Can Behavioral Health Organizations Change Health Behaviors? The STRIDE Study and Lifestyle Interventions for Obesity in Serious Mental Illness

Adults with seriousmental illness represent the single greatest and least recognized health disparity in the nation, reflected in a 13to 30-year reduced life expectancy (1, 2). The primary cause of this epidemic of early mortality is cardiovascular disease associated with disproportionately high rates of obesity and tobacco use (1). Paradoxically, “behavioral health” organizations have been remarkably unengaged in providing evidence-based “health behavior” interventions aimed at preventing chronic health conditions (3) associated with early mortality and health care costs that are two to three times greater in adults with serious mental illness compared with general patient populations (4, 5). The reasons for our failure to engage in a serious effort to treat obesity are likely manifold: lack of expertise, a long-standing schism between physical and mental health care, acceptance of weight gain as an inevitable side effect of antipsychotic medications, and, perhaps most insidiously, a pervasive pessimism regarding our capacity to effectively treat obesity and regarding the ability of people with mental illness to embrace health behavior change (6). A study by Green et al. (7) in this month’s issue of the Journal adds to an emerging evidence base challenging many of these beliefs and assumptions. Outcomes of a randomized trial of the STRIDE weight loss and lifestyle intervention demonstrate that behavioral interventions for obesity in persons with serious mental illness can result in clinically significant reduction in weight and diabetes risk, even when delivered by routine community mental health centers (7). In this study of 200 persons taking antipsychotic medications, thosewhowere randomly assigned to STRIDE lost an average of 4.4 kg (9.7 lbs) and 2.6 kg (5.7 lbs) at 6 and 12 months, respectively, compared with those assigned to usual care. Using a widely accepted threshold for clinically significant weight loss associated with decreased cardiovascular risk (loss of $5% body weight), almost one-half (47%) of those receiving STRIDE achieved this benchmark at 12 months. These findings of reduced cardiovascular risk are remarkably consistent with outcomes of other behavioral interventions for overweight and obese persons with serious mental illness, including the ACHIEVE (Randomized Trial of Achieving Healthy Lifestyles in Psychiatric Rehabilitation) study (37.8% experienced clinically significant weight loss) (8) and the In SHAPE study (49% obtained clinically significant weight loss or clinically significant improvement in cardiovascular fitness) (9). The STRIDE intervention consists of weekly 2-hour group meetings focused on acquiring behavioral self-management skills with 20 minutes of physical activity, delivered over 6 months, followed by 6 months of maintenance groups. The core components include the DASH (Dietary Approaches to Stop Hypertension) diet aimed at weight loss and reducing the risk of developing cardiovascular disease, with a goal of at least 25 minutes of moderate physical activity per day, as well as daily self-monitoring of food intake, calorie consumption, exercise, and sleep. STRIDE adds further evidence to reviews concluding that clinically significant reduction of cardiovascular risk in overweight and obese persons with serious mental illness is most likely to occur in a program of sufficient duration (at least 6 months) that includes both nutrition and exercise and that consists of active learning, coaching, and self-monitoring (10, 11). Of significance, weight loss was obtained regardless of antipsychotic medication weight gain propensity, a finding also described in the ACHIEVE (8) and In SHAPE (9) studies. The STRIDE study also presents several novel findings of particular significance. STRIDE was delivered as an integrated component of routine outpatient community mental health services acrossmultiple sites. In contrast, theACHIEVE trial was conducted in a day treatment program (including providing two meals each day) (8), and the initial In SHAPE randomized trial was limited to a single community mental health center (9). Compared with usual care, the STRIDE intervention was also associated with a significant decline in fasting glucose, in contrast to previous behavioral interventions targeting obesity in mental illness that failed to reduce fasting glucose levels (12). Finally, to our knowledge, this is the first study to demonstrate an impact of a behavioral weight loss intervention in persons with serious mental illness on acute medical service use. Among STRIDE participants, It is safe to conclude that behavioral interventions for obesity in people with serious mental illness should be considered an evidence-based practice.