Reducing Weight and Diabetes Risk in an Underserved Population (STRIDE)

Overweight and obesity are among the leading causes of preventable deaths in the US,
primarily through their effects on Type II diabetes mellitus and other cardiovascular
disease risk factors. Individuals with serious mental illness represent a large underserved
population at greatly increased risk of obesity, diabetes, metabolic syndrome, and
subsequent early mortality. These risks are amplified by the antipsychotic agents that are
often prescribed to treat these mental conditions.

Although strong evidence indicates that lifestyle interventions are effective at reducing
weight and other diabetes risk factors in general populations, and pilot and feasibility
studies suggest that such interventions will be effective with individuals who have mental
illnesses, no large-scale translational trials have examined such interventions in this
population.

STRIDE is a randomized controlled trial to examine the effectiveness, in a mentally ill
population, of a lifestyle intervention previously shown to be effective for reducing weight
and diabetes risk factors. We target a group of individuals taking antipsychotic agents (n
= 280) who receive treatment in one of two clinical settings—a publicly funded behavioral
health care clinic and a non-profit private health plan. Counselors from each clinical
setting will be trained in the intervention and paired with study staff to deliver it,
increasing generalizability, and improving the probability of future adoption. The
intervention promotes moderate calorie reduction, dietary changes, and increased energy
expenditure, and is based on current clinical practice guidelines for treating obesity and
cardiovascular disease.

Specific aims test the hypotheses that the intervention is more effective than usual care
in: 1) reducing weight and Body Mass Index; 2) reducing fasting insulin levels and
increasing insulin sensitivity; and 3) reducing total cholesterol and LDL cholesterol. A
fourth aim explores effects of motivation, social support, and outcomes expectancies on
primary outcomes, and moderators of intervention effectiveness (ethnicity, gender, mental
illness diagnostic group, medication type, metabolic syndrome) on outcomes.

Implementation and process evaluations will assess the fidelity of intervention delivery,
evaluate its acceptability; identify components participants find most and least helpful;
identify barriers to, and facilitators of, lifestyle changes; and evaluate the effects of
the intervention on body image, psychiatric symptoms, adherence to antipsychotic
medications, quality of life, health-related self-efficacy, health, functional status, and
social support. Cost-effectiveness analyses will evaluate incremental costs of producing
change in each primary outcome (weight, BMI, fasting insulin levels, insulin sensitivity,
and cholesterol).