practices that 

work, and offer assistance with selecting and evaluating these practices. 

SAMHSA-HRSA CenteR foR IntegRAted HeAltH SolutIonS 

SAMHSA-HRSA CENTER FOR INTEGRATED HEALTH SOLUTIONS 4 
SAMHSA-HRSA CENTER FOR INTEGRATED HEALTH SOLUTIONS 5 SAMHSA-HRSA Center for Integrated He

alt

h Solutions

 

 

SeCtIon I: overview and background 

The prevalence of obesity is double among persons with serious mental illness (SMI) when compared to the general population1,2, 

and contributes to the severity of health problems and shortened lifespan observed within this population group.3 Many antipsychotic medications are known to cause significant weight gain in persons with SMI,2,4-13 and some are associated with hyperlipidemia and decreased glucose tolerance, both of which are known risk factors for cardiovascular disease.14,15 Behaviors associated 

with poor health outcomes, such as a sedentary lifestyle and poor eating habits, are also more common in persons with SMI than 

the general population.16,17 fewer than 20 percent of individuals with schizophrenia engage in one or more periods of moderate 

exercise on a weekly basis and nearly 40 percent are physically inactive.18 Poor diet, which is characterized by lower consumption 

of fruits, vegetables and fiber, and greater consumption of calories, nutrients and saturated fats, is more prevalent among these 

individuals compared to the general population.18-21 All of these factors combined are largely responsible for the high rates of diabetes, heart disease, and obesity found in persons with SMI. 

Although poor physical health and obesity are common in people with SMI, few programs delivered through publicly-funded mental 

health facilities target physical fitness and wellness.7,22,23 Despite the elevated healthcare costs and adverse outcomes associated 

with the combination of mental illness and poor physical health,24-26 relatively little attention has been given towards developing 

health promotion interventions designed to address the needs of this high-risk group. 

Implementing effective health promotion programs in settings where adults with SMI seek and receive services is critical to lowering the risk associated with preventable medical conditions such as cardiovascular disease and obesity. Implementation of these 

programs requires both an understanding of the evidence behind the programs as well as having an appropriate and appropriately 

trained workforce in place. Despite the growing body of research highlighting the effectiveness of health promotion programs for 

persons with SMI, fitness and nutrition initiatives are rarely included as a component of routine mental health services. The types of 

programs that have proven successful predominantly include interventions focused on a combination of diet and exercise, though 

some programs have placed greater emphasis on one or the other. These health promotion programs are delivered across diverse 

settings and rely on varying formats including group-based programs, individualized sessions, and combined group and individual 

sessions. 

SeCtIon II: weighing the evidence 

for purposes of this guide, evidence-based practices represent treatments and services with well-documented effectiveness. 

These practices have been evaluated in mental health settings using rigorous scientific methods. even when reviewing these different practices, it is important to realize that there are differing levels of evidence, where some practices have characteristics 

associated with greater improvements in patient outcomes than others. 

It is important to distinguish between health promotion practices that contribute to statistically significant changes as opposed 

to those that result in a clinically significant impact. for example, a statistically significant improvement means that the practice 

resulted in observed changes that were not due to chance. These changes, however, could in fact be very small. for example, in 

a large sample a 2-point change on a 100-point scale could be highly statistically significant, even though such a change is not 

clinically significant. 

In contrast, a clinically significant improvement means that the practice contributed to a big enough change that it is associated 

with decreased risk of disease and improved health. When considering two important outcomes of health promotion practices, 

such as weight-loss and physical fitness, very small changes in weight could be observed as statistically significant, however a 

weight-loss of 5% bodyweight or greater would be judged as clinically significant and is more meaningful in terms of the person’s 

health. for example, if an individual weighing 350lbs loses 5lbs of weight, this may be a statistically significant result but would 

not be considered clinically significant because this represents a less than 1.5% reduction in body weight. This distinction between 

statistical and clinical significance emphasizes the need to look at how big the change is in order to determine the potential impact 

of a practice. 
SAMHSA-HRSA CENTER FOR INTEGRATED HEALTH SOLUTIONS 6 SAMHSA-HRSA Center for Integrated He

alt

h Solutions

Another way to consider the evidence is to identify which outcomes are reported. Many studies focus exclusively on weight loss or 

body mass index (BMI), a reliable measure of body fatness for most people calculated as weight (kg) divided by height squared 

(m2), even though there are other important outcomes relevant to health promotion. for example, improved physical fitness is an 

important outcome of many health promotion programs and contributes to well-documented health benefits including decreased 

cardiovascular risk. Studies that report both weight and physical fitness outcomes offer more robust findings. 

Section IV of this guide provides a critical overview of each of the evidence-based health promotion practices, with consideration 

of the impact of each. 

SeCtIon III: Selecting Programs based on the evidence 

There are a number of studies that offer compelling evidence regarding the benefits of health promotion programs for use among 

individuals with SMI. The high participation rates, significant reductions in weight and BMI, as well as improvements in quality of 

life and self-efficacy all support the feasibility of using these programs in community-based or clinical settings for people with SMI. 

However, only a handful of these programs have been implemented in real-world settings following validation through evidencebased research. Insufficient funding is a key reason for the discontinued use of some health promotion programs. for instance, 

many grant-funded interventions were no longer viable following the end of the grant. In addition, many of the studies identified 

in the literature review were of varying methodological quality and were limited by potential risks of bias. These included conflicts 

of interest among study authors as well as a substantial number of studies 

funded through pharmaceutical industry grants. 

Despite these diverse challenges, Section V of this guide identifies nine important health promotion programs that have demonstrated effectiveness 

and training materials or instruction manuals and training curriculums in 

development. These programs are implementation ready, and they may be 

appropriate for dissemination across a number of settings. 

Among all of the interventions described in Section V (see Table 1), it is apparent that by combining an education and activity-based approach, with 

emphasis on both nutrition and physical exercise, it is possible to achieve greater success in effectively reducing weight among 

individuals with SMI. Research studies demonstrate that health promotion programs need to be intensive and based in the science 

of fitness and weight loss, with special adaptations to meet the needs and challenges of those with SMI, to have any real impact 

for a significant number of people. 

SeCtIon IV: what are Implementation-Ready Health Promotion 

Practices? 

Implementation-ready health promotion practices are supported by evidence-based research, and have the materials necessary 

to successfully implement these practices readily available. A small number of studies were not included in this guide because 

they were not implemented beyond the initial research settings and did not have available training materials. These studies were 

excluded because they are not relevant to practitioners or program directors. for a list of the excluded practices, refer to the table 

in Appendix 3. 

for each of the practices described in this guide, there are training manuals available or in preparation and available from the 

program developers, and the practices have been implemented following the completion of their respective research studies. This 

guide includes details on how to access the training materials and contact the program developers to schedule training. 
SAMHSA-HRSA CENTER FOR INTEGRATED HEALTH SOLUTIONS

SAMHSA-HRSA Center for Integrated He

alt

h Solutions

-

SeCtIon V: evidence-based Practices At-A-glance
 

This section includes a summary of each evidence-based health promotion practice for persons with SMI. The purpose is 1) to 

highlight the various settings in which these practices have been implemented following completion of their respective research 

studies; and 2) to identify the characteristics that have contributed to their success. This section also provides an overview of 

the factors important for the implementation of these practices, such as accessing training materials and determining personnel 

requirements. 

Evidence-Based Implementation-Ready Models 

Standard framework for Levels of Integrated Care20 offers a point of reference and reflection for providers planning, implementing, 

and sustaining integration projects. 

A total of nine evidence-based interventions have been implemented in different settings following completion of their respective 

studies. These evidence-based interventions are arranged from the most recent peer-reviewed publication of primary outcome data 

supporting the program’s effectiveness: 

1) In SHAPe27,28 

2) Achieving Healthy Lifestyles in Psychiatric Rehabilitation (ACHIeVe)29 

3) Healthy eating and Activity in Latinos Treated in the Heights (HeALTH)30 

4) Recovering through Nutrition and exercise for Weight Loss (ReNeW)31 

5) Solutions for Wellness (SfW) Manualized Wellness Program 

6) Lifestyle Intervention32 

7) Simplified Intervention to Modify Physical activity, Lifestyle, and eating behavior (SIMPLe)33 

8) Diabetes Awareness and Rehabilitation Training (DART)34 

9) Behavioral Group-Based Treatment for Weight Reduction in Schizophrenia and other Severe Mental Illnesses (BT)35 

Evidence-Based Practices At-A-Glance 

Tables 1-4 provide an overview of the nine evidence-based practices. Table 1 provides a summary of the key research results 

and evidence for each of these practices. It is helpful to consider if the programs report both statistically and clinically significant 

evidence of effectiveness. 

Table 1. Summary of the evidence base for health promotion programs with training materials for 

persons with serious mental illness 

Intervention 

Report 

Weight Loss 

or BMI 

Report Clini 

cally Significant 

Findings 

Report 

Weight Loss 

and Fitness 

Key Findings 

In SHAPe 4

ACHIeVe 4

HeALTH 4

ReNeW 4

SfW 4

Lifestyle Intervention 4

SIMPLe 4

DART 4

Behavioral Therapy 

(BT) 4

4

4

4

4

4

4

50% with ≥5% weight loss or clinically significant increased fitness 

24% improved fitness and ≥5% weight loss 

37.8% with ≥5% weight loss 

24% with ≥5% weight loss 

4.4 lbs weight loss 

0.1-8.7 lbs weight loss 

3-10 lbs weight loss 

6.4 lbs weight loss 

5 lbs weight loss 

27% with ≥5% weight loss 

41% who completed BT with ≥5% weight loss 

7 
SAMHSA-HRSA CENTER FOR INTEGRATED HEALTH SOLUTIONS

SAMHSA-HRSA Center for Integrated He

alt

h Solutions

Table 2 highlights the different components of each of the nine evidence-based practices. As shown, all of the practices target either 

nutrition or physical activity, or both. In general, programs that provide both nutrition and physical activity are more effective. In addition, these practices consist of either education-based or active real-world training within community settings. It is important to make 

the distinction between the more passive didactic or classroom training and involvement in active training as this affects the potential 

impact of each health promotion practice. education-based training consists of classroom education, instruction, or demonstrations 

in nutrition or fitness. In contrast, the active training in physical fitness can be comprised of one-on-one personal training sessions 

at community fitness centers or participation in group exercise classes. Similarly, nutrition practices with active training consist of 

hands-on cooking classes or visits to local grocery stores to select healthier food options. 

Table 2. Components of the evidence-based health promotion programs: Educational vs. Active; 

Nutrition and/or Physical Activity 

Intervention Duration 

Education-based Training Active Training 

Nutrition Physical Activity Nutrition Physical Activity 

In SHAPe 12 months 

ACHIeVe 18 months 

HeALTH 14 weeks 

ReNeW 6 months 

SfW 12 weeks 

Lifestyle Intervention 12 weeks 

SIMPLe 16 weeks 

DART 24 weeks 

Behavioral Therapy (BT) 14 weeks 

4 

4

4 

4

4

4

4

4

4

4 

4

4 

4

4

4

4

4

4

4

4

4

4

4

4

It is also important to consider what the organizational requirements are in order to provide these different practices. This information 

is summarized in Table 3, by types of provider needed to implement the program. 

Table 3. Overview of personnel requirements for evidence-based health promotion programs for 

persons with serious mental illness 

Intervention 

Personnel Requirements 

Nurse Dietitian Fitness Trainer Basic Training Other 

In SHAPe 

ACHIeVe 

HeALTH 

ReNeW 4

SfW 4

Lifestyle Intervention 4

SIMPLe 

DART 

Behavioral Therapy (BT) 

4

4

4

4

4

4

4

4

4

4

4 

4

4

4

4

4

8 
Table 4 contains additional background information about the research supporting each of the practices, including the research design, location of the research, the funding agency who supported the research, and the duration of the study. Table 4 also provides a 

summary of the “implementation-readiness” of each of these practices in terms of the personnel requirements and whether training 

is available from the program developers. 

Table 4. Implementation Readiness: Evidence-based interventions that have been implemented or are in 

preparation for implementation 

Intervention Authors Design Region Funding Duration Personnel Available 

Training Manual 

In SHAPe Bartels 

(2013)27,28 RCT US (NH) NIMH 12 months Health Mentor Yes Yes 

ACHIeVe Daumit 

(2013)29 RCT US (MD) NIMH 18 months 

Trained for 

intervention, 

exercise instructor 

Yes Yes 

HeALTH Mangurian 

(2012)30 

Nonrandomized 

Comparison 

US (NY) Janssen, eli 

Lilly, NARSAD 14 weeks Dietitian Yes Yes 

ReNeW Brown 

(2011)31 

eli Lilly Solutions 

for Wellness and 

related programs 

Porsdal 

(2010)36 

Vreeland 

(2010)37 

Chen 

(2009)38 

Lee (2008)39 

Kwon 

(2006)40 

Skrinar 

(2005)41 

Menza 

(2004)42 

Littrell 

(2003)43 

RCT 

Nonrandomized 

Comparison 

Nonrandomized 

Comparison 

Single Arm 

Single Arm 

RCT 

RCT 

Nonrandomized 

Comparison 

RCT 

US (AZ) 

Denmark 

US (NJ) 

Taiwan 

Korea 

Korea 

US (MA) 

US (NJ) 

US (GA) 

NIMH Grant 

eli Lilly 

Not reported 

eli Lilly 

eli Lilly 

eli Lilly 

eli Lilly 

eli Lilly 

Not reported 

6 months 

12 weeks 

10 weeks 

10 weeks 

12 weeks 

12 weeks 

12 weeks 

12 months 

16 weeks 

No specific 

requirements 

Nurse or 

therapist 

No specific 

requirements 

Psychiatrist, 

psychiatric 

nurse, dietitian, 

fitness coach 

Nurse 

Practitioner 

Nurse 

Practitioner 

fitness coach 

Advanced 

practice nurse, 

nurse, dietitian 

Advanced 

practice nurse, 

nurse, dietitian 

Yes 

Yes 

Yes 

Yes 

Yes Yes 

Yes Yes 

Yes 

Yes 

Yes 

Yes 

Yes 

Yes 

Yes 

Yes 

Yes Yes 

Lifestyle 

Intervention Wu (2008)32 RCT China 

Ministry of 

Science and 

Tech., PRC 

12 weeks 

Nurse, dietitian, 

exercise 

therapist 

Yes Yes 

SIMPLe Jean-Baptiste 

(2007)33 

Randomized 

Controlled 

Pilot 

US (CT) CMHC 16 weeks 

Providers at 

mental health 

settings 

Yes Yes 

DART McKibbin 

(2006)34 RCT US (CA) NIMH & DVA 24 weeks Yes Yes 

Behavioral 

Therapy (BT) Brar (2005)35 RCT US (PA) Janssen 14 weeks experience 

with SMI Yes Yes 

SAMHSA-HRSA CenteR foR IntegRAted HeAltH SolutIonS 

SAMHSA-HRSA CENTER FOR INTEGRATED HEALTH SOLUTIONS 9 
SAMHSA-HRSA CENTER FOR INTEGRATED HEALTH SOLUTIONS

SAMHSA-HRSA Center for Integrated He

alt

h Solutions

 

To obtain training materials such as manuals and pamphlets, or to inquire about scheduling training sessions for the different programs, see Table 5. 

Table 5. Training materials and contact information for implementation ready health promotion practices 

Practice Manual 

Available 

Training 

Available Contact 

In SHAPe 4

ACHIeVe 4

HeALTH 4

ReNeW 4

SfW 4

Lifestyle Intervention 4

SIMPLe 4

DART 4

BT 4

4

4

4

4

4

4

Ken Jue: ken@kenjue.com 

Joseph Gennusa: jgennus1@jhmi.edu 

Dr. Christina Mangurian: Christina.Mangurian@ucsf.edu 

www.cmhsrp.uic.edu/health/weight-wellbeing.asp 

Dr. Catana Brown: cbrown2@midwestern.edu 

Betty Vreeland: vreelael@umdnj.edu 

Dr. Ren-Rong Wu: wurenrong2005@yahoo.com.cn 

www.simpleprogram.org 

Dr. Cenk Tek: cenk.tek@yale.edu. 

Dr. Christine McKibbin: cmckibbi@uwyo.edu 

Rohan Ganguli: Rohan.Ganguli@camh.ca 

SeCtIon VI: evaluating Health Promotion Programs for Persons 

with Serious Mental Illness: what works? 

This section provides a checklist that can be used in evaluating and comparing health promotion programs (exercise and nutrition 

programs) for persons with SMI. each of these features is important to consider in evaluating programs that are a) most effective and b) ready for implementation in real-world settings. This checklist can be used to evaluate the practices described in this 

implementation guide and can also be used to evaluate new practices or “promising practices” that have not been reviewed in this 

guide. A greater number of checked items in either category will be associated with greater confidence in the effectiveness of the 

intervention and the implementation readiness of the program. 

A practice that is effective, but does not have adequate implementation materials, may be difficult to implement in real world 

settings. There may be substantive differences between a manual designed for a carefully planned research study, and a manual 

intended to guide providers in the practical issues associated with real-world implementation. In contrast, a program that has clear 

and appealing manuals, attractively produced implementation materials, and/or easy to implement and inexpensive implementation requirements, but lacks well-documented evidence of effectiveness, should be considered with significant skepticism and 

caution. Programs that are enthusiastically promoted based on anecdotal evidence, general reports of “satisfaction,” or pre-post 

outcomes collected by those who provided the intervention, may be practical and popular, but ineffective when provided in a larger 

scale implementation or program. The following checklist can be used as a helpful guide to evaluating and choosing an appropriate 

health promotion program. 

10 
Checklist for Evaluating Health Promotion Programs for Persons with Serious Mental 

Illness: What Works? 

This checklist can be used for comparing health promotion programs. Check all that apply. Each of these features is important to 

consider in evaluating programs that are a) effective and b) ready for implementation in real-world settings. 

Features Associated with Greater Health Promotion Program Effectiveness 

...............................Program has been specifically designed, evaluated, and proven effective for persons with mental illness
 

...............................Program has been proven effective in a randomized controlled trial (RCT) consistent with establishing an “evidencebased practice” 

...............................outcomes are reported as clinically significant, not just statistically significant (i.e. outcomes include % or total sample 

weight loss of at least 5% or more and/or reports on clinically significant change in fitness) 

...............................Program consists of active participation in physical activity and nutrition (not just education, classroom, or passive 

learning) 

...............................Program includes both physical activity and nutrition components (not just one or the other)
 

...............................Program includes a component of physical activity/and or nutrition with coaching or supervision by a person with training in fitness and/or nutrition coaching 

...............................Program includes ongoing self-monitoring by the participant and review by the coach or provider of goals and outcomes 

(e.g., weight, amount of regular physical activity or exercise, nutrition, etc.) 

...............................Duration of program participation is at least 6 months 


Features of Programs Associated with Greater Implementation Readiness 

...............................The program has been implemented at least once outside of the research setting
 

...............................The program has been implemented in multiple settings by different agencies outside of the initial research setting
 

...............................The program has been implemented and provided without relying on grant funding
 

...............................There is an instruction manual for implementing the program designed for providers in real-world settings (not just a 

research manual) 

...............................Technical assistance for training and implementation of the program is available
 

SAMHSA-HRSA CenteR foR IntegRAted HeAltH SolutIonS 

SAMHSA-HRSA CENTER FOR INTEGRATED HEALTH SOLUTIONS 11 
SAMHSA-HRSA CENTER FOR INTEGRATED HEALTH SOLUTIONS 12 SAMHSA-HRSA Center for Integrated He

alt

h Solutions

SeCtIon VII: evaluating Your organization’s Readiness to 

Adopt a Health Promotion Program for Persons with Serious 

Mental Illness 

This section can be used to evaluate your organization’s readiness to implement a 

health promotion program (exercise and nutrition programs) for persons with serious 

mental illness. The questions in this checklist cover four key domains related to organizational readiness: 1) Defined Need; 2) Readiness for Change in Culture; 3) Time, 

Resources, Personnel; and 4) Sustainment of the Change. This 10-item checklist will 

help your institution understand its level of readiness to initiate a health promotion program. A greater number of checked items will be associated with greater organizational 

readiness to implement a health promotion program. However, a higher score on this 

checklist does not guarantee successful implementation. 

organizational readiness is a complex multi-factorial part of successful implementation, and this checklist is not comprehensive 

and is intended only to provide a preliminary assessment of your organization’s readiness. Staff members and senior leaders at 

your institution should complete the checklist independently, and then responses should be compared as a group in order to stimulate discussion and to help with determining the necessary steps toward implementing a health promotion program. This checklist 

may also be helpful for identifying areas of weakness or disagreement that require further attention. 

This checklist is adapted from the Agency for Healthcare Research and Quality (AHRQ) organizational Readiness Assessment 

Checklist. The AHRQ checklist can be found at: teamstepps.ahrq.gov/readiness/ 

Checklist for Evaluating Your Organization’s Readiness to Adopt a Health Promotion 

Program for Persons with Serious Mental Illness 

This checklist can be used to help your institution understand its level of readiness to initiate a health promotion program targeting 

obesity and fitness among individuals with serious mental illness. Check all that apply. 

Defined Need 

...............................Have you clearly defined the need that is driving your institution to consider implementing a health promotion program?
 

...............................Is building a stronger culture that embraces wellness and health promotion as a key element an appropriate strategy 

to address your institution’s need? 

Readiness for Change in Culture – Adopting a Culture that Promotes Wellness and Health Promotion 

...............................Is now the right time for implementing a culture change (i.e., it will not compete with other major changes currently 

being made at your institution)? 

...............................Is a culture change that emphasizes the importance of wellness and health promotion feasible and acceptable?
 

...............................Will your institution’s leaders support a culture change and the effort required to implement and sustain a health promotion program? 
SAMHSA-HRSA CENTER FOR INTEGRATED HEALTH SOLUTIONS 13 SAMHSA-HRSA Center for Integrated He

alt

h Solutions

Time, Resources, Personnel 

...............................Will your institution provide sufficient resources, materials, and staff with the necessary characteristics and attitudes 

to lead the implementation and delivery of a health promotion program? 

...............................Will your institution allow time to secure necessary materials and resources, and prepare the staff for their role in leading a health promotion program? 

...............................Will your institution allow time for personnel to attend training?
 

Sustainment of the Change 

...............................Will your institution be willing to measure and assess progress of implementing a health promotion program and continuously improve program reach and delivery? 

...............................Will your institution be able to reinforce and reward staff for engaging and retaining consumers with SMI into a health 

promotion program? 

SeCtIon VIII: Individual descriptions of evidence-based 

Implementation Ready Practices 

This section of the Health Promotion Resource Guide provides individual descriptions of the nine selected evidence-based interventions implemented in different settings following completion of their respective studies: 

1) In SHAPe27,28 

2) Achieving Healthy Lifestyles in Psychiatric Rehabilitation (ACHIeVe)29 

3) Healthy eating and Activity in Latinos Treated in the Heights (HeALTH)30 

4) Recovering Through Nutrition and exercise for Weight Loss (ReNeW)31 

5) Solutions for Wellness (SfW) Manualized Wellness Program 

6) Lifestyle Intervention32 

7) Simplified Intervention to Modify Physical activity, Lifestyle, and eating behavior (SIMPLe)33 

8) Diabetes Awareness and Rehabilitation Training (DART)34 

9) Behavioral Group-Based Treatment for Weight Reduction in Schizophrenia and other Severe Mental Illnesses (BT)35 

1) In SHAPE 

In SHAPe is an individualized health promotion program designed to be delivered in community settings, with the goal of improving health behaviors related to diet and exercise among individuals with SMI.44 A certified fitness trainer delivers the program to 

participants, and assists them in identifying personal fitness goals and developing an exercise and diet plan. In this program, the 

plan is tailored according to each participant’s fitness abilities, dietary behaviors, goals, and preferences, and participants are 

provided with a gym membership to a community fitness facility. The trainers are certified in fitness training and CPR, and have 

received additional training from dietitians, as well as instruction in motivational interviewing, goal setting, and the symptoms and 

treatments of mental illnesses. The caseload for the fitness trainers is typically 30 participants per one full-time equivalent. for one 

hour each week, fitness trainers meet with participants to review progress, and provide instruction and education about exercise 

and nutrition. In addition, there are monthly weight-management group sessions, where 6-8 participants can meet with a fitness 

trainer at a community setting to receive healthy eating education and participate in group discussions. 
SAMHSA-HRSA CENTER FOR INTEGRATED HEALTH SOLUTIONS 14 SAMHSA-HRSA Center for Integrated He

alt

h Solutions

A 2013 randomized controlled trial conducted in Concord, New Hampshire compared the In SHAPe program to fitness club membership alone. In this study, 49% of In SHAPe participants achieved either clinically significant increased cardiorespiratory fitness, 

measured as >50 meter increase on the 6-minute Walk Test, or clinically significant weight loss of 5% of body weight or greater. 

Most notably, 24% In SHAPe participants achieved both improved fitness and weight loss.27 This study was supported by a grant 

from the Centers for Disease Control (CDC). A subsequent randomized controlled trial compared the 12-month In SHAPe program 

to fitness club membership within an ethnically diverse sample of 210 individuals with serious mental illness from Boston, Massachusetts.28 In this trial, In SHAPe participants lost significantly more weight compared to fitness club membership participants 

(p=0.029). Additionally, 51% of In SHAPe participants achieved either clinically significant increased cardiorespiratory fitness, 

measured as >50 meter increase on the 6-minute Walk Test, or clinically significant weight loss of 5% of body weight or greater. 

These weight loss outcomes were maintained at 18-month follow-up. This larger randomized control trial was supported by a grant from the National Institute of Mental 

Health (NIMH). 

The effectiveness of the In SHAPe program has been demonstrated in a randomized 

controlled trial and then replicated in a subsequent randomized controlled trial conducted in an entirely different setting, representing a high level of evidence to support 

this program. In SHAPe has since been implemented across numerous mental health 

facilities in New Hampshire and elsewhere. formal training for In SHAPe is available, 

and an abbreviated instruction manual is available free of charge from the program 

coordinator. for enquiries contact Ken Jue at ken@kenjue.com. 

2) Achieving Healthy Lifestyles in Psychiatric Rehabilitation (ACHIEVE) 

This 18-month weight loss intervention consists of three contact types: group weight management sessions, individual weight 

management sessions, and group exercise sessions.29 The intervention is divided into two phases, the initial 6-month intervention 

phase (intensive phase), followed by the maintenance phase from months 7-18. During the initial intervention phase, participants 

attend three monthly 45-minute group weight management sessions led by an interventionist, one monthly 15-20 minute individual 

visit with an interventionist, three weekly 45-minute group exercise sessions, and weekly weigh-ins. During the maintenance phase, 

participants attend one 45-minute group weight-management session each month, one 15-20 minute individual visit with an interventionist each month, three 45-minute group exercise sessions each week, and semi-monthly weigh-ins. 

The group exercise sessions are 45 minutes and place emphasis on moderate intensity physical activity. The weight management 

sessions are 45-minute group sessions that cover diet education, self-monitoring, and include hands-on activities such as measuring portions and grocery shopping. Interventionists deliver both the group exercise and weight management sessions either alone 

or in pairs. Typically, 1-2 interventionists facilitate classes for 20-30 participants. The individual weight loss consultations are 

delivered one-on-one, which allows for a personalized treatment plan and flexibility of scheduling. The interventionists are specifically trained to deliver the intervention, and typically have bachelor degrees in health education, dietetics, or kinesiology, as well 

as relevant experience working with individuals with SMI. Those leading the group exercise classes are certified exercise instructors 

from the community, and are specifically trained for this intervention. 

The feasibility of implementing this program was previously demonstrated in a 2011 pilot study conducted through two psychiatric 

rehabilitation programs in Maryland, and supported by a grant from NIMH.45 A 2013 randomized controlled trial compared this 

intervention to a control group that received standard nutrition and physical-activity information among 291 individuals with SMI.29 

The ACHIeVe program contributed to significant weight loss of 7.0lbs on average (p=0.002) for 10 psychiatric rehabilitation outpatient programs in Maryland.29 Additionally, 37.8% of participants in the intervention group achieved clinically significant weight 

loss (5% or greater) compared to 22% of participants in the control group. The researchers are developing a standardized manual 

and training curriculum that will be made available to psychiatric rehabilitation programs and other mental health organizations. 

Inquiries can be addressed by contacting the study director Joseph Gennusa at jgennus1@jhmi.edu. 
SAMHSA-HRSA CENTER FOR INTEGRATED HEALTH SOLUTIONS 15 SAMHSA-HRSA Center for Integrated He

alt

h Solutions

3) Healthy Eating and Activity in Latinos Treated in the Heights (HEALTH) 

The description for the HeALTH intervention is brief because this program is modeled after the Behavioral Therapy (BT) approach 

developed by Brar et al (2005)35 and described in item number 10 in this section. This intervention was culturally adapted for 

Latinos with SMI, is taught by a bilingual dietitian, and consists of 20 classes spanning 14 weeks.30 During each class, participants 

weigh-in, provide the number of steps taken daily as measured using a pedometer, followed by instruction on how to incorporate 

exercise into daily routine. A quasi-experimental study of program implementation involved a clinic in Northern Manhattan in New 

York who provides mental health services to a predominantly Hispanic (75%), low-income population.30 There were no significant 

differences for weight loss between the HeALTH group and a control group receiving basic nutrition education. However, 88% of 

participants completed follow-up for the intervention group, and 24% achieved clinically significant weight loss of 5% or greater. 

The manual is available for this program free of charge. for enquiries, contact Dr. Christina Mangurian at Christina.Mangurian@ 

ucsf.edu. 

4) Recovering Through Nutrition and Exercise for Weight Loss (RENEW) 

ReNeW is a 12-month intervention focused around nutrition and physical activity, and it is delivered in three separate phases: 1) 

a 3-month intensive phase with weekly 3-hour sessions to learn about nutrition, participate in physical activity, set individualized 

goals, and eat meals together; 2) a 3-month maintenance phase with monthly 3-hour meetings and weekly phone support; and 3) 

a 6-month intermittent support phase.31 During the intensive phase, participants are provided with two meal replacements each 

day, and are encouraged to reduce their daily calorie intake by 500 calories and to participate in a minimum of 30 minutes of daily 

physical activity. 

The initial randomized controlled trial was funded by NIMH and demonstrated significant improvement with respect to weight 

loss. Participants in the ReNeW program lost an average of 5.3 and 4.4 pounds at three and six months compared to an average 

weight gain of 0.1 and 0.9 pounds among participants in the control group (p=0.005).31 The ReNeW program is targeted toward 

community-dwelling individuals with SMI with a BMI greater than or equal to 25. The program was developed by a nurse, dietitian, 

occupational therapist, and certified fitness trainer, however specific qualifications are not required for its implementation. It is 

recommended that a minimum of two group leaders deliver the program. 

The manual for the ReNeW program is available free of charge. In addition, the manual for an abbreviated version of the ReNeW program, called Nutrition and exercise for Wellness and Recovery (NeW-R), is available for download free of charge at: www.cmhsrp. 

uic.edu/health/weight-wellbeing.asp. The primary expenses associated with both the ReNeW and NeW-R programs are the staffing 

requirements, as well as the meal costs for participants during the first 12 weeks. for additional details regarding either model, and 

for inquiries regarding the formal training curriculum, contact Dr. Catana Brown at cbrown2@midwestern.edu. 

5) Solutions for Wellness (SFW) Manualized Wellness Program 

SfW is a copyrighted manualized psychoeducational program developed, published, and distributed by eli Lilly and Company. The 

program was first released in 1998, and while the format varies somewhat between settings, it is intended for persons with SMI 

who use psychotropic medications and have weight problems. The program typically consists of a 10-12 week curriculum focused 

around education to promote healthier diet and increased physical activity, and is based on written materials for both patients and 

program coordinators available to download free of charge. Within these materials, there are 18 subjects related to diet and 14 

subjects related to exercise. The program coordinator or lesson facilitator - usually a nurse or therapist - can choose which subjects 

to include to tailor each lesson to meet the participants’ needs.36 Groups range in size from 4-12 participants. 

SfW has been implemented and evaluated across numerous settings both nationally and internationally. There are several published studies evaluating SfW and prior versions of the program, though all of this research has been funded fully or in part by eli 

Lilly or has been completed by researchers who are funded or have previously received funding from eli Lilly in their research work. 

As such, the results from these studies must be interpreted with caution due to potential industry biases. 
SAMHSA-HRSA CENTER FOR INTEGRATED HEALTH SOLUTIONS 16 SAMHSA-HRSA Center for Integrated He

alt

h Solutions

 

In general, the results have been mixed, with the SfW program and its variants contributing to a range of average weight losses 

from less than 0.1 pounds43 to over 8.6 pounds.40 Nevertheless, these studies provide important evidence when considering evidence-based health promotion practices for individuals with SMI. Specifically, a 2010 non-randomized comparison study from New 

Jersey found significant improvements in weight and BMI among SfW participants compared to controls, although the control group 

was considerably unmatched on demographic and health status variables, including race and psychiatric diagnosis.37 Prior versions 

of SfW were evaluated in a 2003 mixed methods study in Georgia,43 where the control group experienced significant weight gain 

compared to the experimental group, and also in a 2004 non-randomized comparison study from New Jersey42 that demonstrated 

significant improvements in weight and BMI in pre-post analyses as well as compared to usual care controls. A different version of 

the intervention was also evaluated in a Massachusetts randomized controlled trial where greater, though non-significant, weight 

loss was observed in program participants compared to the control group.41 

Internationally, SfW and variations of this eli Lilly funded program have been tested across diverse settings. from South Korea, 

participation in this 12-week program showed significant improvements in weight and BMI in a 2006 randomized controlled-trial,40 

and in follow up, a 2008 multi-center pre-post evaluation of the same intervention demonstrated significant reductions in BMI 

(-0.98 +/-1.01 kg/m2, p<0.001) and weight (-2.64 +/- 2.75 kg, p<0.001).39 A variation of the SfW program tested in Taiwan 

found significant decreases in weight (-2.7 +/-2.2, p<0.001) and BMI (-1.1 +/-1.0, p<0.001) after 48 weeks.38 The Scandinavian 

SfW study was associated with maintaining or decreasing weight among participants.36 

Manuals for the SfW program are available for download from www.treatmentteam. 

com/Pages/solutionsforWellness.aspx and international versions from www.solutionsforwellness.org/. for additional inquiries, contact eli Lilly’s Neuroscience Information 

Line at 1-888-354-8326. for enquiries regarding evaluation, implementation, and 

training in relation to the SfW program in the United States contact Betty Vreeland at 

vreelael@umdnj.edu. 

6) Lifestyle Intervention 

The 12-week lifestyle intervention was developed and validated among patients with schizophrenia through a randomized controlled trial in Changsha, China.32 The program consists of a nutrition component that is based on the American Heart Association 

(AHA) diet plan that places emphasis on a reduction in calories from fats and carbohydrates, and an increase in fiber intake. A 

dietitian assisted program participants with diet recording, and adjusting dietary intake according to the AHA program. The second 

component of the intervention was comprised of intensive daily exercise sessions directed by an exercise physiologist for the first 

week, followed by home-based exercises for the remainder of the program. The therapists helped participants develop an individualized exercise plan consisting of a variety of light, moderate and vigorous activities to be completed at home. Participants were 

instructed to keep a log of their activities. follow-up sessions to assess exercise adherence and offer advice were held after 4, 8 

and 12-weeks, in conjunction with psychoeducational sessions focused on managing weight and describing the benefits of healthy 

diet and physical activity. 

This intervention was evaluated in a four-arm randomized controlled trial comparing the lifestyle intervention and metformin to 

metformin alone, lifestyle intervention and placebo, and a placebo alone.32 A total of 32 participants were in each arm. Significant 

decreases in weight and BMI were observed in the lifestyle intervention and metformin group, the metformin alone group, and the 

lifestyle intervention and placebo group, while the same measures increased in the placebo group over time. The lifestyle intervention and metformin group experienced a decrease in weight of 7.3% (mean, 4.7 kg; 95% CI, 3.4-5.7 kg) and a decrease in BMI 

of 1.8 (95% CI, 1.3-2.3). The lifestyle intervention and placebo group experienced a decrease in weight of 2.2% (1.4 kg; 95% CI, 

0.7-2.0 kg) and a decrease in BMI of 0.5 (95% CI, 0.3-0.8). Between group comparison revealed significant reductions in weight 

and BMI in the lifestyle intervention and metformin group compared to all other groups. The lifestyle intervention and placebo 

group lost significantly more weight (p<0.001) and lowered BMI (p<0.001) compared to the placebo alone group. This study was 

completed as part of the lead author’s doctoral dissertation, and was funded through a grant from the Ministry of Science and 

Technology of the People’s Republic of China. 
SAMHSA-HRSA CENTER FOR INTEGRATED HEALTH SOLUTIONS 17 SAMHSA-HRSA Center for Integrated He

alt

h Solutions

This lifestyle intervention has been implemented for use among patients with schizophrenia within other hospitals in China. A 

manual describing the intervention in Chinese is available free of charge. To obtain the manual, contact Dr. Ren-Rong Wu by email 

at wurenrong2005@yahoo.com.cn. 

7) Simplified Intervention to Modify Physical activity, Lifestyle, and Eating behavior 

(SIMPLE) 

SIMPLe is a lifestyle program focused broadly on nutrition and physical activity that 

consists of one-hour group sessions with 8-12 attendees held weekly over a 16-week 

period. The program places emphasis on providing weight loss support and teaching 

healthy eating habits including important skills such as shopping, label reading, food 

preparation and portion control. This program involves active real-world training in nutrition where persons with SMI are taken to local grocery stores to do shopping and 

receive assistance with selecting healthier food choices. Through the program, participants also receive financial reimbursement for healthy foods for a total of $25 each 

week. A 2007 pilot study (n=18), funded by the Connecticut Mental Health Center 

foundation, highlighted the potential efficacy of this program, as participants with SMI 

lost an average of 6.4 pounds compared to a 5.9-pound weight gain on average among controls (p=0.026). Weight loss continued 

following completion of the intervention among participants who completed a 6-month follow-up. This intervention has since been 

evaluated as part of a larger randomized controlled trial, to which the results are not yet available. This program will be implemented 

clinically for use among patients at community mental health centers in New Haven, CT. Training is available at cost to all non-profit 

entities. The manual describing this intervention as well as participant handouts are available free of charge at www.simpleprogram.org. for additional inquiries, contact Dr. Cenk Tek at cenk.tek@yale.edu. 

8) Diabetes Awareness and Rehabilitation Training (DART) 

DART is a 24 week manualized intervention consisting of three primary components: 1) diabetes education; 2) nutrition; and 3) 

lifestyle exercise.34 The education component covers several topics related to diabetes and diabetes management, including basic 

symptoms, complications, medications, how to use a glucose meter, and how to talk with your doctor. During the nutrition component, participants learn about food groups, portion sizes, selecting healthy meals, how to read labels, and how to replace sugar 

with fat and fiber. Lastly, the lifestyle exercise component reviews different types of exercise, the relationship between blood sugar 

and exercise, how to track exercise using pedometers, and the importance of foot care during exercise. 

The intervention is designed for middle-aged and older adults with serious mental illness (Schizophrenia or schizoaffective disorder) and type-2 diabetes mellitus who are taking a second-generation antipsychotic medication. The program has been implemented in community mental health centers and delivered by counselors with master’s level training and experience working with 

persons with serious mental illness. 

In a 2006 randomized controlled trial with 64 participants, those receiving DART (N=32) achieved significantly greater weight loss 

when compared to the usual care control group (5 lbs loss vs. 6 lbs gain, p<0.001).34 Additionally, 38% of DART participants 

achieved clinically significant weight loss of 5% bodyweight or greater compared to 12% in the control group.34 This study was supported by grants from NIMH and the Department of Veterans Affairs. 

Currently, this program is being expanded to include people with bipolar disorder and major depression. The manual is available by 

contacting the program developer, Dr. Christine McKibbin at cmckibbi@uwyo.edu. 
SAMHSA-HRSA CENTER FOR INTEGRATED HEALTH SOLUTIONS 18 SAMHSA-HRSA Center for Integrated He

alt

h Solutions

9) A Behavioral Group-Based Treatment for Weight Reduction in Schizophrenia and 

Other Severe Mental Illnesses (BT) 

In this 14-week behavioral treatment program, the primary focus is around diet and nutrition, and working through incremental 

steps towards developing an understanding of caloric content of foods, self-monitoring, and portion control among program participants.35 The program consists of 20 sessions separated into seven steps, where two sessions are held each week for the first 

six weeks, and one weekly session for the remaining eight weeks. In the later sessions, there is some emphasis on exercise participation and calorie burning activities, though the program predominantly focuses on developing healthy eating habits.35 Sessions 

are typically one hour in length and have 3-6 participants. Anyone with experience working with persons with SMI in group-based 

settings can deliver the program. 

This program was evaluated in a 2005 randomized controlled trial in Pennsylvania. This study formed part of a larger trial that 

examined the effects of changing antipsychotics, from olanzapine to risperidone, on body weight among participants with SMI.46 

Both of these trials were funded by Janssen Pharmaceutica, the developer and manufacturer of risperidone (Risperdal), therefore 

the results should be interpreted with caution given potential conflicts of interest and industry bias. out of 72 patients with SMI 

and BMI >26 kg/m2, significant weight loss and reductions in BMI were observed in both the behavioral therapy group (n=34; 

-2.0 +/- 3.79 kg, p=0.005; -0.9 +/- 1.38, p=0.003 respectively) and the usual care group (n=37; -1.1 +/- 3.11 kg, p=0.042; -0.5 

+/- 1.19, p=0.029, respectively). While the behavioral therapy group lost more weight and experienced greater reduction in BMI 

when compared to controls, the between group differences were not significant. 

Among participants who attended at least one behavioral therapy session, significantly more participants in the behavioral therapy 

group reported clinically significant reductions in weight (≥5% of body weight) compared to the control group (32.1% vs. 10.8%, 

p=0.038). And for participants who completed the 14-week intervention, 40.9% achieved clinically significant weight loss. This 

behavioral therapy program has subsequently been evaluated in a larger randomized controlled trial funded by a NIMH R01 grant, 

to which the results are in preparation. The manual for the behavioral therapy program is available free of charge by contacting the 

study authors, Dr. Rohan Ganguli at Rohan.Ganguli@camh.ca. 
SAMHSA-HRSA CENTER FOR INTEGRATED HEALTH SOLUTIONS

SAMHSA-HRSA Center for Integrated He

alt

h Solutions

APPendIx I: Search Methods 

Literature Review 

The research team updated a previous review of the literature completed for SAMHSA in 2011 by Bartels & Desilets (refer to 

Box 1 for full description). Consistent with the methods used in the prior review, the research team conducted a comprehensive 

search of published systematic reviews and research studies indexed in the following electronic databases in August 2012: PubMed (MeDLINe), PsycINfo, The Cochrane Library and CINAHL. Search terms included a combination of keywords and medical 

subject headings (MeSH) relating to persons with SMI, physical health related co-morbidities and health promotion interventions. Specifically, the following search parameters were used: (“Schizophrenia”[MeSH] or “Psychotic Disorders”[MeSH] or “Bipolar Disorder”[MeSH] or “Depressive Disorder, Major”[MeSH] or “serious mental illness”) AND (“obesity”[MeSH] or “Diabetes 

Mellitus”[MeSH] or “Hypertension”[MeSH] or “Heart failure”[MeSH] or “Hyperlipidemias”[MeSH] or “Myocardial Infarction”[MeSH] 

or “Comorbidity”[MeSH] or “physical health” or “co-existing” or “co-occurring” or “comorbid”) AND (“Health Promotion”[MeSH] 

or “Diet”[MeSH] or “Diet Therapy”[MeSH] or “exercise”[MeSH] or “exercise Therapy”[MeSH] or “Health Behavior”[MeSH] or “Life 

Style”[MeSH]). Searches were limited to clinical trials, meta-analyses, randomized controlled trials (RCT) and reviews published 

in the past 20 years, written in the english language and with adult (aged 18+) subjects. In addition, the research team handselected and retrieved relevant articles from the review articles, from the reference lists of relevant articles, and following full text 

examination. 

Box 1. Summary of Systematic Review 

Title: Physical Activity and Nutrition Health Promotion Programs for Overweight People with Serious Mental Illness: What 

Works? 

A 2011 Systematic Review and Analysis of the evidence Base in the Published Research Literature by the Dartmouth Health 

Promotion Research Team 

Stephen J. Bartels, MD, MS & Rebecca Desilets 

In early 2011, a Dartmouth research team reviewed the published research literature addressing non-pharmacological 

lifestyle interventions aimed at reducing obesity and improving fitness for persons with SMI. An electronic database search 

was conducted to identify high quality research studies based on pre-designated inclusion and exclusion criteria. The initial 

search identified 728 articles that were screened for content, resulting in 52 articles specifically addressing the topic area. 

from this set, 6 systematic review articles and 24 research trials met predetermined criteria for quality, including 12 randomized controlled trials (RCTs), 6 comparison studies and 6 pre-post outcome studies. The majority of the trials incorporated both nutritional and exercise components into their interventions, although several studies focused on either nutrition 

or exercise. Interventions were characterized according to whether they provided an educational approach, an activity-based 

approach or combined education and activity. 

Weight loss achieved for the interventions studied in the RCT studies consisted of a median 2.5 kg (5.5 lbs). All of the controlled studies reported differences in weight and/or BMI change between the intervention and control groups, and those 

differences were statistically significant in 10 of the controlled studies. Intervention group participants achieved a mean 

weight loss or reduction in BMI in 22 of the 24 studies selected for this review. Percentage weight loss was reported in 19 

of the research trials, with a median of 2.6%. only one study achieved a clinically significant median weight loss of 5% or 

greater (5.4%), although one other study reported that a significant proportion of participants (38%) lost at least 5% of their 

baseline weight. Clinically significant increases in physical fitness (as measured by the 6-minute walk test) were achieved 

in several of the trials. Statistically significant health benefits were reported more frequently among the interventions that 

utilized a combined educational- and activity-based approach than among those that used one or the other alone. finally, 

lifestyle interventions demonstrated improved psychological functioning among people with SMI: over half of the studies 

that measured depression symptoms reported statistically significant symptomatic improvement from the beginning until 

the end of the intervention among program participants. 

19 
SAMHSA-HRSA CENTER FOR INTEGRATED HEALTH SOLUTIONS

SAMHSA-HRSA Center for Integrated He

alt

h Solutions

Using these search terms, and combining the results of the prior review, a total of 1,541 articles were retrieved, screened, and 

evaluated for relevance, of which the majority (n = 1,450) were not relevant or did not meet inclusion criteria (n = 61) following 

full-text review. The remaining 30 studies represented evidence-based practices that satisfied the following inclusion criteria: 

8 Trials including a behavioral or educational (non-pharmacological) health promotion intervention 

8 Reported results that used standard measures of physical health outcomes, such as weight, body mass index (BMI), 

waist circumference, or other measures of physical fitness 

8 Study participants were primarily adults diagnosed with SMI, including schizophrenia, schizoaffective disorder, bipolar 

disorder, or severe depression 

8 Minimum of 30 participants in the study 

Among these 30 peer-reviewed studies, some interventions were described more than once by the same study authors, leaving a 

total of 27 unique evaluations of evidence-based practices aimed at reducing obesity and improving physical fitness for people 

with serious mental illness. These 27 trials consisted of 15 randomized controlled trials (RCTs), 6 non-randomized comparison 

studies, and 6 single arm trials. Results were not limited to studies conducted in the U.S., and of the 27 trials identified, 11 were 

from 9 countries abroad: Canada (n=1); China (n=1); Denmark (n=1); Israel (n = 1); Italy (n = 1); Korea (n=2); Switzerland (n=1); 

Taiwan (n=2); and Thailand (n=1). 

Follow-up with Study Authors 

The next step was to expand upon the information collected through the literature review, and to determine the extent to which each 

of the 27 evidence-based programs were “implementation-ready” for use by usual care providers, and to determine the resources 

and costs associated with their implementation. To address these questions, the research team contacted each of the study authors and program developers to obtain responses to the detailed questions described in Box 2. 

Box 2. Survey Questions 

1) Was your program and research study grant funded? If so, did the program continue following the end of the grant? 

2) Has your program been disseminated or implemented in other settings following the initial research study? 

If you answered ‘yes’ to this question, please proceed to the following questions (3-12). If you answered ‘no’, then it is not 

necessary to answer the following questions. Thank you for your time. 

3)	 What is the target population of your program? Are there specific BMI or weight criteria? Are there pre-specified psychiatric or 

medical conditions? 

4)	 What qualifications must the providers have in order to implement and deliver your program? (eg: Nutritionist, nurse, physician, certified fitness trainer etc.) 

5)	 What are the staffing requirements, and the ratio of full-time providers to the number of participants necessary to deliver your 

program? 

6)	 Has your program been used or implemented in clinical or other settings outside of the original study? If so, in what settings? 

(Not including any follow up research) 

7)	 Is there an instruction manual available for clinicians, providers and health care systems for your program? Are there additional materials describing your program, such as video or web-based content? 

8)	 Are the manuals or other materials proprietary or are they available in the public domain? Is there a cost in order to obtain the 

instruction manual or other materials? 

9)	 Is there a formal training curriculum available in order to learn how to implement your program? If so, do you offer training? 

10) What is the estimated cost for an agency or provider group to receive training in order to implement your program? 

11) Has the overall cost (eg. training, staffing, supervisions, materials, etc.) of implementing your program in a usual care setting 

been estimated? (Yes/No) If so, what is the approximate cost per person or per 100 persons? 

12) Where can someone go to learn more about your program? (eg. website, email or phone number of contact person, pamphlet, 

etc.) Please provide details. 

20 
SAMHSA-HRSA CENTER FOR INTEGRATED HEALTH SOLUTIONS

SAMHSA-HRSA Center for Integrated He

alt

h Solutions

APPendIx II: Search Results 

over a 6-week period from mid-September to late November 2012, a total of 20 out of the 27 study authors (74%) responded with 

completed questionnaires. There were 14 respondents for studies conducted in the United States (Seven RCTs, three comparison 

studies, and four single arm studies), and six respondents for studies conducted at international sites (Three RCTs, one comparison 

study, and two single arm studies). The majority of these interventions consisted of combined nutrition and fitness education, but 

with varying formats and intensities, while some programs focused either on exercise or diet only. The results are organized according to whether the interventions are implementation ready or not. In the first section, a detailed description is provided of each 

intervention that has been implemented outside of the research setting and for which manuals and training are available or are in 

preparation. In the second section, an overview of all the other models is provided. 

APPendIx III: evidence-based Health Promotion Programs not 

Available for Implementation 

There were also several models that have been evaluated and validated in studies, but that have not been implemented elsewhere. 

Most often, these interventions were discontinued due to lack of funding. The table below provides an overview of these models. 

Evidence-based interventions that discontinued after completion of the study 

Study Region Design Funding Duration Description Reason to 

Discontinue 

Zhang US (NY) Single arm Health System 12 months Weekly group or individual cognitive- Lack of funding. 

(2012)47 behavioral weight management. 

Methapatara Thailand RCT Internal 12 weeks Pedometer walking program with goal Research study 

(2011)48 setting, group education on nutrition and only. 

exercise. 

Melamed Israel Non-Ran­ eli Lilly in part 12 weeks facility-based combination of nutritional Program was not 

(2008)49 domized counseling, group behavioral therapy, continued. 

Comparison mealtimes overseen by supervisor, and 

walking sessions multiple times per week. 

Wu (2007)50 Taiwan RCT China Medical 24 weeks facility-based intervention consisting of Research study 

University reduced calorie diet and exercise program only. 

Grant 

Beebe US (TN) RCT NIMH Grant 16 weeks exercise-based intervention consisting of 3 Research study 

(2005)51 weekly treadmill-walking sessions. only. 

Kalarchian US (PA) Single arm NARSAD Grant 12 weeks Diet intervention based on the Stoplight end of funding. 

(2005)52 Diet with 12 hour-long educational sessions 

Richardson US (MI) Single arm Internal – 12 weeks Lifestyle intervention program consisting end of funding. 

(2005)53 University of of nutrition and exercise education sesMichigan sions plus a group walk at the end of each 

session. 

21 
SAMHSA-HRSA CENTER FOR INTEGRATED HEALTH SOLUTIONS 22 SAMHSA-HRSA Center for Integrated He

alt

h Solutions

RefeRenCeS
 

1.	 Allison DB, fontaine KR, Heo M, et al. The distribution of body mass index among individuals with and without schizophrenia. Journal of 

Clinical Psychiatry. 1999;60(4):215-220. 

2.	 De Hert M, Correll C, Bobes J, et al. Physical illness in patients with severe mental disorders. I. Prevalence, impact of medications and 

disparities in health care. World Psychiatry. 2011;10(1):52-77. 

3.	 Jones DR, Macias C, Barreira PJ, fisher WH, Hargreaves WA, Harding CM. Prevalence, severity, and co-occurrence of chronic physical health 

problems of persons with serious mental illness. Psychiatric Services. Nov 2004;55(11):1250-1257. 

4.	 Baxter DN. The mortality experience of individuals on the Salford Psychiatric Case Register. I. All-cause mortality. British Journal of Psychiatry. Jun 1996;168(6):772-779. 

5.	 Goldman LS. Medical illness in patients with schizophrenia. Journal of Clinical Psychiatry. 1999;60(Suppl 21):10-15. 

6.	 Holmberg SK, Kane C. Health and self-care practices of persons with schizophrenia. Psychiatric Services. 1999;50(6):827-829. 

7.	 Jeste DV, Gladsjo JA, Lindamer LA, Lacro JP. Medical comorbidity in schizophrenia. Schizophrenia Bulletin. 1996;22(3):413-430. 

8.	 Sokal J, Messias e, Dickerson fB, et al. Comorbidity of medical illnesses among adults with serious mental illness who are receiving community psychiatric services. Journal of Nervous and Mental Disease. 2004;192(6):421-427. 

9.	 Allison DB, Mentore JL, Heo M, et al. Antipsychotic-induced weight gain: a comprehensive research synthesis. American Journal of Psychiatry. 1999;156(11):1686-1696. 

10.	 Wisniewski H, Wegiel J, Morys J, Bobinski M. Alzheimer dementia neuropathology. In: emery V, oxman T, eds. Dementia Presentations, 

Differential Diagnosis, and Nosology. Baltimore & London: The Johns Hopkins University Press; 1994:79-93. 

11.	 Allison DB, Casey De. Antipsychotic-induced weight gain: a review of the literature. J Clin Psychiatry. 2001;62 Suppl 7:22-31. 

12.	 Treuer T, Hoffmann VP, Chen AK, et al. factors associated with weight gain during olanzapine treatment in patients with schizophrenia or 

bipolar disorder: results from a six-month prospective, multinational, observational study. World J Biol Psychiatry. 2009;10(4 Pt 3):729­

740. 

13.	 Strassnig M, Miewald J, Keshavan M, Ganguli R. Weight gain in newly diagnosed first-episode psychosis patients and healthy comparisons: 

one-year analysis. Schizophrenia Research. Jul 2007;93(1-3):90-98. 

14.	 Consensus development conference on antipsychotic drugs and obesity and diabetes. Diabetes Care. feb 2004;27(2):596-601. 

15.	 Melkersson KI, Hulting AL, Brismar Ke. elevated levels of insulin, leptin, and blood lipids in olanzapine-treated patients with schizophrenia 

or related psychoses. J Clin Psychiatry. oct 2000;61(10):742-749. 

16.	 Roick C, fritz-Wieacker A, Matschinger H, et al. Health habits of patients with schizophrenia. Social Psychiatry and Psychiatric Epidemiology. May 2007;42(4):268-276. 

17.	 Kilbourne AM, Rofey DL, McCarthy Jf, Post eP, Welsh D, Blow fC. Nutrition and exercise behavior among patients with bipolar disorder. 

Bipolar Disord. Aug 2007;9(5):443-452. 

18.	 Brown S, Birtwistle J, Roe L, Thompson C. The unhealthy lifestyle of people with schizophrenia. Psychological Medicine. May 1999;29(3):697­

701. 

19.	 McCreadie RG, Scottish Schizophrenia Lifestyle Group. Diet, smoking and cardiovascular risk in people with schizophrenia: descriptive 

study. British Journal of Psychiatry. Dec 2003;183(12):534-539. 

20.	 Strassnig M, Brar JS, Ganguli R. Nutritional assessment of patients with schizophrenia: a preliminary study. Schizophrenia Bulletin. 

2003;29(2):393-397. 

21.	 Ryan MC, Collins P, Thakore JH. Impaired fasting glucose tolerance in first-episode, drug-naive patients with schizophrenia. American 

Journal of Psychiatry. feb 2003;160(2):284-289. 

22.	 Lawrence D, Holman CDJ, Jablensky AV. Preventable Physical Illness in People with Mental Illness. Perth, Australia: The University of Western Australia;2001. 

23.	 Dixon L, Postrado L, Delahanty J, fischer PJ, Lehman A. The association of medical comorbidity in schizophrenia with poor physical and 

mental health. J Nerv Ment Dis. 1999;187(8):496-502. 

24.	 Bartels SJ, Clark Re, Peacock WJ, Dums AR, Pratt SI. Medicare and Medicaid costs for schizophrenia patients by age cohort compared with 

depression, dementia, and medically ill patients. Am J Geriatr Psychiatry. Nov 2003;11(6):648-657. 
SAMHSA-HRSA CENTER FOR INTEGRATED HEALTH SOLUTIONS 23 SAMHSA-HRSA Center for Integrated He

alt

h Solutions

25.	 Mossey JM, Knott K, Craik R. The effects of persistent depressive symptoms on hip fracture recovery. J Gerontol. 1990;45(5):M163-168. 

26.	 Lawrence D, Holman CD, Jablensky AV, Threlfall TJ, fuller SA. excess cancer mortality in Western Australian psychiatric patients due to 

higher case fatality rates. Acta Psychiatr Scand. May 2000;101(5):382-388. 

27.	 Bartels SJ, Pratt SI, Aschbrenner KA, et al. Clinically Significant Improved fitness and Weight Loss Among overweight Persons With Serious 

Mental Illness. Psychiatric Services. 2013;64(8):729-736. 

28.	 Bartels SJ, Pratt SI, Aschbrenner KA, et al. Pragmatic Randomized Trial of Health Promotion Coaching for obesity in Serious Mental Illness 

and Maintenance of outcomes . Under Review. 

29.	 Daumit GL, Dickerson fB, Wang N-Y, et al. A behavioral weight-loss intervention in persons with serious mental illness. New England Journal 

of Medicine. 2013;368(17):1594-1602. 

30.	 Mangurian C, Chaudhry S, Capitelli L, et al. Implementation of a Weight Loss Program for Latino outpatients with Severe Mental Illness. 

Community mental health journal. 2012:1-7. 

31.	 Brown C, Goetz J, Hamera e. Weight Loss Intervention for People With Serious Mental Illness: A Randomized Controlled Trial of the ReNeW 

Program. Psychiatric Services. 2011;62(7):800-802. 

32.	 Wu RR, Zhao JP, Jin H, et al. Lifestyle intervention and metformin for treatment of antipsychotic-induced weight gain: a randomized controlled trial. Jama. Jan 9 2008;299(2):185-193. 

33.	 Jean-Baptiste M, Tek C, Liskov e, et al. A pilot study of a weight management program with food provision in schizophrenia. Schizophr Res. 

Nov 2007;96(1-3):198-205. 

34.	 McKibbin CL, Patterson TL, Norman G, et al. A lifestyle intervention for older schizophrenia patients with diabetes mellitus: a randomized 

controlled trial. Schizophr Res. Sep 2006;86(1-3):36-44. 

35.	 Brar JS, Ganguli R, Pandina G, Turkoz I, Berry S, Mahmoud R. effects of behavioral therapy on weight loss in overweight and obese patients 

with schizophrenia or schizoaffective disorder. J Clin Psychiatry. feb 2005;66(2):205-212. 

36.	 Porsdal V, Beal C, Kleivenes oK, et al. The Scandinavian Solutions for Wellness study - a two-arm observational study on the effectiveness 

of lifestyle intervention on subjective well-being and weight among persons with psychiatric disorders. BMC Psychiatry. 2010;10:42. 

37.	 Vreeland B, Minsky S, Gara MA, et al. Solutions for wellness: results of a manualized psychoeducational program for adults with psychiatric 

disorders. American Journal of Psychiatric Rehabilitation. 2010 Jan-Mar 2010;13(1):55-72. 

38.	 Chen CK, Chen YC, Huang YS. effects of a 10-week weight control program on obese patients with schizophrenia or schizoaffective disorder: a 12-month follow up. Psychiatry Clin Neurosci. feb 2009;63(1):17-22. 

39.	 Lee SJ, Choi eJ, Kwon JS. A naturalistic multicenter trial of a 12-week weight management program for overweight and obese patients with 

schizophrenia or schizoaffective disorder. J Clin Psychiatry. Apr 2008;69(4):555-562. 

40.	 Kwon JS, Choi JS, Bahk WM, 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. Apr 2006;67(4):547-553. 

41.	 Skrinar GS, Huxley NA, Hutchinson DS, Menninger e, Glew P. The role of a fitness intervention on people with serious psychiatric disabilities. 

Psychiatric Rehabilitation Journal. fall 2005;29(2):122-127. 

42.	 Menza M, Vreeland B, Minsky S, Gara M, Radler DR, Sakowitz M. Managing atypical antipsychotic-associated weight gain: 12-month data 

on a multimodal weight control program. Journal of Clinical Psychiatry. 2004;65(4):471-477. 

43.	 Littrell KH, Hilligoss NM, Kirshner CD, Petty RG, Johnson CG. The effects of an educational intervention on antipsychotic-induced weight 

gain. Journal of Nursing Scholarship. 2003;35(3):237-241. 

44.	 Van Citters AD, Pratt SI, Jue K, et al. A pilot evaluation of the In SHAPe individualized health promotion intervention for adults with mental 

illness. Community mental health journal. 2009:1-13. 

45.	 Daumit GL, Dalcin AT, Jerome GJ, et al. A behavioral weight-loss intervention for persons with serious mental illness in psychiatric rehabilitation centers. Int J Obes (Lond). Aug 2011;35(8):1114-1123. 

46.	 Ganguli R, Brar JS, Mahmoud R, Berry SA, Pandina GJ. Assessment of strategies for switching patients from olanzapine to risperidone: a 

randomized, open-label, rater-blinded study. BMC medicine. 2008;6(1):17. 

47.	 Zhang JP, Weiss JJ, McCardle M, et al. effectiveness of a Cognitive Behavioral Weight Management Intervention in obese Patients with 

Psychotic Disorders Compared to Patients with Non-Psychotic Disorders or No Psychiatric Disorders: Results from a 12-month, Real-World 

Study. J Clin Psychopharmacol. 2012;32(4):458. 
SAMHSA-HRSA CENTER FOR INTEGRATED HEALTH SOLUTIONS 24 SAMHSA-HRSA Center for Integrated He

alt

h Solutions

48.	 Methapatara W, Srisurapanont M. Pedometer walking plus motivational interviewing program for Thai schizophrenic patients with obesity 

or overweight: a 12-week, randomized, controlled trial. Psychiatry Clin Neurosci. Jun 2011;65(4):374-380. 

49.	 Melamed Y, Stein-Reisner o, Gelkopf M, et al. Multi-modal weight control intervention for people with persistent mental disorders. Psychiatr 

Rehabil J. Winter 2008;31(3):194-200. 

50.	 Wu MK, Wang CK, Bai YM, Huang CY, Lee SD. outcomes of obese, clozapine-treated inpatients with schizophrenia placed on a six-month 

diet and physical activity program. Psychiatr Serv. Apr 2007;58(4):544-550. 

51.	 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 in Mental Health Nursing. Jul 2005;26(6):661-676. 

52.	 Kalarchian MA, Marcus MD, Levine MD, et al. Behavioral treatment of obesity in patients taking antipsychotic medications. Journal of Clinical Psychiatry. Aug 2005;66(8):1058-1063. 

53.	 Richardson CR, Avripas SA, Neal DL, Marcus SM. Increasing lifestyle physical activity in patients with depression or other serious mental 

illness. Journal of Psychiatric Practice. Nov 2005;11(6):379-388.