Dietary intervention for people with mental illness in South Australia

Dietary intervention for people with mental illness in South Australia Abstract Background People with serious mental illness (SMI) have a 25–30 year lower life expectancy than the general population due largely to cardiovascular disease (CVD). Mediterranean diet can reduce CVD risk and repeat events by 30–70%. We conducted a pilot feasibility study (HELFIMED) with people who have SMI residing within a Community Rehabilitation Centre in South Australia, aimed at improving participants’ diets according to Mediterranean diet principles. Methods During a 3-month intervention, participants were provided with nutrition education, food hampers, and twice-weekly cooking workshops and guided shopping trips. This report presents the results of a mixed method evaluation of the programme using thorough in-depth interviews with participants and support staff (n = 20), contextualized by changes in dietary biomarkers and CVD risk factors. Results The framework thematic analysis revealed evidence of improvements in participants’ knowledge of and intake of the key elements of a Mediterranean-style diet (fruit and vegetables, olive oil, fish, legumes), reduction in poor nutrition habits (soft drinks, energy drinks, take away meals) and development of independent living skills—culinary skills such as food preparation and cooking based on simple recipes, food shopping and budgeting, healthy meal planning and social interaction. These changes were supported by dietary biomarkers, and were associated with reduced CVD risk factors. Conclusions A Mediterranean diet-based pilot study achieved positive change in dietary behaviours associated with CVD risk for participants with SMI. This supports a need to include dietary education and cooking skills into rehabilitation programmes for people with SMI. cardiovascular disease risk, serious mental illness, schizophrenia, Mediterranean diet, nutrition, lifestyle, behaviour INTRODUCTION Cardiovascular disease (CVD) is the leading cause of death in people with serious mental illnesses (SMI) (Colton and Manderschied, 2006) such as schizophrenia, bipolar disorder and major depression. People with SMI experience higher rates of chronic illness and all-cause mortality than the general population—with up to 25–30 year lower life expectancy (Colton and Manderschied, 2006; Newcomer, 2007) due primarily to modifiable risk factors including diet and obesity (Parks et al., 2006). Strong associations of CVD with schizophrenia and depression (Osborn, 2001) may be attributable in part to common underlying biological mechanisms associated with poor nutrition status, e.g. low levels of long-chain omega-3 fatty acids (n-3 PUFA; Sinn and Howe, 2008). There is evidence that the diet of individuals with schizophrenia is particularly unhealthy compared with the general population (McCreadie, 2003; Strassnig et al., 2003), characterized by a lack of fruit, vegetables and fibre, and an excess of calories from processed foods rich in sugars and saturated fat (Bushe et al., 2005). Weight gain is a well-established side effect of first- and second-generation antipsychotic (SGA) therapy (Newcomer, 2005) used for the management of schizophrenia. SGA medications are also associated with insulin resistance, hyperglycemia and type 2 diabetes (Lambert and Chapman, 2004). This combination of poor diet and medication side-effects leaves people with SMI at significantly increased risk of metabolic syndrome (Newcomer, 2007), a major risk factor for CVD (Malik et al., 2004). Fewer people with SMI have knowledge about CVD (Osborn et al., 2007) and associations between lifestyle and poor health (Parletta et al., under review). This provides an opportunity for targeting health education and lifestyle risk factors in this high risk population. Indeed, a 30-min food and nutrition education session for people with psychosis was moderately successful in improving their knowledge (Wirshing et al., 2006). Mediterranean-style dietary patterns can improve cardiometabolic risk factors and are superior and more sustainable for weight loss than low fat diets (Mente et al., 2009; Shai et al., 2008). A meta-analysis of dietary patterns associated with reduced CVD risk identified the Mediterranean dietary pattern as the most protective over other dietary interventions, including low-fat diets (Nordmann et al., 2011). Two large randomized controlled trials reported that a Mediterranean diet reduced risk of repeat cardiovascular events by 70% in secondary prevention (de Lorgeril et al., 1999) and major cardiovascular events by 30% in people at high risk (Estruch et al., 2013). Traditional, Mediterranean-style diets are characterized by consumption of whole, minimally processed plant foods (vegetables, fruit, legumes, nuts, grains, seeds and olives), olive oil as the main culinary fat, moderate to high consumption of fish, moderate consumption of eggs, poultry, dairy products and red wine and low consumption of red meat and confectionary (Bach-Faig et al., 2011). The nutrient profile includes a high ratio of monounsaturated to saturated fat, high intakes of n-3 PUFA, fibre, micronutrients, and polyphenols. Some of these elements have been individually associated with cardio-protective effects but the whole dietary pattern is thought to be greater than the sum of its parts (Martinez-Gonzalez and Gea, 2012). These nutrients are not only essential for optimal physical health but are required for healthy brain function (Parletta et al., 2013). One of the benefits of a Mediterranean-style diet is that it is appealing and can be incorporated into a healthy lifestyle; hence has potential to be sustainable. However, changing established dietary behaviours and preferences is challenging even in the general population and requires multi-level approaches (Ory et al., 2002). To facilitate dietary behaviour change in individuals with SMI it is necessary to address the very early stages (Prochaska and DiClemente, 1994); namely readiness to change, where education, motivation and skill development are the primary focus. Furthermore, healthy foods are more likely to be consumed when they are more available, salient and easily accessible therefore requiring minimal cognitive effort (Reinaerts et al., 2007; Hanks et al., 2012). Increased liking and preferences for vegetables can be achieved through up to 10–14 exposures in young children; this might take longer for adults with established food preferences (Wardle et al., 2003; Cooke 2007; Price and Riis 2012). A recent review identified 16 weight loss or weight gain prevention interventions in people with SMI living in the community, ranging from short conversations with healthcare providers to a comprehensive 48-session enrichment programme (Galletly and Murray, 2009). Targets included healthful eating, exercise and fitness, healthy living, and goal setting and self-regulation skills. Overall there was a modest prevention of/reduction in weight although not necessarily sustained. The programme that included practical skills around healthy meal plans, shopping and meal preparation appeared to have the greatest weight loss over the intervention period (Galletly and Murray, 2009). People with schizophrenia tend to have notable deficits in various areas of life functioning (Mausbach et al., 2007); hence the development of, and confidence in, independent living skills such as budgeting, shopping and cooking is a necessary foundation for encouraging healthy dietary behaviours in this population. The current article reports on a mixed method evaluation of a pilot feasibility study (Healthy Eating for Life with a Mediterranean-style diet; HELFIMED) with people with SMI residing in a Community Rehabilitation Centres (CRC), part of a stepped rehabilitation care system. The CRC care is a middle step between hospital care and independent living, where CRC residents often require substantial staff support to fulfil everyday chores, such as cooking, cleaning, and shopping. Therefore, one of the CRC’s primary aims is to provide its residents with skills they would need when they transition to independent living. To achieve this goal CRC partners with various programs, such as HELFIMED. The primary aim of the HELFIMED intervention was to improve dietary behaviours and nutrition status of individuals with SMI via nutrition education, cooking workshops, food hampers, shopping vouchers, and accompanied shopping trips. Although some cooking is generally included in the existing rehabilitation plan for CRC residents, the explicit focus on a healthy Mediterranean-style diet, nutrition education and lifestyle is a novel treatment for this population. The aim of this article was to evaluate the effectiveness of HELFIMED for improving healthy eating and behaviours of individuals with SMI, using a mixed-methods approach combining data from dietary biomarkers and CVD risk factors, with in-depth semi-structured interviews with CRC residents and staff. INTERVENTION STUDY METHODS This project was a partnership between the University of South Australia and the Mental Health Directorate in the Southern Adelaide Local Health Network. Ethics approval was obtained from the Southern Adelaide Clinical and University of South Australia’s Human Research Ethics Committees. CRC staff were consulted in the programme design stage to assist in identifying barriers, opportunities and optimal mode of delivery. Participants and recruitment Participants were recruited from residents of a 20-bed CRC in Adelaide, South Australia (∼75% of beds were occupied during the study). Table 1 summarizes the participant profile, which is typical for CRC residents; the majority had schizophrenia. All residents were eligible to participate. Over 6 months, 25 participants were recruited, with 13 finishing the programme and undertaking 3-month assessments and 10 completing interviews at 3-months. Following the recommendations in the literature for working with such populations, in this study the researchers worked very closely with CRC management and staff to incorporate the HELFIMED protocol into the participants’ daily routine. These measures included booking the cooking and information sessions into each resident’s weekly schedule, staff reminding participants on the day about the workshops, and staff actively promoting HELFIMED recipes when assisting participants with cooking. The attrition was still reasonably high, but this was primarily driven by changes in health conditions (having to return to hospital) or transitioning to independent living, rather than the programme itself. Future researchers who work with residential centres that have transient populations need to work with community case workers who look after participants when they leave to assist them with continuing the program. Table 1: Summary characteristics of study participants and 3-month changes in dietary biomarkers and CVD risk factors (n = 13)   Baseline    Demographic characteristics      Age (years)  29.9 ± 11.0    Gender (%): Male  61.5    Family status (%): Single  100    Race (%):      Caucasian  92.3    Aboriginal or Torres Strait  7.7    Mental illness diagnosis (%):       Schizophrenia  41.7 (n = 5)     Paranoid Schizophrenia  16.7 (n = 2)     Schizoaffective disorder  16.7 (n = 2)     Bipolar Affective Disorder  7.7 (n = 1)     Unspecific non-organic psychosis  7.7 (n = 1)     Disturbance of activity and attention  7.7 (n = 1)     Borderline personality disorder  7.7 (n = 1)        Baseline  3-months    Dietary intake biomarkers and CVD risk factors  Homocysteinea (µmol/l)  *16.8±23.2  (4.4–90.0)  11.7 ± 6.2  (5.4–31.0)  Blood glucose (mmol/l)  6.21 ± 1.54  (4.1–9.9)  5.64 ± 1.30  (4.4–8.8)  Sodium/potassium ratioa (mmol/l)  *2.1±1.2  (0.50–3.9)  *1.5±0.63  (0.26–2.6)  Systolic blood pressurea (mmHg)  119.3 ± 13.3  (96.0–140.5)  122.3 ± 12.6  (105.5–147.0)  Diastolic blood pressurea (mmHg)  76.6 ± 8.1  (64.0–92.5)  76.8 ± 5.1  (70.0–84.0)  Waist circumferencea (cm)—male (n = 8)  *102.6±18.4  (75.0–135.0)  90.6 ± 12.4  (81.0–107)  Waist circumference (cm)—female (n = 5)  *96.9±12.3  (76.0–108.5)  *95.6±14.3  (81.0–113.5)  Weight (kg)—male (n = 8)  88.1 ± 19.7  (63.8–126.8)  77.5 ± 15.4  (65.0–98.4)  Weight (kg)—female (n = 5)  85.4 ± 14.8  (64.9–98.1)  87.8 ± 17.2  (70.5–107.6)  BMI (kg/m2)—male(n = 8)  *28.1±5.0  (23.4–39.6)  25.0 ± 2.6  (22.4–28.1)  BMI (kg/m2)—female (n = 5)  *30.6±6.5  (21.0–36.5)  *32.3±6.6  (26.2–40.5)    Baseline    Demographic characteristics      Age (years)  29.9 ± 11.0    Gender (%): Male  61.5    Family status (%): Single  100    Race (%):      Caucasian  92.3    Aboriginal or Torres Strait  7.7    Mental illness diagnosis (%):       Schizophrenia  41.7 (n = 5)     Paranoid Schizophrenia  16.7 (n = 2)     Schizoaffective disorder  16.7 (n = 2)     Bipolar Affective Disorder  7.7 (n = 1)     Unspecific non-organic psychosis  7.7 (n = 1)     Disturbance of activity and attention  7.7 (n = 1)     Borderline personality disorder  7.7 (n = 1)        Baseline  3-months    Dietary intake biomarkers and CVD risk factors  Homocysteinea (µmol/l)  *16.8±23.2  (4.4–90.0)  11.7 ± 6.2  (5.4–31.0)  Blood glucose (mmol/l)  6.21 ± 1.54  (4.1–9.9)  5.64 ± 1.30  (4.4–8.8)  Sodium/potassium ratioa (mmol/l)  *2.1±1.2  (0.50–3.9)  *1.5±0.63  (0.26–2.6)  Systolic blood pressurea (mmHg)  119.3 ± 13.3  (96.0–140.5)  122.3 ± 12.6  (105.5–147.0)  Diastolic blood pressurea (mmHg)  76.6 ± 8.1  (64.0–92.5)  76.8 ± 5.1  (70.0–84.0)  Waist circumferencea (cm)—male (n = 8)  *102.6±18.4  (75.0–135.0)  90.6 ± 12.4  (81.0–107)  Waist circumference (cm)—female (n = 5)  *96.9±12.3  (76.0–108.5)  *95.6±14.3  (81.0–113.5)  Weight (kg)—male (n = 8)  88.1 ± 19.7  (63.8–126.8)  77.5 ± 15.4  (65.0–98.4)  Weight (kg)—female (n = 5)  85.4 ± 14.8  (64.9–98.1)  87.8 ± 17.2  (70.5–107.6)  BMI (kg/m2)—male(n = 8)  *28.1±5.0  (23.4–39.6)  25.0 ± 2.6  (22.4–28.1)  BMI (kg/m2)—female (n = 5)  *30.6±6.5  (21.0–36.5)  *32.3±6.6  (26.2–40.5)  Values are presented as (Mean ± SD) and (range), or percentage if indicated. Missing data at baseline: Blood pressure n = 2 missing. Missing data at 3months: Blood pressure n = 4 missing; Sodium/potassium ration n = 3 missing; Homocysteine n = 1 missing; Weight, BMI and waist circumference male: n = 3 and female: n = 1 missing. a Reference ranges for dietary intake biomarkers and CVD risk factors; Indicates value elevated above normal range. Homocysteine: Normal: 7–14 µmol/l; moderately elevated: 15–30 µmol/l; intermediately elevated: 30–100 µmol/l; severely elevated >100 µmol/l; Blood glucose: normal random (non-fasted) blood glucose levels 4.0-7.8 mmol/L; Sodium/potassium ratio: Reduced disease risk if ratio below 1.0; Blood pressure: Normal<120/80 mmHg; High-normal 120–139/80–89 mmHg; Hypertension (mild) ≥140/90 mm Hg; Hypertension (severe) ≥180/110 mmHg; Waist circumference: Men > 94 cm increased risk to health; >102 cm substantially increased disease risk; Women > 80 cm increased risk to health; >88 cm substantially increased disease risk; BMI: Healthy weight 18.5–24.9 kg/m2; Overweight 25.0–29.9 kg/m2; Obese ≥ 30 kg/m2. Intervention measures Participant assessments were conducted at baseline, three and six months. Height, weight, waist circumference, blood pressure and finger-prick blood glucose measurements were measured by CRC staff. Fasted blood and urine samples were taken and analysed by the local pathology clinic to measure homocysteine, sodium and potassium levels. This manuscript utilizes the results from baseline and 3-month blood and urine samples and anthropometric measurements, to complement dietary and behaviour changes reported in qualitative data (Table 1). Height and weight and were used to calculate Body Mass Index (BMI: kg/m2), to classify participants’ body composition according to established obesity categories (18.5–24.9 = normal weight; 25–29.9 = overweight; >30 = obese). Waist circumference measurements were classified according to published guidelines (National Vascular Disease Prevention Alliance, 2012: men: >94 cm increased risk to health; >102 cm substantially increased risk to health; women: >80 cm increased risk to health; >88 cm substantially increased risk to health). Homocysteine levels, measured in plasma from fasting (8 h) blood samples, and sodium/potassium, measured in 10 ml urine samples, were used as complementary indicators of self-reported dietary changes. Sodium levels reflect processed food intake and potassium reflect whole food intake (Meneton et al., 2009). Therefore a reduced sodium/potassium ratio suggests improved dietary intake. Recommendations suggest that a higher sodium/potassium ratio (> 1.0) indicates increased risk of high blood pressure and CVD (Yang et al., 2011; Drewnowski et al., 2012). Homocysteine is an intermediary molecule produced during amino acid metabolism in the body. Vitamins B6, B12 and folate are required to modulate levels of homocysteine in the body. Insufficient intake of these nutrients causes homocysteine levels to become elevated, which is a recognized marker for CVD risk. Evidence also suggests that elevated homocysteine may be associated with poor mental health (Parletta et al., 2013). Reduced plasma homocysteine levels can indicate increased intake of these nutrients, found in a wide range of unprocessed foods such as whole grains, lentils, beans, bananas and nuts. Reference ranges propose normal plasma homocysteine levels between 7 and 14 µmol/l; moderately elevated 15–30 µmol/l; intermediately elevated 30–100 µmol/l; and severely elevated >100 µmol/l. Intervention protocol Following completion of baseline assessments participants began the HELFIMED programme. Nutrition education sessions were conducted with staff and residents using an interactive quiz and food modelling activity, based on healthy eating guidelines adapted from the Australian Guide to Healthy Eating (Department of Health and Ageing, 2010). Follow up nutrition education sessions were conducted periodically throughout the study as reinforcement and to engage new residents entering the CRC. Cooking workshops were conducted twice weekly and were rotated among residents’ own kitchens. Participants prepared and cooked a supplied recipe with instruction provided by two research assistants, supported by CRC staff. Recipes were designed to be simple, tasty, affordable meals based on Mediterranean diet principles. Participants received food hampers once per week containing a variety of ingredients including nuts, extra virgin olive oil, legumes, and fresh seasonal fruit and vegetables. At 3-month food hampers were replaced with four weeks of shopping vouchers, which participants used to purchase whole foods during guided shopping trips. This enabled participants to learn skills around meal planning and using a shopping list. The structure, content and implementation of the intervention protocol were tailored for participants with SMI who may experience cognitive barriers; this included using at least two workshop instructors (researchers and CRC staff member), repetition, multiple teaching modalities (interactive activities, verbal information) and skill building. QUALITATIVE EVALUATION METHOD In the qualitative phase of the assessment, in-depth interviews with CRC residents and staff investigated different aspects of participants’ experiences with the HELFIMED program. Specifically, the following research questions were explored: RQ1: What changes in food-related behaviours occurred during HELFIMED, and how were these associated with the Mediterranean diet? RQ2: What changes occurred in participants’ independent living skills, including cooking and shopping ability, confidence to cook independently and social skills? The qualitative approach is ideally suited to address these questions, as it allows for in-depth understanding of the circumstances under which the changes took place and the barriers and levers to change. Qualitative research can help to assess complex lifestyle interventions, such as behaviour-change studies where numerous factors influence the relevant behaviours (Wansink and Sobal, 2007) and can help to explain individual variability in outcomes with diverse and complex participant profiles. Where possible, we report available data on changes in dietary biomarkers and CVD risk factors to contextualize the qualitative data. For this study, the major unit of analysis was the participant case. Each case study contained: (i) one in-depth interview with a resident (n = 10); (ii) one expert interview with a supporting staff member (n = 10); and (iii) supporting ‘field’ notes made by researchers and staff. The majority of participants who completed 3-months (i.e. 10 cases out of 13 completions) were examined qualitatively; two participants exited the CRC before undertaking the interview, and one participant was unable to complete interviews due to cognitive difficulties. This sampling contained a natural bias typical for Appreciative enquiry-type studies (Shiner et al., 2008), which includes only participants who have successfully completed all programme requirements. The resulting sample allowed identification of factors that contributed to success in the programme and modelling of future interventions based on these outcomes. All interviews took place between February and May of 2014 at the CRC. Data collection procedure Many individuals with SMI face challenges with social interaction due to low self-esteem, social anxiety and negative self-stigma (Mashiach-Eizenberg et al., 2013). Despite these challenges, personal in-depth interviews have been successfully used with people with SMI (Shiner et al., 2008). Therefore we used personal interviews, conducted by two of the researchers who worked with the participants throughout the programme and established close rapport with them, a necessary condition for a qualitative enquiry (Dickson-Swift et al., 2007). A semi-structured interview guide (see Supplementary Appendix S1) was used to prompt for key information, allowing participants to talk about their own feelings, circumstances and experiences. Key themes included the description of food habits and any changes, knowledge and the use of Mediterranean diet principles, attitudes to healthier eating, changes in self-confidence and independent living skills, and HELFIMED programme feedback on what they liked and disliked about the program. A flexible schedule enabled the interview to be conducted on a day when the participant felt well and up to the task, which was necessary due to daily fluctuations in severity of symptoms and mood. To accommodate participants’ mental conditions, including easy mental fatigue, short attention span, often, limited ability to elaborate on narratives, the interviews with participants were made a little shorter than the usual practice (M = 13 min), but still covered key aspects of their experiences. To augment these data, each participant’s interview was followed by a longer (M = 25 min) supporting interview with a staff member from the participant’s core rehabilitation team. The staff member was asked to comment on the participant’s progress in the programme and whether they observed changes in diet and lifestyle behaviours. Comparative analysis of the participant and corresponding staff interviews showed that both provided similar information. However, staff members were more capable of noting specific behavioural changes, offer factual information and link health incidents and other information they knew about the cases. Finally, participant data were enriched with staff and researcher ‘field’ notes collated throughout the programme focusing on meaningful events (e.g. when a participant bought herself a smoothie maker to increase her fruit intake) or memorable phrases (e.g. ‘I did not know vegetables could taste so good!’; a comment by a number of participants after initial cooking workshops). Notes about participants’ mental and physical health-related events that might have affected their programme participation were also recorded. These methodological steps ensured that rich data were obtained for each participant case and provided the opportunity for cross-validation and reliability checks. Each interview was audio-taped and transcribed verbatim. For initial interviews, two researchers paired to ensure consistency in the questioning technique. Then, all team members read a sample of the interviews and compared their own impressions with the original researcher’s interpretations and coding. This process minimized possible interpretation biases and ensured no important information was overlooked (Wallendorf and Belk, 1989). Triangulation of information from participant interviews, supporting staff transcripts and field notes ensured within-case consistency and internal validity of the data. The Framework Method and thematic analysis This study followed the Framework Method of analysing qualitative data (Smith and Firth, 2011); specifically, the process described by Gale et al. (2013) which has been recommended for multi-disciplinary health studies. A combined inductive-deductive approach included some pre-existing themes guided by programme objectives (changes in dietary behaviours) and allowed for new themes to emerge (e.g. barriers and benefits of social interactions during cooking workshops). Verbatim transcripts of the interviews were used to code statements into themes, focusing on evidence of behaviour change associated with the program. Four researchers (including two who conducted interviews) reviewed the transcripts and collaboratively developed an analytical framework outlining key themes. Three coders independently coded statements using agreed themes. New codes were created (as per the ‘open coding’ technique) for the statements that did not fit established themes. Following the Framework method of qualitative analysis (Gale et al., 2013), results were organized under the main themes and supported with illustrative quotes to demonstrate the full array of possible behaviour changes and experiences during the intervention. No quantification or prevalence of the opinions (i.e. six out of eight) was attempted, as this would represent a misleading use of the data at hand due to the small sample size. RESULTS The description of the behavioural changes made by participants during 3-months of the programme is summarized under three categories: changes in biomarkers of dietary intake and CVD risk factors; changes related to food behaviours (healthier eating habits, knowledge and adoption of the Mediterranean-style diet); changes in independent living skills (increased cooking and shopping skills, confidence to cook independently, improved social skills). Changes in biomarkers of dietary intake and CVD risk factors Table 1 shows changes in biomarkers of dietary intake and CVD risk factors. At baseline homocysteine levels were moderately elevated whereas at 3-months homocysteine fell within the normal range. The mean sodium/potassium ratio was elevated at baseline, falling closer to the recommended value of 1.0 at 3 months. From baseline to 3-months mean weight, waist circumference and BMI fell within healthy ranges for males; however, small increases were observed for females. These changes in biomarkers are reflected in the specific dietary changes reported by participants in interviews (below). Specifically, changes in sodium potassium ratio reflect reported increased intake in fruit and vegetables, and decreased intake of processed and takeaway foods. Reductions in homocysteine levels may reflect reported decreases in processed meat intake and increased intake of legumes, nuts, fruit and vegetables. Weight reductions in males reflect the reported shift towards overall healthier dietary patterns, particularly reduced intake of soft-drinks, increased cooking of Mediterranean-style meals replacing takeaway meals high in fat, sugar and salt, and greater intake of fruit and vegetables. Healthier eating habits All participants made positive changes to their eating habits (Table 2). In particular, changes were evident in swapping unhealthy snacks for healthier options such as fruit, nuts and yoghurt. At the beginning of the programme staff and residents noted that consumption of drinks high in sugar and caffeine was a major problem, with many, especially male participants, consuming up to 2 L of soft drink per day. As such, male participants demonstrated greater improvements in swapping energy or soft drinks for fruit juice or drinks lower in sugar and caffeine. Another common unhealthy eating habit prior to the programme was high consumption of take away and junk foods. The programme focused on teaching participants to cook home-made meals, highlighting the taste, ease of preparation, time and money savings. Multiple participants reported at 3 months that they reduced the amount of take away meals they ate. Table 2: Summary of qualitative findings and example quotes Theme  Findings and example quotes  Healthier eating habits  Swapping unhealthy snacks for fruits, nuts or yoghurt: ‘Last week I went and bought more bananas. If I’m on the run, like lately, I'll go and try eat a banana before I go or a piece of fruit to take it with me’ (female, 40). ‘All through last year, she had a goal of stopping chocolate biscuits and she’s managed to do that. She has sweet things now that include fruit and yoghurt so her knowledge has definitely changed, there has definitely been a shift in what she views as a “desserty” kind of thing or a sweet kind of thing’ (staff about female, 33). ‘I’ve seen him eat an apple and a banana and things like that just as a snack food’ (staff about male, 22). Swapping energy or soft drinks to fruit-based drinks or drinks lower in sugar and caffeine: ‘I use to have more coffees and I don’t have that anymore. But I think that’s more to do with that I don’t feel like I need it anymore’ (male, 28). ‘I got picked up on the amount of sugar that I consume through soft drink, and I’ve probably cut down on soft drink in the last couple of weeks… I’ve also been drinking orange juice’ (male, 48) Reduced consumption of takeaway meals and convenience foods: ‘[before the program] he was choosing to go down the path of convenience food rather than doing more preparation work himself… And now. he is actually replicating these recipes, so he definitely, has to have been learning stuff…’ (staff about male, 22).  Knowledge and adoption of Mediterranean diet  Increased knowledge of the Mediterranean diet: ‘I had no idea what a Mediterranean diet was, just looking into all the recipes I now know different recipes that I can use to cook with and what kinds of meats to use and like I buy leaner meats and fish and things like that I can use to make lots of different things’ (female, 30). Increased consumption of fruit and vegetables, especially salads: ‘I have tried lots of salad recipes. I never use to eat salads or anything like that’. (female, 30). ‘I have increased my salad intake since I have joined, but my fruit intake has stayed about the same, and that is a lot’ (male, 28). Increased use of olive oil: ‘She uses olive oil whenever she cooks’(staff about female, 33). ‘Because they have had that continuous exposure [to olive oil], when he went shopping he would automatically buy it’ (staff about male, 25). Increased fish intake: ‘She is consistently eating avocado and tuna, and I think she feels that those are ingredients that have been inspired by the HELFIMED project’ (staff about female, 33). Reduced intake of red and processed meats (such as sausages and hamburgers): ‘I think I have gravitated more towards fish and white meats now’ (female, 30). ‘… and I don’t have sausages anymore. So that’s changed’ (male, 28). Increased intake and/or familiarity with and preference for legumes and lentils: ‘One time I made a chickpea and veggie curry with him…then he has made homemade yiros and lentil shepherd pie’ (staff about male, 25).  Nutrition knowledge  Improved knowledge and an increased interest in learning more about nutrition: ‘…before he didn’t even know what it [a vegetable] was and now he knows what it is. he may have not heard about it [before], or heard about it and not even bothered to consider what it was about. Now he is aware of what it is because HELFIMED has shown him’ (staff about male, 22). Improved recognition of unhealthy foods and their damaging impact on health: ‘Like I was saying before I used to only eat stuff like noodles and pasta and stuff like that and yeah that’s not healthy’ (male, 29). ‘He will say something like ‘yeah that is meant to be good for you’. He also knows…too much coffee or energy drinks etc. isn’t good for him’ (staff about male, 25). Some misconceptions about nutrition knowledge, and confusion about unfamiliar foods: ‘I’m pretty sure if you have seven pieces of fruit it counteracts the five vegetables’ (male, 28). ‘I still get confused between a cucumber and a zucchini’ (female, 40).  Attitudes and motivations to eating healthy foods  Development of positive attitudes and increased intentions to eat healthier foods: ‘She’s been someone who has genuinely taken on board a lot of what has been spoken about in the workshops’ (staff about female participant, 33). ‘She is promoting [healthy eating] with the other residents and staff’ (staff about female participant, 40). Willingness and persistence in trying new, unfamiliar and previously disliked foods: ‘I don’t think I’d had eggplant before; I’d never used it in anything I had prepared anyway. Um and ah zucchini I wasn’t…um yeah probably a bit more diverse in vegetables than I’d eat in the past’ (Male, 48). ‘… she is trying to like some of the foods. It’s definitely on her radar now’ (staff about female, 40). Increased motivation to eat healthy food, aligned with overall pursuits of becoming ‘healthier’: ‘He does want to get healthier, fitter and he wants to be more motivated in terms of . his more career-based goals… And he knows that healthy lifestyle will contribute to that in a positive way’ (staff about male participant, 22). ‘I can see that he is asking more questions about like “what’s this”; “how do you prepare this, you know; what’s this for” which is huge … he is actually digging deep and wanting to know’ (staff about male, 22).  Improved cooking skills  Improved cooking skills, including: basic knife skills, chopping, cooking on the stove, steaming, baking in the oven, cooking vegetables: ‘I have learnt lots of cooking skills like I wasn’t very good at cooking before this so I have learnt like chopping up salads and things like that and cooking on the stove…’ (female, 30). ‘Didn’t know how to make recipes and that, now I’ve done a few recipes. New stuff to cook for when I move out’ (male, 22). ‘… when I was growing up I actually never got taught how to use a fork and knife, so it’s a hell of a time trying to learn at this age… when I first started [HELFIMED] I used to [cut] the simple ones cause I could never cut properly with a knife so that has improved majorly. It was a major fear probably at the start because you know … I’ve been working on it. …I always had problems cutting so, yeah, that’s really improved.’ (female, 40). ‘When she first came, she was really struggling with a knife and fork, preparing vegetables and that kind of thing. She’s a lot more independent with that now, so she’s independently eating and she’ll independently cook herself a meal’ (staff about female, 40).  Increased confidence in cooking independently  Increased confidence and more undertaking of independent cooking and meal preparation: ‘My cooking skills have got better… I'm more confident cooking by myself now’ (male, 22). The staff member agreed: ‘…a lot times he has asked me to help and he doesn’t need a lot of help, he just needs., he just wants a bit of company. his confidence is building up that he’s replicating recipes’ (staff about male, 22). ‘From little things, like trying new ingredients to the bigger things like cooking whole meals that are different and new, and that she’s even made up [new recipes] using the ingredients that she’s been inspired to use’ (staff about female, 33).  Shopping and budgeting  Limited success for improvements in meal planning, many struggled to follow-through when shopping: ‘When I do my shopping I usually think about it then. But I don’t really plan it.’ (male, 21). ‘I see other things in the shop and I think ‘oh, yeah, I’ll grab this, I’ll grab that!’. Last week I think I went way off my shopping list. I have started buying Christmas stuff and all as well like fruit mince pies.’ (female, 40).  Social skills and social anxiety  Social anxiety initially identified as a barrier/concern for attending cooking workshops: ‘Just being in a big group. Sometimes I feel uncomfortable, self-conscious and stuff like that’ (male, 22). [Interviewer: Any barriers?] ‘Oh. probably getting myself to go…Cause I’m not feeling that great in myself’ (male, 21). After attending the groups for a while the majority of participants, experienced less social anxiety and enjoyed the social aspect of being involved in the cooking workshops: ‘I was getting better the longer I stayed here as I get to know people I’m not so nervous. I don’t get so anxious about that’ (male, 22). ‘It was great how we all work together that’s what is the good thing about it. being able to work with people because that’s always been a huge fear for me’ (female, 40).  Theme  Findings and example quotes  Healthier eating habits  Swapping unhealthy snacks for fruits, nuts or yoghurt: ‘Last week I went and bought more bananas. If I’m on the run, like lately, I'll go and try eat a banana before I go or a piece of fruit to take it with me’ (female, 40). ‘All through last year, she had a goal of stopping chocolate biscuits and she’s managed to do that. She has sweet things now that include fruit and yoghurt so her knowledge has definitely changed, there has definitely been a shift in what she views as a “desserty” kind of thing or a sweet kind of thing’ (staff about female, 33). ‘I’ve seen him eat an apple and a banana and things like that just as a snack food’ (staff about male, 22). Swapping energy or soft drinks to fruit-based drinks or drinks lower in sugar and caffeine: ‘I use to have more coffees and I don’t have that anymore. But I think that’s more to do with that I don’t feel like I need it anymore’ (male, 28). ‘I got picked up on the amount of sugar that I consume through soft drink, and I’ve probably cut down on soft drink in the last couple of weeks… I’ve also been drinking orange juice’ (male, 48) Reduced consumption of takeaway meals and convenience foods: ‘[before the program] he was choosing to go down the path of convenience food rather than doing more preparation work himself… And now. he is actually replicating these recipes, so he definitely, has to have been learning stuff…’ (staff about male, 22).  Knowledge and adoption of Mediterranean diet  Increased knowledge of the Mediterranean diet: ‘I had no idea what a Mediterranean diet was, just looking into all the recipes I now know different recipes that I can use to cook with and what kinds of meats to use and like I buy leaner meats and fish and things like that I can use to make lots of different things’ (female, 30). Increased consumption of fruit and vegetables, especially salads: ‘I have tried lots of salad recipes. I never use to eat salads or anything like that’. (female, 30). ‘I have increased my salad intake since I have joined, but my fruit intake has stayed about the same, and that is a lot’ (male, 28). Increased use of olive oil: ‘She uses olive oil whenever she cooks’(staff about female, 33). ‘Because they have had that continuous exposure [to olive oil], when he went shopping he would automatically buy it’ (staff about male, 25). Increased fish intake: ‘She is consistently eating avocado and tuna, and I think she feels that those are ingredients that have been inspired by the HELFIMED project’ (staff about female, 33). Reduced intake of red and processed meats (such as sausages and hamburgers): ‘I think I have gravitated more towards fish and white meats now’ (female, 30). ‘… and I don’t have sausages anymore. So that’s changed’ (male, 28). Increased intake and/or familiarity with and preference for legumes and lentils: ‘One time I made a chickpea and veggie curry with him…then he has made homemade yiros and lentil shepherd pie’ (staff about male, 25).  Nutrition knowledge  Improved knowledge and an increased interest in learning more about nutrition: ‘…before he didn’t even know what it [a vegetable] was and now he knows what it is. he may have not heard about it [before], or heard about it and not even bothered to consider what it was about. Now he is aware of what it is because HELFIMED has shown him’ (staff about male, 22). Improved recognition of unhealthy foods and their damaging impact on health: ‘Like I was saying before I used to only eat stuff like noodles and pasta and stuff like that and yeah that’s not healthy’ (male, 29). ‘He will say something like ‘yeah that is meant to be good for you’. He also knows…too much coffee or energy drinks etc. isn’t good for him’ (staff about male, 25). Some misconceptions about nutrition knowledge, and confusion about unfamiliar foods: ‘I’m pretty sure if you have seven pieces of fruit it counteracts the five vegetables’ (male, 28). ‘I still get confused between a cucumber and a zucchini’ (female, 40).  Attitudes and motivations to eating healthy foods  Development of positive attitudes and increased intentions to eat healthier foods: ‘She’s been someone who has genuinely taken on board a lot of what has been spoken about in the workshops’ (staff about female participant, 33). ‘She is promoting [healthy eating] with the other residents and staff’ (staff about female participant, 40). Willingness and persistence in trying new, unfamiliar and previously disliked foods: ‘I don’t think I’d had eggplant before; I’d never used it in anything I had prepared anyway. Um and ah zucchini I wasn’t…um yeah probably a bit more diverse in vegetables than I’d eat in the past’ (Male, 48). ‘… she is trying to like some of the foods. It’s definitely on her radar now’ (staff about female, 40). Increased motivation to eat healthy food, aligned with overall pursuits of becoming ‘healthier’: ‘He does want to get healthier, fitter and he wants to be more motivated in terms of . his more career-based goals… And he knows that healthy lifestyle will contribute to that in a positive way’ (staff about male participant, 22). ‘I can see that he is asking more questions about like “what’s this”; “how do you prepare this, you know; what’s this for” which is huge … he is actually digging deep and wanting to know’ (staff about male, 22).  Improved cooking skills  Improved cooking skills, including: basic knife skills, chopping, cooking on the stove, steaming, baking in the oven, cooking vegetables: ‘I have learnt lots of cooking skills like I wasn’t very good at cooking before this so I have learnt like chopping up salads and things like that and cooking on the stove…’ (female, 30). ‘Didn’t know how to make recipes and that, now I’ve done a few recipes. New stuff to cook for when I move out’ (male, 22). ‘… when I was growing up I actually never got taught how to use a fork and knife, so it’s a hell of a time trying to learn at this age… when I first started [HELFIMED] I used to [cut] the simple ones cause I could never cut properly with a knife so that has improved majorly. It was a major fear probably at the start because you know … I’ve been working on it. …I always had problems cutting so, yeah, that’s really improved.’ (female, 40). ‘When she first came, she was really struggling with a knife and fork, preparing vegetables and that kind of thing. She’s a lot more independent with that now, so she’s independently eating and she’ll independently cook herself a meal’ (staff about female, 40).  Increased confidence in cooking independently  Increased confidence and more undertaking of independent cooking and meal preparation: ‘My cooking skills have got better… I'm more confident cooking by myself now’ (male, 22). The staff member agreed: ‘…a lot times he has asked me to help and he doesn’t need a lot of help, he just needs., he just wants a bit of company. his confidence is building up that he’s replicating recipes’ (staff about male, 22). ‘From little things, like trying new ingredients to the bigger things like cooking whole meals that are different and new, and that she’s even made up [new recipes] using the ingredients that she’s been inspired to use’ (staff about female, 33).  Shopping and budgeting  Limited success for improvements in meal planning, many struggled to follow-through when shopping: ‘When I do my shopping I usually think about it then. But I don’t really plan it.’ (male, 21). ‘I see other things in the shop and I think ‘oh, yeah, I’ll grab this, I’ll grab that!’. Last week I think I went way off my shopping list. I have started buying Christmas stuff and all as well like fruit mince pies.’ (female, 40).  Social skills and social anxiety  Social anxiety initially identified as a barrier/concern for attending cooking workshops: ‘Just being in a big group. Sometimes I feel uncomfortable, self-conscious and stuff like that’ (male, 22). [Interviewer: Any barriers?] ‘Oh. probably getting myself to go…Cause I’m not feeling that great in myself’ (male, 21). After attending the groups for a while the majority of participants, experienced less social anxiety and enjoyed the social aspect of being involved in the cooking workshops: ‘I was getting better the longer I stayed here as I get to know people I’m not so nervous. I don’t get so anxious about that’ (male, 22). ‘It was great how we all work together that’s what is the good thing about it. being able to work with people because that’s always been a huge fear for me’ (female, 40).  Knowledge and adoption of Mediterranean diet Most participants demonstrated increased knowledge of the Mediterranean diet and its elements, including consistent use of olive oil, higher intake of fish and seafood as protein source, and reducing intake of red and processed meat products such as sausages and hamburgers. Fish featured in the most popular recipes and participants asked staff to cook fish and seafood recipes in cooking workshops. All participants indicated that they had increased their intake of fruits and vegetables, in particular identifying salad consumption as an easy way to do this. Beans and lentils were frequently consumed during cooking workshops and enjoyed by most participants. Some participants also cooked with and consumed beans and lentils outside of cooking workshops. For instance, one liked the chickpea salad with cucumber, tomato and avocado, and started making other salads with beans and lentils, while another used beans and legumes in hot dishes. Increased nutrition knowledge Some participants demonstrated improved nutrition knowledge and an interest in learning more. The staff noted improvement in overall knowledge of foods and their impact on health, for instance greater knowledge of a range of vegetables and recognition that unhealthy foods may be damaging to health. Through cooking workshops and food hampers, participants were introduced to a number of ingredients previously unfamiliar to them, which are commonly used in the Mediterranean diet. For instance, feta and bocconcini cheese, legumes and lentils, vegetables and whole grains such as zucchini, quinoa, polenta, couscous, passionfruit, and natural (unsweetened) yoghurt. However, there was evidence of some misconceptions about nutrition knowledge, indicating the steep learning curve that the participants had to ‘climb’. For instance, one participant expressed frustration with mixing up two vegetables (cucumber and zucchini) indicating she would use both in cooking and wanted a better understanding. Attitudes and motivations for eating healthy foods All participants developed more positive attitudes towards healthy eating. Participants became more receptive to learning new knowledge, they experienced enjoyment from learning about and eating healthier food, increased their intentions to eat healthier food, and encouraged their peers to follow healthier lifestyles. One participant demonstrated particularly strong motivations to eat more healthy food, recognizing that this aligned with his overall pursuits of becoming healthier, fitter and getting back to ‘normal’ life. The majority of participants demonstrated willingness and increased their confidence in trying new and previously unfamiliar foods. One participant persisted in trying dishes with lentils, even though she didn’t like lentils, until she found a dish that she really liked (lentil Shepherd’s pie) and reported that she regularly cooked this dish. In another case, staff considered it a positive sign that one participant felt confident challenging herself and her prior pre-conceptions about food. For instance, despite having difficulty with trying new foods, she tried two dishes during cooking workshops that had ingredients she did not like (cheese triangular filo pastry with spinach and Asian beef salad). The participant felt proud that she ‘pushed’ herself beyond her comfort zone to try those dishes. Improved cooking skills and confidence in cooking independently The development of independent living skills (as an alternative to costly assisted living) is an important part of the CRC care. Initially many participants lacked even the most basic cooking skills, such as basic knife skills. The small group format of the workshops was targeted at different levels of skills and confidence. All participants demonstrated improvements in their cooking skills as cooking workshops progressed. Newly acquired skills included: basic knife skills, chopping, cooking on the stove, steaming, baking in the oven and cooking vegetables. Similarly, the lack of basic cooking skills meant many participants originally relied on (unhealthy) convenience and takeaway foods. As the programme progressed, most participants undertook more independent cooking, in particular, cooking evening meals. Some participants reported feeling more confident cooking independently, needing staff only for reassurance. Many tried to cook new recipes they were introduced to during cooking workshops, and one participant invented new recipes inspired by Mediterranean diet principles. Residents also started cooking meals together using HELFIMED-inspired recipes such as stir-fries (incorporating lots of vegetables), vegetable and legume curries and stews, baked fish with vegetables. Shopping and budgeting Individual shopping trips accompanied by researchers were undertaken during the phasing out of food hampers to help participants apply their new knowledge in practice. Participants were provided with supermarket vouchers which could only be used to buy foods that were consistent with Mediterranean diet principles. The results indicated mixed success. All participants successfully completed shopping trips, choosing healthy whole foods to cook with at home. Some participants tried to pre-plan their weekly meals before shopping independently, but many did not and struggled to follow through with cooking planned meals. Social skills The social aspect of eating (sharing food) is an important component of the Mediterranean style diet and lifestyle (Bach-Faig et al., 2011). The cooking workshops encouraged participants to interact while cooking and eating. Accordingly, the social aspect of the cooking workshops emerged as an important component of the programme for all participants. Many of the participants suffered from social anxiety, which was initially a significant concern and barrier to attending cooking workshops. However, after attending the workshops for a while the majority of participants found it became easier to be involved, and reported that they enjoyed the social aspects of the workshops. Staff reported that the cooking workshops were the most popular activity of those provided at the CRC. DISCUSSION This article describes a mixed-method assessment of the HELFIMED study, a Mediterranean diet-based intervention designed for people with SMI, using qualitative data provided by study participants and support staff and relevant biomarkers. The participants reported improvements in their diet habits and cooking skills, which may be associated with improved cardiovascular health: swapping from unhealthy to healthy options (e.g. less energy/caffeinated drinks or consumption of healthier snacks, such as fruit, nuts and yoghurts); engaging in behaviours associated with healthier diets—consumption of breakfast; cooking and consuming regular home-cooked meals; reduction in consumption of highly processed, high in fat and sugar take away meals; increasing intake from food groups associated with better cardiovascular health and Mediterranean diet principles—vegetables and fruits, olive oil as the main dietary fat, fish and legumes. These observations were supported by reduced sodium/potassium ratio, homocysteine levels and weight loss in the males reflecting increased intake of whole foods and improved dietary behaviours. Participants further reported improvements in their cooking skills and confidence in many aspects of independent living such as trying new foods, cooking new recipes and social interaction. Improvements in self-confidence may positively impact on mental health, by reducing thought ruminations, stress and anxiety (Strecher et al., 1986). Importantly, the development of healthy independent living skills and confidence may support long-term maintenance of the new behavioural changes beyond the intervention period. Participants also reported reductions in social anxiety associated with working with others in the cooking workshops and sharing meals. Social anxiety is a frequent feature in schizophrenia, and can be associated with worse social adjustment in work, social situations and personal well-being, as well as negatively impacting on quality of life (Pallanti et al., 2004). Sharing food in the company of others builds social support and a sense of community, and pleasure associated with meal-time conviviality may positively influence both eating behaviours and health status (Bach-Faig et al., 2011). These independent skills, confidence and improvements in social anxiety could contribute to better integration of people with SMI into society, improving their quality of life, independence and hence reducing the societal burden of the cost of providing assisted living. Barriers to behaviour change and maintenance An important part of the qualitative phase of the assessment was identifying barriers that participants had to overcome as well as which aspects of the programme participants did not find useful or feasible. One barrier to healthy eating identified at the beginning of the programme was the lack of structured planning during grocery shopping. Short attention span and being easily distracted are common characteristics among people with schizophrenia (Liu et al., 2002). Therefore, supermarkets with the overload of visual stimuli (price promotions, media messages, free gifts etc.) are particularly challenging environments for this population. At the beginning of the intervention we observed participants overspending on unhealthy items (such as snack foods, take away or convenience foods) and having little or no money left for healthy foods. The link between poverty and mental illness has been established in previous studies (Wilton 2003). Most participants are recipients of Government welfare payments, meaning they live week by week on strict and modest budgets. Learning to shop for healthy economical foods was an important skill taught during nutrition workshops. The skills covered reading nutrition information on packaged foods, writing a shopping list (to make sure all essential foods groups are budgeted for), and using the unit pricing (comparative price information per standardized unit of measure, i.e. per 100g) to find better value for money. Despite the above skills workshops, results showed that sticking to a planned shopping list proved difficult for most participants. Yet, it appears that this skill would be helpful to sustain diet and lifestyle changes, particularly after leaving the rehabilitation centre. We recommend future interventions with SMI populations include budgeting and shopping as a cornerstone to successful and independent maintenance of newly developed healthier eating habits. Strengths and limitations A major strength of this study is that the intervention was incorporated into the rehabilitation framework of the CRC, incorporating a focus on healthy lifestyle behaviours into independent living skills taught at the Centre. CRC staff attended health and nutrition education sessions and were involved in all steps of programme delivery, assisting them to develop the skills and knowledge to continue implementing the healthy lifestyle principles (i.e. ‘train-the-trainer’ approach and extra skill development for staff). As this was a pilot feasibility study, continual feedback was sought from CRC staff during the implementation of the programme, informing practical aspects of programme delivery. This allowed for the design and delivery of the intervention to be modified to account for practicalities of working within this setting and strengthen the study methodology. In this study, the translation from research programme into an ongoing real word lifestyle programme was successfully achieved. By the conclusion of the study, CRC staff had implemented a ‘Physical Health Clinic’ at the CRC, linking the mental health rehabilitation programme with individual physical health goals, allowing for continued implementation of the healthy eating principles and key programme elements introduced during the study. This indicates the suitability of implementing a health promotion approach within a real world mental health framework, and points to the need for policy makers to provide funding for more health promotion programmes and workers with nutrition expertise within the mental health settings. As this was a pilot study conducted at one CRC it was not possible to include a control group. Future studies should be conducted as randomized controlled trials across multiple centres with longer time frames and larger participant numbers. It was difficult for participants to continue their involvement in the intervention once they exited the CRC as they were dependent on the support of care workers external to the CRC (and not directly involved with the study) to do so, and therefore most discontinued. In future implementation it is necessary to form stronger links with community service providers to ensure continued participation in such programmes to support long-term sustainability of behavioural changes. It must be acknowledged that there is a risk of response bias as the researchers who conducted the interviews also worked with the participants during the intervention. CRC staff, who were consulted during the protocol development, felt strongly that participants would not respond well to strangers, so researchers needed to establish good rapport with the participants before beginning the interviews. Participant engagement with the intervention was impacted by their mental health symptoms. Although this population voluntarily reside in the CRC with mostly stabilized medication and symptoms, they were still in a transitional phase of stabilizing mental health symptoms and developing independent living skills. For some participants, involvement in the intervention was periodically impacted by the relapse of mental health symptoms, which affected the intervention outcomes. However, this needs to be considered as a reality of developing and implementing interventions with this population group. Importantly, this should not detract from the necessity and significance of providing lifestyle intervention at this point of their rehabilitation. CONCLUSIONS This pilot study provides support for the feasibility and effectiveness of a dietary intervention using Mediterranean diet principles, implemented within a real world mental health rehabilitation setting, for improving dietary behaviours, cooking skills, self-efficacy and confidence preparing foods in people with SMI. We observed preliminary indicators that these changes in behaviours and self-efficacy may lead to improved cardiovascular health of participants with SMI. A randomized controlled wait-list trial in rehabilitation centres is required to further investigate these findings, and support a recent call to include dietitians into the multi-disciplinary teams responsible for the routine care of people with SMI to prevent induced weight gain in first-episode psychosis (Teasdale et al., 2015). ACKNOWLEDGEMENTS We gratefully acknowledge the CRC staff and residents who took part in this study and not only made it possible but provided significant input and support. FUNDING N.P (formerly Sinn), D.Z., A.W. and K.O.D. are supported by National Health and Medical Research Council Programme Grant funding (no. 320860 and 631947). S.B. is supported by Australian Research Council DECRA funding (no. DE130101577). Fish oil capsules were provided by Vifor Pharma. SUPPLEMENTARY MATERIAL Supplementary material is available at Health Promotion International online. REFERENCES Bach-Faig A., Berry E. M., Lairon D., Reguant J., Trichopoulou A., Dernini S., et al.   ( 2011) Mediterranean diet pyramid today. Science and cultural updates. Public Health Nutrition , 14, 2274– 2284. Google Scholar CrossRef Search ADS PubMed  Bushe C., Haddad P., Peveler R., Pendlebury J. ( 2005) The role of lifestyle interventions and weight management in schizophrenia. Journal of Psychopharmacology , 19, 28– 35. Google Scholar CrossRef Search ADS PubMed  Colton C. W., Manderschied R. W. ( 2006). Congruencies in increased mortality rates, years of potential life lost, and causes of death among public mental health clients in eight states. Preventing Chronic Disease , 3, A42. Google Scholar PubMed  Cooke L. ( 2007). The importance of exposure for healthy eating in children. Journal of Human Nutrition and Dietetics , 20, 294– 301. Google Scholar CrossRef Search ADS PubMed  de Lorgeril M., Salen P., Martin J.-L., Monjaud I., Delaye J., Mamelle N. ( 1999). Mediterranean diet, traditional risk factors, and the rate of cardiovascular complications after myocardial infarction: final report of the Lyon Diet Heart Study. Circulation , 99. 779– 785. Google Scholar CrossRef Search ADS PubMed  Dickson-Swift V., James E. L., Kippen S., Liamputtong P. ( 2007). Doing sensitive research: what challenges do qualitative researchers face? Qualitative Research , 7, 327– 353. Google Scholar CrossRef Search ADS   Drewnowski A., Maillot M., Rehm C. ( 2012). Reducing the sodium-potassium ratio in the US diet: a challenge for public health. American Journal of Clinical Nutrition , 96, 439– 444. Google Scholar CrossRef Search ADS PubMed  Estruch R., Ros E., Salas-Salvado J., Covas M.-I., Corella D., Aros F.et al.   ( 2013) Primary prevention of cardiovascular disease with a Mediterranean diet. The New England Journal of Medicine , 368, 1279– 1290. Google Scholar CrossRef Search ADS PubMed  Gale N. K., Heath G., Cameron E., Rashid S., Redwood S. ( 2013) Using the framework method for the analysis of qualitative data in multi-disciplinary health research. BMC Medical Research Methodology , 13, 117. Galletly C. L., Murray L. E. ( 2009) Managing weight in persons living with severe mental illness in community settings: A review of strategies used in community interventions. Issues in Mental Health Nursing , 30: 660– 668. Google Scholar CrossRef Search ADS PubMed  Hanks A. S., Just D. R., Smith L. E., Wansink B. ( 2012) Healthy convenience: nudging students toward healthier choices in the lunchroom. Journal of Public Health , 34, 370– 376. Google Scholar CrossRef Search ADS PubMed  Lambert T. J. R., Chapman L. H. ( 2004) Diabetes, psychotic disorders and antipsychotic therapy: a consensus statement. Medical Journal of Australia , 181, 544– 548. Google Scholar PubMed  Liu S. K., Chiu C.-H., Chang C.-J., Hwang T.-J., Hwu H.-G., Chen W. J. ( 2002) Deficits in sustained attention in schizophrenia and affective disorders: stable versus state-dependent markers. American Journal of Psychiatry , 159, 975– 982. Google Scholar CrossRef Search ADS PubMed  Malik S., Wong N. D., Franklin S. S., Kamath T. V., L’Italien G. J., Pio J. R. et al.   ( 2004) Impact of the metablic syndrome on mortality from coronary heart disease, cardiovascular disease, and all causes in United States adults. Circulation , 110, 1245– 1250. Google Scholar CrossRef Search ADS PubMed  Mashiach-Eizenberg M., Hasson-Ohayon I., Yanos P. T., Lysaker P. H., Roe D. ( 2013). Internalized stigma and quality of life among persons with severe mental illness: The mediating roles of self-esteem and hope. Psychiatry Research , 208, 15– 20. Google Scholar CrossRef Search ADS PubMed  Mausbach B. T., Harvey P. D., Goldman S. R., Jeste D. V., Patterson T. L. ( 2007). Development of a brief scale of everyday functioning in persons with serious mental illness. Schizophrenia Bulletin, , 33, 1364– 1372. Google Scholar CrossRef Search ADS   McCreadie R. ( 2003) Diet, smoking and cardiovascular risk in people with schizophrenia: descriptive study. British Journal of Psychiatry , 183, 534– 539. Google Scholar CrossRef Search ADS PubMed  Meneton P., Lafay L., Tard A., Dufour A., Ireland J., Menard J., et al.   ( 2009). Dietary sources and correlates of sodium and potassium intakes in the French general population. European Journal of Clinical Nutrition , 63, 1169– 1175. Google Scholar CrossRef Search ADS PubMed  Mente A., de Koning L. D., Shannon H. S., Anand S. S. ( 2009). A systematic review of the evidence supporting a causal link between dietary factors and coronary heart disease. JAMA Internal Medicine , 169: 659– 669. National Vascular Disease Prevention Alliance. ( 2012) Guidelines for the management of absolute cardiovascular disease risk. http://www.cvdcheck.org.au/index.php?option=com_content&view=article&id=47&Itemid=27 (7 July 2016, date last accessed). Newcomer J. W. ( 2005). Second-generation (atypical) antipsychotics and metabolic effects: A comprehensive literature review. CNS Drugs , 19, 1–93. Google Scholar CrossRef Search ADS PubMed  Newcomer J. W. ( 2007). Metabolic syndrome and mental illness. The American Journal of Managed Care , 13,: S170– S177. Google Scholar PubMed  Nordmann A. J., Suter-Zimmermann K., Bucher H. C., Shai I., Tuttle K. R., Estruch R.et al.   ( 2011). Meta-analysis comparing Mediterranean to low-fat diets for modification of cardiovascular risk factors. The American Journal of Medicine , 124, 841– 851. Google Scholar CrossRef Search ADS PubMed  Ory M. G., Jordan P. J., Bazzarre T. ( 2002). The Behaviour Change Consortium: setting the stage for a new century of health behaviour-change research. Health Education Research , 17, 500– 511. Google Scholar CrossRef Search ADS PubMed  Osborn D. P. ( 2001). The poor physical health of people with mental illness. Western Journal of Medicine , 175, 329– 332. Google Scholar CrossRef Search ADS PubMed  Osborn D. P. J., Nazareth I., King M. B. ( 2007). Physical activity, dietary habits and Coronary Heart Disease risk factor knowledge amongst people with severe mental illness. Social Psychiatry and Psychiatric Epidemiology , 42: 787– 793. Google Scholar CrossRef Search ADS PubMed  Pallanti S., Quercioli L., Hollander E. ( 2004) Social anxiety in outpatients with schizophrenia: a relevant cause of disability. American Journal of Psychiatry , 161, 53– 58. Google Scholar CrossRef Search ADS PubMed  Parks J., Svendsen D., Singer P., Foti M. E. ( 2006). Morbidity and mortality in people with serious mental illness. National Association of State Mental Health Program Directors Medical Directors Council 2006. http://tinyurl.com/nyyqn6s. Parletta N., Aljeesh Y., Baune B. T. (under review). Health behaviours, knowledge, life satisfaction and wellbeing in people with mental illness across four countries and comparisons with normative sample. Parletta N., Milte C. M., Meyer B. ( 2013). Nutritional modulation of cognitive function and mental health. Journal of Nutritional Biochemistry , 24, 725– 743. Price J., Riis J. ( 2012). Behavioural economics and the psychology of fruit and vegetable consumption. Journal of Food Studies , 1, 1– 13. Google Scholar CrossRef Search ADS   Prochaska J. O., DiClemente C. C. ( 1994). The Transtheoretical Approach: Crossing Traditional Boundaries of Therapy . Krieger, US. Reinaerts E., de Nooijer J., Candel M., de Vries N. ( 2007). Explaining school children's fruit and vegetable consumption: the contributions of availability, accessibility, exposure, parental consumption and habit in addition to psychosocial factor. Appetite , 48, 248– 258. Google Scholar CrossRef Search ADS PubMed  Shai I., Schwarzfuchs D., Henkin Y., Shahar D. R., Witkow S., Greenberg I.et al.   ( 2008) Weight loss with a low-carbohydrate, Mediterranean, or low-fat diet. New England Journal of Medicine , 359, 229– 241. Google Scholar CrossRef Search ADS PubMed  Shiner B., Whitley R., Van Citters A. D., Pratt S. I., Bartels S. J. ( 2008). Learning what matters for patients: qualitative evaluation of a health promotion program for those with serious mental illness. Health Promotion International , 23, 275– 282. Google Scholar CrossRef Search ADS PubMed  Sinn N., Howe P. R. C. ( 2008). Mental health benefits of omega-3 fatty acids may be mediated by improvements in cerebral vascular function. Bioscience Hypotheses , 1, 103– 108. Google Scholar CrossRef Search ADS   Smith J., Firth J. ( 2011). Qualitative data analysis: the framework approach. Nurse Researcher , 18, 52– 62. Google Scholar CrossRef Search ADS PubMed  Strassnig M., Brar J. S., Ganguli R. ( 2003). Nutritional assessment of patients with schizophrenia: a preliminary study. Schizophrenia Bulletin , 29, 393– 397. Google Scholar CrossRef Search ADS PubMed  Teasdale S. B., Rosenbaum S., Watkins A., Curtis J., Kalucy M., Samaras K., Ward P. B. ( 2015). Preventing antipsychotic‐induced weight gain in first‐episode psychosis: transitioning dietitians into routine care. Nutrition and Dietetics , 2015. DOI: 10.1111/1747-0080.12211. Wallendorf M., Belk R. ( 1989). Assessing trustworthiness in naturalistic consumer research. In Hirschman E. C.(ed), Interpretive Consumer Research . Association for Consumer Research, Provo, UT, pp. 69– 83. Wansink B., Sobal J. ( 2007). Mindless eating the 200 daily food decisions we overlook. Environment and Behaviour , 39, 106– 123. Google Scholar CrossRef Search ADS   Wardle J., Cooke L. J., Gibson L., Sapochnik M., Sheiham A., Lawson M. ( 2003). Increasing children's acceptance of vegetables: a randomized trial of parent-led exposure. Appetite , 40, 155– 162. Google Scholar CrossRef Search ADS PubMed  Wilton R. D. ( 2003). Poverty and mental health: a qualitative study of residential care facility tenants. Community Mental Health Journal , 39, 139– 156. Google Scholar CrossRef Search ADS PubMed  Wirshing D. A., Smith R. A., Erickson Z. D., Mena S. J., Wirshing W. C. ( 2006). A wellness class for inpatients with psychotic disorders. Journal of Psychiatric Practice , 12, 24– 29. Google Scholar CrossRef Search ADS PubMed  Yang Q., Liu T., Kuklina E. V., Flander W. D., Hong Y, Gillespie C., et al.   ( 2011). Sodium and potassium intake and mortality among us adults: prospective data from the third national health and nutrition examination survey. Archives of Internal Medicine , 171, 1183– 1191. Google Scholar CrossRef Search ADS PubMed  © The Author 2016. Published by Oxford University Press. All rights reserved. For permissions, please e-mail: journals.permissions@oup.com http://www.deepdyve.com/assets/images/DeepDyve-Logo-lg.png Health Promotion International Oxford University Press

Loading next page...
 
/lp/ou_press/dietary-intervention-for-people-with-mental-illness-in-south-australia-A0pOeu4vtb
Publisher
Oxford University Press
Copyright
© The Author 2016. Published by Oxford University Press. All rights reserved. For permissions, please e-mail: journals.permissions@oup.com
ISSN
0957-4824
eISSN
1460-2245
D.O.I.
10.1093/heapro/daw055
Publisher site
See Article on Publisher Site

Abstract

Abstract Background People with serious mental illness (SMI) have a 25–30 year lower life expectancy than the general population due largely to cardiovascular disease (CVD). Mediterranean diet can reduce CVD risk and repeat events by 30–70%. We conducted a pilot feasibility study (HELFIMED) with people who have SMI residing within a Community Rehabilitation Centre in South Australia, aimed at improving participants’ diets according to Mediterranean diet principles. Methods During a 3-month intervention, participants were provided with nutrition education, food hampers, and twice-weekly cooking workshops and guided shopping trips. This report presents the results of a mixed method evaluation of the programme using thorough in-depth interviews with participants and support staff (n = 20), contextualized by changes in dietary biomarkers and CVD risk factors. Results The framework thematic analysis revealed evidence of improvements in participants’ knowledge of and intake of the key elements of a Mediterranean-style diet (fruit and vegetables, olive oil, fish, legumes), reduction in poor nutrition habits (soft drinks, energy drinks, take away meals) and development of independent living skills—culinary skills such as food preparation and cooking based on simple recipes, food shopping and budgeting, healthy meal planning and social interaction. These changes were supported by dietary biomarkers, and were associated with reduced CVD risk factors. Conclusions A Mediterranean diet-based pilot study achieved positive change in dietary behaviours associated with CVD risk for participants with SMI. This supports a need to include dietary education and cooking skills into rehabilitation programmes for people with SMI. cardiovascular disease risk, serious mental illness, schizophrenia, Mediterranean diet, nutrition, lifestyle, behaviour INTRODUCTION Cardiovascular disease (CVD) is the leading cause of death in people with serious mental illnesses (SMI) (Colton and Manderschied, 2006) such as schizophrenia, bipolar disorder and major depression. People with SMI experience higher rates of chronic illness and all-cause mortality than the general population—with up to 25–30 year lower life expectancy (Colton and Manderschied, 2006; Newcomer, 2007) due primarily to modifiable risk factors including diet and obesity (Parks et al., 2006). Strong associations of CVD with schizophrenia and depression (Osborn, 2001) may be attributable in part to common underlying biological mechanisms associated with poor nutrition status, e.g. low levels of long-chain omega-3 fatty acids (n-3 PUFA; Sinn and Howe, 2008). There is evidence that the diet of individuals with schizophrenia is particularly unhealthy compared with the general population (McCreadie, 2003; Strassnig et al., 2003), characterized by a lack of fruit, vegetables and fibre, and an excess of calories from processed foods rich in sugars and saturated fat (Bushe et al., 2005). Weight gain is a well-established side effect of first- and second-generation antipsychotic (SGA) therapy (Newcomer, 2005) used for the management of schizophrenia. SGA medications are also associated with insulin resistance, hyperglycemia and type 2 diabetes (Lambert and Chapman, 2004). This combination of poor diet and medication side-effects leaves people with SMI at significantly increased risk of metabolic syndrome (Newcomer, 2007), a major risk factor for CVD (Malik et al., 2004). Fewer people with SMI have knowledge about CVD (Osborn et al., 2007) and associations between lifestyle and poor health (Parletta et al., under review). This provides an opportunity for targeting health education and lifestyle risk factors in this high risk population. Indeed, a 30-min food and nutrition education session for people with psychosis was moderately successful in improving their knowledge (Wirshing et al., 2006). Mediterranean-style dietary patterns can improve cardiometabolic risk factors and are superior and more sustainable for weight loss than low fat diets (Mente et al., 2009; Shai et al., 2008). A meta-analysis of dietary patterns associated with reduced CVD risk identified the Mediterranean dietary pattern as the most protective over other dietary interventions, including low-fat diets (Nordmann et al., 2011). Two large randomized controlled trials reported that a Mediterranean diet reduced risk of repeat cardiovascular events by 70% in secondary prevention (de Lorgeril et al., 1999) and major cardiovascular events by 30% in people at high risk (Estruch et al., 2013). Traditional, Mediterranean-style diets are characterized by consumption of whole, minimally processed plant foods (vegetables, fruit, legumes, nuts, grains, seeds and olives), olive oil as the main culinary fat, moderate to high consumption of fish, moderate consumption of eggs, poultry, dairy products and red wine and low consumption of red meat and confectionary (Bach-Faig et al., 2011). The nutrient profile includes a high ratio of monounsaturated to saturated fat, high intakes of n-3 PUFA, fibre, micronutrients, and polyphenols. Some of these elements have been individually associated with cardio-protective effects but the whole dietary pattern is thought to be greater than the sum of its parts (Martinez-Gonzalez and Gea, 2012). These nutrients are not only essential for optimal physical health but are required for healthy brain function (Parletta et al., 2013). One of the benefits of a Mediterranean-style diet is that it is appealing and can be incorporated into a healthy lifestyle; hence has potential to be sustainable. However, changing established dietary behaviours and preferences is challenging even in the general population and requires multi-level approaches (Ory et al., 2002). To facilitate dietary behaviour change in individuals with SMI it is necessary to address the very early stages (Prochaska and DiClemente, 1994); namely readiness to change, where education, motivation and skill development are the primary focus. Furthermore, healthy foods are more likely to be consumed when they are more available, salient and easily accessible therefore requiring minimal cognitive effort (Reinaerts et al., 2007; Hanks et al., 2012). Increased liking and preferences for vegetables can be achieved through up to 10–14 exposures in young children; this might take longer for adults with established food preferences (Wardle et al., 2003; Cooke 2007; Price and Riis 2012). A recent review identified 16 weight loss or weight gain prevention interventions in people with SMI living in the community, ranging from short conversations with healthcare providers to a comprehensive 48-session enrichment programme (Galletly and Murray, 2009). Targets included healthful eating, exercise and fitness, healthy living, and goal setting and self-regulation skills. Overall there was a modest prevention of/reduction in weight although not necessarily sustained. The programme that included practical skills around healthy meal plans, shopping and meal preparation appeared to have the greatest weight loss over the intervention period (Galletly and Murray, 2009). People with schizophrenia tend to have notable deficits in various areas of life functioning (Mausbach et al., 2007); hence the development of, and confidence in, independent living skills such as budgeting, shopping and cooking is a necessary foundation for encouraging healthy dietary behaviours in this population. The current article reports on a mixed method evaluation of a pilot feasibility study (Healthy Eating for Life with a Mediterranean-style diet; HELFIMED) with people with SMI residing in a Community Rehabilitation Centres (CRC), part of a stepped rehabilitation care system. The CRC care is a middle step between hospital care and independent living, where CRC residents often require substantial staff support to fulfil everyday chores, such as cooking, cleaning, and shopping. Therefore, one of the CRC’s primary aims is to provide its residents with skills they would need when they transition to independent living. To achieve this goal CRC partners with various programs, such as HELFIMED. The primary aim of the HELFIMED intervention was to improve dietary behaviours and nutrition status of individuals with SMI via nutrition education, cooking workshops, food hampers, shopping vouchers, and accompanied shopping trips. Although some cooking is generally included in the existing rehabilitation plan for CRC residents, the explicit focus on a healthy Mediterranean-style diet, nutrition education and lifestyle is a novel treatment for this population. The aim of this article was to evaluate the effectiveness of HELFIMED for improving healthy eating and behaviours of individuals with SMI, using a mixed-methods approach combining data from dietary biomarkers and CVD risk factors, with in-depth semi-structured interviews with CRC residents and staff. INTERVENTION STUDY METHODS This project was a partnership between the University of South Australia and the Mental Health Directorate in the Southern Adelaide Local Health Network. Ethics approval was obtained from the Southern Adelaide Clinical and University of South Australia’s Human Research Ethics Committees. CRC staff were consulted in the programme design stage to assist in identifying barriers, opportunities and optimal mode of delivery. Participants and recruitment Participants were recruited from residents of a 20-bed CRC in Adelaide, South Australia (∼75% of beds were occupied during the study). Table 1 summarizes the participant profile, which is typical for CRC residents; the majority had schizophrenia. All residents were eligible to participate. Over 6 months, 25 participants were recruited, with 13 finishing the programme and undertaking 3-month assessments and 10 completing interviews at 3-months. Following the recommendations in the literature for working with such populations, in this study the researchers worked very closely with CRC management and staff to incorporate the HELFIMED protocol into the participants’ daily routine. These measures included booking the cooking and information sessions into each resident’s weekly schedule, staff reminding participants on the day about the workshops, and staff actively promoting HELFIMED recipes when assisting participants with cooking. The attrition was still reasonably high, but this was primarily driven by changes in health conditions (having to return to hospital) or transitioning to independent living, rather than the programme itself. Future researchers who work with residential centres that have transient populations need to work with community case workers who look after participants when they leave to assist them with continuing the program. Table 1: Summary characteristics of study participants and 3-month changes in dietary biomarkers and CVD risk factors (n = 13)   Baseline    Demographic characteristics      Age (years)  29.9 ± 11.0    Gender (%): Male  61.5    Family status (%): Single  100    Race (%):      Caucasian  92.3    Aboriginal or Torres Strait  7.7    Mental illness diagnosis (%):       Schizophrenia  41.7 (n = 5)     Paranoid Schizophrenia  16.7 (n = 2)     Schizoaffective disorder  16.7 (n = 2)     Bipolar Affective Disorder  7.7 (n = 1)     Unspecific non-organic psychosis  7.7 (n = 1)     Disturbance of activity and attention  7.7 (n = 1)     Borderline personality disorder  7.7 (n = 1)        Baseline  3-months    Dietary intake biomarkers and CVD risk factors  Homocysteinea (µmol/l)  *16.8±23.2  (4.4–90.0)  11.7 ± 6.2  (5.4–31.0)  Blood glucose (mmol/l)  6.21 ± 1.54  (4.1–9.9)  5.64 ± 1.30  (4.4–8.8)  Sodium/potassium ratioa (mmol/l)  *2.1±1.2  (0.50–3.9)  *1.5±0.63  (0.26–2.6)  Systolic blood pressurea (mmHg)  119.3 ± 13.3  (96.0–140.5)  122.3 ± 12.6  (105.5–147.0)  Diastolic blood pressurea (mmHg)  76.6 ± 8.1  (64.0–92.5)  76.8 ± 5.1  (70.0–84.0)  Waist circumferencea (cm)—male (n = 8)  *102.6±18.4  (75.0–135.0)  90.6 ± 12.4  (81.0–107)  Waist circumference (cm)—female (n = 5)  *96.9±12.3  (76.0–108.5)  *95.6±14.3  (81.0–113.5)  Weight (kg)—male (n = 8)  88.1 ± 19.7  (63.8–126.8)  77.5 ± 15.4  (65.0–98.4)  Weight (kg)—female (n = 5)  85.4 ± 14.8  (64.9–98.1)  87.8 ± 17.2  (70.5–107.6)  BMI (kg/m2)—male(n = 8)  *28.1±5.0  (23.4–39.6)  25.0 ± 2.6  (22.4–28.1)  BMI (kg/m2)—female (n = 5)  *30.6±6.5  (21.0–36.5)  *32.3±6.6  (26.2–40.5)    Baseline    Demographic characteristics      Age (years)  29.9 ± 11.0    Gender (%): Male  61.5    Family status (%): Single  100    Race (%):      Caucasian  92.3    Aboriginal or Torres Strait  7.7    Mental illness diagnosis (%):       Schizophrenia  41.7 (n = 5)     Paranoid Schizophrenia  16.7 (n = 2)     Schizoaffective disorder  16.7 (n = 2)     Bipolar Affective Disorder  7.7 (n = 1)     Unspecific non-organic psychosis  7.7 (n = 1)     Disturbance of activity and attention  7.7 (n = 1)     Borderline personality disorder  7.7 (n = 1)        Baseline  3-months    Dietary intake biomarkers and CVD risk factors  Homocysteinea (µmol/l)  *16.8±23.2  (4.4–90.0)  11.7 ± 6.2  (5.4–31.0)  Blood glucose (mmol/l)  6.21 ± 1.54  (4.1–9.9)  5.64 ± 1.30  (4.4–8.8)  Sodium/potassium ratioa (mmol/l)  *2.1±1.2  (0.50–3.9)  *1.5±0.63  (0.26–2.6)  Systolic blood pressurea (mmHg)  119.3 ± 13.3  (96.0–140.5)  122.3 ± 12.6  (105.5–147.0)  Diastolic blood pressurea (mmHg)  76.6 ± 8.1  (64.0–92.5)  76.8 ± 5.1  (70.0–84.0)  Waist circumferencea (cm)—male (n = 8)  *102.6±18.4  (75.0–135.0)  90.6 ± 12.4  (81.0–107)  Waist circumference (cm)—female (n = 5)  *96.9±12.3  (76.0–108.5)  *95.6±14.3  (81.0–113.5)  Weight (kg)—male (n = 8)  88.1 ± 19.7  (63.8–126.8)  77.5 ± 15.4  (65.0–98.4)  Weight (kg)—female (n = 5)  85.4 ± 14.8  (64.9–98.1)  87.8 ± 17.2  (70.5–107.6)  BMI (kg/m2)—male(n = 8)  *28.1±5.0  (23.4–39.6)  25.0 ± 2.6  (22.4–28.1)  BMI (kg/m2)—female (n = 5)  *30.6±6.5  (21.0–36.5)  *32.3±6.6  (26.2–40.5)  Values are presented as (Mean ± SD) and (range), or percentage if indicated. Missing data at baseline: Blood pressure n = 2 missing. Missing data at 3months: Blood pressure n = 4 missing; Sodium/potassium ration n = 3 missing; Homocysteine n = 1 missing; Weight, BMI and waist circumference male: n = 3 and female: n = 1 missing. a Reference ranges for dietary intake biomarkers and CVD risk factors; Indicates value elevated above normal range. Homocysteine: Normal: 7–14 µmol/l; moderately elevated: 15–30 µmol/l; intermediately elevated: 30–100 µmol/l; severely elevated >100 µmol/l; Blood glucose: normal random (non-fasted) blood glucose levels 4.0-7.8 mmol/L; Sodium/potassium ratio: Reduced disease risk if ratio below 1.0; Blood pressure: Normal<120/80 mmHg; High-normal 120–139/80–89 mmHg; Hypertension (mild) ≥140/90 mm Hg; Hypertension (severe) ≥180/110 mmHg; Waist circumference: Men > 94 cm increased risk to health; >102 cm substantially increased disease risk; Women > 80 cm increased risk to health; >88 cm substantially increased disease risk; BMI: Healthy weight 18.5–24.9 kg/m2; Overweight 25.0–29.9 kg/m2; Obese ≥ 30 kg/m2. Intervention measures Participant assessments were conducted at baseline, three and six months. Height, weight, waist circumference, blood pressure and finger-prick blood glucose measurements were measured by CRC staff. Fasted blood and urine samples were taken and analysed by the local pathology clinic to measure homocysteine, sodium and potassium levels. This manuscript utilizes the results from baseline and 3-month blood and urine samples and anthropometric measurements, to complement dietary and behaviour changes reported in qualitative data (Table 1). Height and weight and were used to calculate Body Mass Index (BMI: kg/m2), to classify participants’ body composition according to established obesity categories (18.5–24.9 = normal weight; 25–29.9 = overweight; >30 = obese). Waist circumference measurements were classified according to published guidelines (National Vascular Disease Prevention Alliance, 2012: men: >94 cm increased risk to health; >102 cm substantially increased risk to health; women: >80 cm increased risk to health; >88 cm substantially increased risk to health). Homocysteine levels, measured in plasma from fasting (8 h) blood samples, and sodium/potassium, measured in 10 ml urine samples, were used as complementary indicators of self-reported dietary changes. Sodium levels reflect processed food intake and potassium reflect whole food intake (Meneton et al., 2009). Therefore a reduced sodium/potassium ratio suggests improved dietary intake. Recommendations suggest that a higher sodium/potassium ratio (> 1.0) indicates increased risk of high blood pressure and CVD (Yang et al., 2011; Drewnowski et al., 2012). Homocysteine is an intermediary molecule produced during amino acid metabolism in the body. Vitamins B6, B12 and folate are required to modulate levels of homocysteine in the body. Insufficient intake of these nutrients causes homocysteine levels to become elevated, which is a recognized marker for CVD risk. Evidence also suggests that elevated homocysteine may be associated with poor mental health (Parletta et al., 2013). Reduced plasma homocysteine levels can indicate increased intake of these nutrients, found in a wide range of unprocessed foods such as whole grains, lentils, beans, bananas and nuts. Reference ranges propose normal plasma homocysteine levels between 7 and 14 µmol/l; moderately elevated 15–30 µmol/l; intermediately elevated 30–100 µmol/l; and severely elevated >100 µmol/l. Intervention protocol Following completion of baseline assessments participants began the HELFIMED programme. Nutrition education sessions were conducted with staff and residents using an interactive quiz and food modelling activity, based on healthy eating guidelines adapted from the Australian Guide to Healthy Eating (Department of Health and Ageing, 2010). Follow up nutrition education sessions were conducted periodically throughout the study as reinforcement and to engage new residents entering the CRC. Cooking workshops were conducted twice weekly and were rotated among residents’ own kitchens. Participants prepared and cooked a supplied recipe with instruction provided by two research assistants, supported by CRC staff. Recipes were designed to be simple, tasty, affordable meals based on Mediterranean diet principles. Participants received food hampers once per week containing a variety of ingredients including nuts, extra virgin olive oil, legumes, and fresh seasonal fruit and vegetables. At 3-month food hampers were replaced with four weeks of shopping vouchers, which participants used to purchase whole foods during guided shopping trips. This enabled participants to learn skills around meal planning and using a shopping list. The structure, content and implementation of the intervention protocol were tailored for participants with SMI who may experience cognitive barriers; this included using at least two workshop instructors (researchers and CRC staff member), repetition, multiple teaching modalities (interactive activities, verbal information) and skill building. QUALITATIVE EVALUATION METHOD In the qualitative phase of the assessment, in-depth interviews with CRC residents and staff investigated different aspects of participants’ experiences with the HELFIMED program. Specifically, the following research questions were explored: RQ1: What changes in food-related behaviours occurred during HELFIMED, and how were these associated with the Mediterranean diet? RQ2: What changes occurred in participants’ independent living skills, including cooking and shopping ability, confidence to cook independently and social skills? The qualitative approach is ideally suited to address these questions, as it allows for in-depth understanding of the circumstances under which the changes took place and the barriers and levers to change. Qualitative research can help to assess complex lifestyle interventions, such as behaviour-change studies where numerous factors influence the relevant behaviours (Wansink and Sobal, 2007) and can help to explain individual variability in outcomes with diverse and complex participant profiles. Where possible, we report available data on changes in dietary biomarkers and CVD risk factors to contextualize the qualitative data. For this study, the major unit of analysis was the participant case. Each case study contained: (i) one in-depth interview with a resident (n = 10); (ii) one expert interview with a supporting staff member (n = 10); and (iii) supporting ‘field’ notes made by researchers and staff. The majority of participants who completed 3-months (i.e. 10 cases out of 13 completions) were examined qualitatively; two participants exited the CRC before undertaking the interview, and one participant was unable to complete interviews due to cognitive difficulties. This sampling contained a natural bias typical for Appreciative enquiry-type studies (Shiner et al., 2008), which includes only participants who have successfully completed all programme requirements. The resulting sample allowed identification of factors that contributed to success in the programme and modelling of future interventions based on these outcomes. All interviews took place between February and May of 2014 at the CRC. Data collection procedure Many individuals with SMI face challenges with social interaction due to low self-esteem, social anxiety and negative self-stigma (Mashiach-Eizenberg et al., 2013). Despite these challenges, personal in-depth interviews have been successfully used with people with SMI (Shiner et al., 2008). Therefore we used personal interviews, conducted by two of the researchers who worked with the participants throughout the programme and established close rapport with them, a necessary condition for a qualitative enquiry (Dickson-Swift et al., 2007). A semi-structured interview guide (see Supplementary Appendix S1) was used to prompt for key information, allowing participants to talk about their own feelings, circumstances and experiences. Key themes included the description of food habits and any changes, knowledge and the use of Mediterranean diet principles, attitudes to healthier eating, changes in self-confidence and independent living skills, and HELFIMED programme feedback on what they liked and disliked about the program. A flexible schedule enabled the interview to be conducted on a day when the participant felt well and up to the task, which was necessary due to daily fluctuations in severity of symptoms and mood. To accommodate participants’ mental conditions, including easy mental fatigue, short attention span, often, limited ability to elaborate on narratives, the interviews with participants were made a little shorter than the usual practice (M = 13 min), but still covered key aspects of their experiences. To augment these data, each participant’s interview was followed by a longer (M = 25 min) supporting interview with a staff member from the participant’s core rehabilitation team. The staff member was asked to comment on the participant’s progress in the programme and whether they observed changes in diet and lifestyle behaviours. Comparative analysis of the participant and corresponding staff interviews showed that both provided similar information. However, staff members were more capable of noting specific behavioural changes, offer factual information and link health incidents and other information they knew about the cases. Finally, participant data were enriched with staff and researcher ‘field’ notes collated throughout the programme focusing on meaningful events (e.g. when a participant bought herself a smoothie maker to increase her fruit intake) or memorable phrases (e.g. ‘I did not know vegetables could taste so good!’; a comment by a number of participants after initial cooking workshops). Notes about participants’ mental and physical health-related events that might have affected their programme participation were also recorded. These methodological steps ensured that rich data were obtained for each participant case and provided the opportunity for cross-validation and reliability checks. Each interview was audio-taped and transcribed verbatim. For initial interviews, two researchers paired to ensure consistency in the questioning technique. Then, all team members read a sample of the interviews and compared their own impressions with the original researcher’s interpretations and coding. This process minimized possible interpretation biases and ensured no important information was overlooked (Wallendorf and Belk, 1989). Triangulation of information from participant interviews, supporting staff transcripts and field notes ensured within-case consistency and internal validity of the data. The Framework Method and thematic analysis This study followed the Framework Method of analysing qualitative data (Smith and Firth, 2011); specifically, the process described by Gale et al. (2013) which has been recommended for multi-disciplinary health studies. A combined inductive-deductive approach included some pre-existing themes guided by programme objectives (changes in dietary behaviours) and allowed for new themes to emerge (e.g. barriers and benefits of social interactions during cooking workshops). Verbatim transcripts of the interviews were used to code statements into themes, focusing on evidence of behaviour change associated with the program. Four researchers (including two who conducted interviews) reviewed the transcripts and collaboratively developed an analytical framework outlining key themes. Three coders independently coded statements using agreed themes. New codes were created (as per the ‘open coding’ technique) for the statements that did not fit established themes. Following the Framework method of qualitative analysis (Gale et al., 2013), results were organized under the main themes and supported with illustrative quotes to demonstrate the full array of possible behaviour changes and experiences during the intervention. No quantification or prevalence of the opinions (i.e. six out of eight) was attempted, as this would represent a misleading use of the data at hand due to the small sample size. RESULTS The description of the behavioural changes made by participants during 3-months of the programme is summarized under three categories: changes in biomarkers of dietary intake and CVD risk factors; changes related to food behaviours (healthier eating habits, knowledge and adoption of the Mediterranean-style diet); changes in independent living skills (increased cooking and shopping skills, confidence to cook independently, improved social skills). Changes in biomarkers of dietary intake and CVD risk factors Table 1 shows changes in biomarkers of dietary intake and CVD risk factors. At baseline homocysteine levels were moderately elevated whereas at 3-months homocysteine fell within the normal range. The mean sodium/potassium ratio was elevated at baseline, falling closer to the recommended value of 1.0 at 3 months. From baseline to 3-months mean weight, waist circumference and BMI fell within healthy ranges for males; however, small increases were observed for females. These changes in biomarkers are reflected in the specific dietary changes reported by participants in interviews (below). Specifically, changes in sodium potassium ratio reflect reported increased intake in fruit and vegetables, and decreased intake of processed and takeaway foods. Reductions in homocysteine levels may reflect reported decreases in processed meat intake and increased intake of legumes, nuts, fruit and vegetables. Weight reductions in males reflect the reported shift towards overall healthier dietary patterns, particularly reduced intake of soft-drinks, increased cooking of Mediterranean-style meals replacing takeaway meals high in fat, sugar and salt, and greater intake of fruit and vegetables. Healthier eating habits All participants made positive changes to their eating habits (Table 2). In particular, changes were evident in swapping unhealthy snacks for healthier options such as fruit, nuts and yoghurt. At the beginning of the programme staff and residents noted that consumption of drinks high in sugar and caffeine was a major problem, with many, especially male participants, consuming up to 2 L of soft drink per day. As such, male participants demonstrated greater improvements in swapping energy or soft drinks for fruit juice or drinks lower in sugar and caffeine. Another common unhealthy eating habit prior to the programme was high consumption of take away and junk foods. The programme focused on teaching participants to cook home-made meals, highlighting the taste, ease of preparation, time and money savings. Multiple participants reported at 3 months that they reduced the amount of take away meals they ate. Table 2: Summary of qualitative findings and example quotes Theme  Findings and example quotes  Healthier eating habits  Swapping unhealthy snacks for fruits, nuts or yoghurt: ‘Last week I went and bought more bananas. If I’m on the run, like lately, I'll go and try eat a banana before I go or a piece of fruit to take it with me’ (female, 40). ‘All through last year, she had a goal of stopping chocolate biscuits and she’s managed to do that. She has sweet things now that include fruit and yoghurt so her knowledge has definitely changed, there has definitely been a shift in what she views as a “desserty” kind of thing or a sweet kind of thing’ (staff about female, 33). ‘I’ve seen him eat an apple and a banana and things like that just as a snack food’ (staff about male, 22). Swapping energy or soft drinks to fruit-based drinks or drinks lower in sugar and caffeine: ‘I use to have more coffees and I don’t have that anymore. But I think that’s more to do with that I don’t feel like I need it anymore’ (male, 28). ‘I got picked up on the amount of sugar that I consume through soft drink, and I’ve probably cut down on soft drink in the last couple of weeks… I’ve also been drinking orange juice’ (male, 48) Reduced consumption of takeaway meals and convenience foods: ‘[before the program] he was choosing to go down the path of convenience food rather than doing more preparation work himself… And now. he is actually replicating these recipes, so he definitely, has to have been learning stuff…’ (staff about male, 22).  Knowledge and adoption of Mediterranean diet  Increased knowledge of the Mediterranean diet: ‘I had no idea what a Mediterranean diet was, just looking into all the recipes I now know different recipes that I can use to cook with and what kinds of meats to use and like I buy leaner meats and fish and things like that I can use to make lots of different things’ (female, 30). Increased consumption of fruit and vegetables, especially salads: ‘I have tried lots of salad recipes. I never use to eat salads or anything like that’. (female, 30). ‘I have increased my salad intake since I have joined, but my fruit intake has stayed about the same, and that is a lot’ (male, 28). Increased use of olive oil: ‘She uses olive oil whenever she cooks’(staff about female, 33). ‘Because they have had that continuous exposure [to olive oil], when he went shopping he would automatically buy it’ (staff about male, 25). Increased fish intake: ‘She is consistently eating avocado and tuna, and I think she feels that those are ingredients that have been inspired by the HELFIMED project’ (staff about female, 33). Reduced intake of red and processed meats (such as sausages and hamburgers): ‘I think I have gravitated more towards fish and white meats now’ (female, 30). ‘… and I don’t have sausages anymore. So that’s changed’ (male, 28). Increased intake and/or familiarity with and preference for legumes and lentils: ‘One time I made a chickpea and veggie curry with him…then he has made homemade yiros and lentil shepherd pie’ (staff about male, 25).  Nutrition knowledge  Improved knowledge and an increased interest in learning more about nutrition: ‘…before he didn’t even know what it [a vegetable] was and now he knows what it is. he may have not heard about it [before], or heard about it and not even bothered to consider what it was about. Now he is aware of what it is because HELFIMED has shown him’ (staff about male, 22). Improved recognition of unhealthy foods and their damaging impact on health: ‘Like I was saying before I used to only eat stuff like noodles and pasta and stuff like that and yeah that’s not healthy’ (male, 29). ‘He will say something like ‘yeah that is meant to be good for you’. He also knows…too much coffee or energy drinks etc. isn’t good for him’ (staff about male, 25). Some misconceptions about nutrition knowledge, and confusion about unfamiliar foods: ‘I’m pretty sure if you have seven pieces of fruit it counteracts the five vegetables’ (male, 28). ‘I still get confused between a cucumber and a zucchini’ (female, 40).  Attitudes and motivations to eating healthy foods  Development of positive attitudes and increased intentions to eat healthier foods: ‘She’s been someone who has genuinely taken on board a lot of what has been spoken about in the workshops’ (staff about female participant, 33). ‘She is promoting [healthy eating] with the other residents and staff’ (staff about female participant, 40). Willingness and persistence in trying new, unfamiliar and previously disliked foods: ‘I don’t think I’d had eggplant before; I’d never used it in anything I had prepared anyway. Um and ah zucchini I wasn’t…um yeah probably a bit more diverse in vegetables than I’d eat in the past’ (Male, 48). ‘… she is trying to like some of the foods. It’s definitely on her radar now’ (staff about female, 40). Increased motivation to eat healthy food, aligned with overall pursuits of becoming ‘healthier’: ‘He does want to get healthier, fitter and he wants to be more motivated in terms of . his more career-based goals… And he knows that healthy lifestyle will contribute to that in a positive way’ (staff about male participant, 22). ‘I can see that he is asking more questions about like “what’s this”; “how do you prepare this, you know; what’s this for” which is huge … he is actually digging deep and wanting to know’ (staff about male, 22).  Improved cooking skills  Improved cooking skills, including: basic knife skills, chopping, cooking on the stove, steaming, baking in the oven, cooking vegetables: ‘I have learnt lots of cooking skills like I wasn’t very good at cooking before this so I have learnt like chopping up salads and things like that and cooking on the stove…’ (female, 30). ‘Didn’t know how to make recipes and that, now I’ve done a few recipes. New stuff to cook for when I move out’ (male, 22). ‘… when I was growing up I actually never got taught how to use a fork and knife, so it’s a hell of a time trying to learn at this age… when I first started [HELFIMED] I used to [cut] the simple ones cause I could never cut properly with a knife so that has improved majorly. It was a major fear probably at the start because you know … I’ve been working on it. …I always had problems cutting so, yeah, that’s really improved.’ (female, 40). ‘When she first came, she was really struggling with a knife and fork, preparing vegetables and that kind of thing. She’s a lot more independent with that now, so she’s independently eating and she’ll independently cook herself a meal’ (staff about female, 40).  Increased confidence in cooking independently  Increased confidence and more undertaking of independent cooking and meal preparation: ‘My cooking skills have got better… I'm more confident cooking by myself now’ (male, 22). The staff member agreed: ‘…a lot times he has asked me to help and he doesn’t need a lot of help, he just needs., he just wants a bit of company. his confidence is building up that he’s replicating recipes’ (staff about male, 22). ‘From little things, like trying new ingredients to the bigger things like cooking whole meals that are different and new, and that she’s even made up [new recipes] using the ingredients that she’s been inspired to use’ (staff about female, 33).  Shopping and budgeting  Limited success for improvements in meal planning, many struggled to follow-through when shopping: ‘When I do my shopping I usually think about it then. But I don’t really plan it.’ (male, 21). ‘I see other things in the shop and I think ‘oh, yeah, I’ll grab this, I’ll grab that!’. Last week I think I went way off my shopping list. I have started buying Christmas stuff and all as well like fruit mince pies.’ (female, 40).  Social skills and social anxiety  Social anxiety initially identified as a barrier/concern for attending cooking workshops: ‘Just being in a big group. Sometimes I feel uncomfortable, self-conscious and stuff like that’ (male, 22). [Interviewer: Any barriers?] ‘Oh. probably getting myself to go…Cause I’m not feeling that great in myself’ (male, 21). After attending the groups for a while the majority of participants, experienced less social anxiety and enjoyed the social aspect of being involved in the cooking workshops: ‘I was getting better the longer I stayed here as I get to know people I’m not so nervous. I don’t get so anxious about that’ (male, 22). ‘It was great how we all work together that’s what is the good thing about it. being able to work with people because that’s always been a huge fear for me’ (female, 40).  Theme  Findings and example quotes  Healthier eating habits  Swapping unhealthy snacks for fruits, nuts or yoghurt: ‘Last week I went and bought more bananas. If I’m on the run, like lately, I'll go and try eat a banana before I go or a piece of fruit to take it with me’ (female, 40). ‘All through last year, she had a goal of stopping chocolate biscuits and she’s managed to do that. She has sweet things now that include fruit and yoghurt so her knowledge has definitely changed, there has definitely been a shift in what she views as a “desserty” kind of thing or a sweet kind of thing’ (staff about female, 33). ‘I’ve seen him eat an apple and a banana and things like that just as a snack food’ (staff about male, 22). Swapping energy or soft drinks to fruit-based drinks or drinks lower in sugar and caffeine: ‘I use to have more coffees and I don’t have that anymore. But I think that’s more to do with that I don’t feel like I need it anymore’ (male, 28). ‘I got picked up on the amount of sugar that I consume through soft drink, and I’ve probably cut down on soft drink in the last couple of weeks… I’ve also been drinking orange juice’ (male, 48) Reduced consumption of takeaway meals and convenience foods: ‘[before the program] he was choosing to go down the path of convenience food rather than doing more preparation work himself… And now. he is actually replicating these recipes, so he definitely, has to have been learning stuff…’ (staff about male, 22).  Knowledge and adoption of Mediterranean diet  Increased knowledge of the Mediterranean diet: ‘I had no idea what a Mediterranean diet was, just looking into all the recipes I now know different recipes that I can use to cook with and what kinds of meats to use and like I buy leaner meats and fish and things like that I can use to make lots of different things’ (female, 30). Increased consumption of fruit and vegetables, especially salads: ‘I have tried lots of salad recipes. I never use to eat salads or anything like that’. (female, 30). ‘I have increased my salad intake since I have joined, but my fruit intake has stayed about the same, and that is a lot’ (male, 28). Increased use of olive oil: ‘She uses olive oil whenever she cooks’(staff about female, 33). ‘Because they have had that continuous exposure [to olive oil], when he went shopping he would automatically buy it’ (staff about male, 25). Increased fish intake: ‘She is consistently eating avocado and tuna, and I think she feels that those are ingredients that have been inspired by the HELFIMED project’ (staff about female, 33). Reduced intake of red and processed meats (such as sausages and hamburgers): ‘I think I have gravitated more towards fish and white meats now’ (female, 30). ‘… and I don’t have sausages anymore. So that’s changed’ (male, 28). Increased intake and/or familiarity with and preference for legumes and lentils: ‘One time I made a chickpea and veggie curry with him…then he has made homemade yiros and lentil shepherd pie’ (staff about male, 25).  Nutrition knowledge  Improved knowledge and an increased interest in learning more about nutrition: ‘…before he didn’t even know what it [a vegetable] was and now he knows what it is. he may have not heard about it [before], or heard about it and not even bothered to consider what it was about. Now he is aware of what it is because HELFIMED has shown him’ (staff about male, 22). Improved recognition of unhealthy foods and their damaging impact on health: ‘Like I was saying before I used to only eat stuff like noodles and pasta and stuff like that and yeah that’s not healthy’ (male, 29). ‘He will say something like ‘yeah that is meant to be good for you’. He also knows…too much coffee or energy drinks etc. isn’t good for him’ (staff about male, 25). Some misconceptions about nutrition knowledge, and confusion about unfamiliar foods: ‘I’m pretty sure if you have seven pieces of fruit it counteracts the five vegetables’ (male, 28). ‘I still get confused between a cucumber and a zucchini’ (female, 40).  Attitudes and motivations to eating healthy foods  Development of positive attitudes and increased intentions to eat healthier foods: ‘She’s been someone who has genuinely taken on board a lot of what has been spoken about in the workshops’ (staff about female participant, 33). ‘She is promoting [healthy eating] with the other residents and staff’ (staff about female participant, 40). Willingness and persistence in trying new, unfamiliar and previously disliked foods: ‘I don’t think I’d had eggplant before; I’d never used it in anything I had prepared anyway. Um and ah zucchini I wasn’t…um yeah probably a bit more diverse in vegetables than I’d eat in the past’ (Male, 48). ‘… she is trying to like some of the foods. It’s definitely on her radar now’ (staff about female, 40). Increased motivation to eat healthy food, aligned with overall pursuits of becoming ‘healthier’: ‘He does want to get healthier, fitter and he wants to be more motivated in terms of . his more career-based goals… And he knows that healthy lifestyle will contribute to that in a positive way’ (staff about male participant, 22). ‘I can see that he is asking more questions about like “what’s this”; “how do you prepare this, you know; what’s this for” which is huge … he is actually digging deep and wanting to know’ (staff about male, 22).  Improved cooking skills  Improved cooking skills, including: basic knife skills, chopping, cooking on the stove, steaming, baking in the oven, cooking vegetables: ‘I have learnt lots of cooking skills like I wasn’t very good at cooking before this so I have learnt like chopping up salads and things like that and cooking on the stove…’ (female, 30). ‘Didn’t know how to make recipes and that, now I’ve done a few recipes. New stuff to cook for when I move out’ (male, 22). ‘… when I was growing up I actually never got taught how to use a fork and knife, so it’s a hell of a time trying to learn at this age… when I first started [HELFIMED] I used to [cut] the simple ones cause I could never cut properly with a knife so that has improved majorly. It was a major fear probably at the start because you know … I’ve been working on it. …I always had problems cutting so, yeah, that’s really improved.’ (female, 40). ‘When she first came, she was really struggling with a knife and fork, preparing vegetables and that kind of thing. She’s a lot more independent with that now, so she’s independently eating and she’ll independently cook herself a meal’ (staff about female, 40).  Increased confidence in cooking independently  Increased confidence and more undertaking of independent cooking and meal preparation: ‘My cooking skills have got better… I'm more confident cooking by myself now’ (male, 22). The staff member agreed: ‘…a lot times he has asked me to help and he doesn’t need a lot of help, he just needs., he just wants a bit of company. his confidence is building up that he’s replicating recipes’ (staff about male, 22). ‘From little things, like trying new ingredients to the bigger things like cooking whole meals that are different and new, and that she’s even made up [new recipes] using the ingredients that she’s been inspired to use’ (staff about female, 33).  Shopping and budgeting  Limited success for improvements in meal planning, many struggled to follow-through when shopping: ‘When I do my shopping I usually think about it then. But I don’t really plan it.’ (male, 21). ‘I see other things in the shop and I think ‘oh, yeah, I’ll grab this, I’ll grab that!’. Last week I think I went way off my shopping list. I have started buying Christmas stuff and all as well like fruit mince pies.’ (female, 40).  Social skills and social anxiety  Social anxiety initially identified as a barrier/concern for attending cooking workshops: ‘Just being in a big group. Sometimes I feel uncomfortable, self-conscious and stuff like that’ (male, 22). [Interviewer: Any barriers?] ‘Oh. probably getting myself to go…Cause I’m not feeling that great in myself’ (male, 21). After attending the groups for a while the majority of participants, experienced less social anxiety and enjoyed the social aspect of being involved in the cooking workshops: ‘I was getting better the longer I stayed here as I get to know people I’m not so nervous. I don’t get so anxious about that’ (male, 22). ‘It was great how we all work together that’s what is the good thing about it. being able to work with people because that’s always been a huge fear for me’ (female, 40).  Knowledge and adoption of Mediterranean diet Most participants demonstrated increased knowledge of the Mediterranean diet and its elements, including consistent use of olive oil, higher intake of fish and seafood as protein source, and reducing intake of red and processed meat products such as sausages and hamburgers. Fish featured in the most popular recipes and participants asked staff to cook fish and seafood recipes in cooking workshops. All participants indicated that they had increased their intake of fruits and vegetables, in particular identifying salad consumption as an easy way to do this. Beans and lentils were frequently consumed during cooking workshops and enjoyed by most participants. Some participants also cooked with and consumed beans and lentils outside of cooking workshops. For instance, one liked the chickpea salad with cucumber, tomato and avocado, and started making other salads with beans and lentils, while another used beans and legumes in hot dishes. Increased nutrition knowledge Some participants demonstrated improved nutrition knowledge and an interest in learning more. The staff noted improvement in overall knowledge of foods and their impact on health, for instance greater knowledge of a range of vegetables and recognition that unhealthy foods may be damaging to health. Through cooking workshops and food hampers, participants were introduced to a number of ingredients previously unfamiliar to them, which are commonly used in the Mediterranean diet. For instance, feta and bocconcini cheese, legumes and lentils, vegetables and whole grains such as zucchini, quinoa, polenta, couscous, passionfruit, and natural (unsweetened) yoghurt. However, there was evidence of some misconceptions about nutrition knowledge, indicating the steep learning curve that the participants had to ‘climb’. For instance, one participant expressed frustration with mixing up two vegetables (cucumber and zucchini) indicating she would use both in cooking and wanted a better understanding. Attitudes and motivations for eating healthy foods All participants developed more positive attitudes towards healthy eating. Participants became more receptive to learning new knowledge, they experienced enjoyment from learning about and eating healthier food, increased their intentions to eat healthier food, and encouraged their peers to follow healthier lifestyles. One participant demonstrated particularly strong motivations to eat more healthy food, recognizing that this aligned with his overall pursuits of becoming healthier, fitter and getting back to ‘normal’ life. The majority of participants demonstrated willingness and increased their confidence in trying new and previously unfamiliar foods. One participant persisted in trying dishes with lentils, even though she didn’t like lentils, until she found a dish that she really liked (lentil Shepherd’s pie) and reported that she regularly cooked this dish. In another case, staff considered it a positive sign that one participant felt confident challenging herself and her prior pre-conceptions about food. For instance, despite having difficulty with trying new foods, she tried two dishes during cooking workshops that had ingredients she did not like (cheese triangular filo pastry with spinach and Asian beef salad). The participant felt proud that she ‘pushed’ herself beyond her comfort zone to try those dishes. Improved cooking skills and confidence in cooking independently The development of independent living skills (as an alternative to costly assisted living) is an important part of the CRC care. Initially many participants lacked even the most basic cooking skills, such as basic knife skills. The small group format of the workshops was targeted at different levels of skills and confidence. All participants demonstrated improvements in their cooking skills as cooking workshops progressed. Newly acquired skills included: basic knife skills, chopping, cooking on the stove, steaming, baking in the oven and cooking vegetables. Similarly, the lack of basic cooking skills meant many participants originally relied on (unhealthy) convenience and takeaway foods. As the programme progressed, most participants undertook more independent cooking, in particular, cooking evening meals. Some participants reported feeling more confident cooking independently, needing staff only for reassurance. Many tried to cook new recipes they were introduced to during cooking workshops, and one participant invented new recipes inspired by Mediterranean diet principles. Residents also started cooking meals together using HELFIMED-inspired recipes such as stir-fries (incorporating lots of vegetables), vegetable and legume curries and stews, baked fish with vegetables. Shopping and budgeting Individual shopping trips accompanied by researchers were undertaken during the phasing out of food hampers to help participants apply their new knowledge in practice. Participants were provided with supermarket vouchers which could only be used to buy foods that were consistent with Mediterranean diet principles. The results indicated mixed success. All participants successfully completed shopping trips, choosing healthy whole foods to cook with at home. Some participants tried to pre-plan their weekly meals before shopping independently, but many did not and struggled to follow through with cooking planned meals. Social skills The social aspect of eating (sharing food) is an important component of the Mediterranean style diet and lifestyle (Bach-Faig et al., 2011). The cooking workshops encouraged participants to interact while cooking and eating. Accordingly, the social aspect of the cooking workshops emerged as an important component of the programme for all participants. Many of the participants suffered from social anxiety, which was initially a significant concern and barrier to attending cooking workshops. However, after attending the workshops for a while the majority of participants found it became easier to be involved, and reported that they enjoyed the social aspects of the workshops. Staff reported that the cooking workshops were the most popular activity of those provided at the CRC. DISCUSSION This article describes a mixed-method assessment of the HELFIMED study, a Mediterranean diet-based intervention designed for people with SMI, using qualitative data provided by study participants and support staff and relevant biomarkers. The participants reported improvements in their diet habits and cooking skills, which may be associated with improved cardiovascular health: swapping from unhealthy to healthy options (e.g. less energy/caffeinated drinks or consumption of healthier snacks, such as fruit, nuts and yoghurts); engaging in behaviours associated with healthier diets—consumption of breakfast; cooking and consuming regular home-cooked meals; reduction in consumption of highly processed, high in fat and sugar take away meals; increasing intake from food groups associated with better cardiovascular health and Mediterranean diet principles—vegetables and fruits, olive oil as the main dietary fat, fish and legumes. These observations were supported by reduced sodium/potassium ratio, homocysteine levels and weight loss in the males reflecting increased intake of whole foods and improved dietary behaviours. Participants further reported improvements in their cooking skills and confidence in many aspects of independent living such as trying new foods, cooking new recipes and social interaction. Improvements in self-confidence may positively impact on mental health, by reducing thought ruminations, stress and anxiety (Strecher et al., 1986). Importantly, the development of healthy independent living skills and confidence may support long-term maintenance of the new behavioural changes beyond the intervention period. Participants also reported reductions in social anxiety associated with working with others in the cooking workshops and sharing meals. Social anxiety is a frequent feature in schizophrenia, and can be associated with worse social adjustment in work, social situations and personal well-being, as well as negatively impacting on quality of life (Pallanti et al., 2004). Sharing food in the company of others builds social support and a sense of community, and pleasure associated with meal-time conviviality may positively influence both eating behaviours and health status (Bach-Faig et al., 2011). These independent skills, confidence and improvements in social anxiety could contribute to better integration of people with SMI into society, improving their quality of life, independence and hence reducing the societal burden of the cost of providing assisted living. Barriers to behaviour change and maintenance An important part of the qualitative phase of the assessment was identifying barriers that participants had to overcome as well as which aspects of the programme participants did not find useful or feasible. One barrier to healthy eating identified at the beginning of the programme was the lack of structured planning during grocery shopping. Short attention span and being easily distracted are common characteristics among people with schizophrenia (Liu et al., 2002). Therefore, supermarkets with the overload of visual stimuli (price promotions, media messages, free gifts etc.) are particularly challenging environments for this population. At the beginning of the intervention we observed participants overspending on unhealthy items (such as snack foods, take away or convenience foods) and having little or no money left for healthy foods. The link between poverty and mental illness has been established in previous studies (Wilton 2003). Most participants are recipients of Government welfare payments, meaning they live week by week on strict and modest budgets. Learning to shop for healthy economical foods was an important skill taught during nutrition workshops. The skills covered reading nutrition information on packaged foods, writing a shopping list (to make sure all essential foods groups are budgeted for), and using the unit pricing (comparative price information per standardized unit of measure, i.e. per 100g) to find better value for money. Despite the above skills workshops, results showed that sticking to a planned shopping list proved difficult for most participants. Yet, it appears that this skill would be helpful to sustain diet and lifestyle changes, particularly after leaving the rehabilitation centre. We recommend future interventions with SMI populations include budgeting and shopping as a cornerstone to successful and independent maintenance of newly developed healthier eating habits. Strengths and limitations A major strength of this study is that the intervention was incorporated into the rehabilitation framework of the CRC, incorporating a focus on healthy lifestyle behaviours into independent living skills taught at the Centre. CRC staff attended health and nutrition education sessions and were involved in all steps of programme delivery, assisting them to develop the skills and knowledge to continue implementing the healthy lifestyle principles (i.e. ‘train-the-trainer’ approach and extra skill development for staff). As this was a pilot feasibility study, continual feedback was sought from CRC staff during the implementation of the programme, informing practical aspects of programme delivery. This allowed for the design and delivery of the intervention to be modified to account for practicalities of working within this setting and strengthen the study methodology. In this study, the translation from research programme into an ongoing real word lifestyle programme was successfully achieved. By the conclusion of the study, CRC staff had implemented a ‘Physical Health Clinic’ at the CRC, linking the mental health rehabilitation programme with individual physical health goals, allowing for continued implementation of the healthy eating principles and key programme elements introduced during the study. This indicates the suitability of implementing a health promotion approach within a real world mental health framework, and points to the need for policy makers to provide funding for more health promotion programmes and workers with nutrition expertise within the mental health settings. As this was a pilot study conducted at one CRC it was not possible to include a control group. Future studies should be conducted as randomized controlled trials across multiple centres with longer time frames and larger participant numbers. It was difficult for participants to continue their involvement in the intervention once they exited the CRC as they were dependent on the support of care workers external to the CRC (and not directly involved with the study) to do so, and therefore most discontinued. In future implementation it is necessary to form stronger links with community service providers to ensure continued participation in such programmes to support long-term sustainability of behavioural changes. It must be acknowledged that there is a risk of response bias as the researchers who conducted the interviews also worked with the participants during the intervention. CRC staff, who were consulted during the protocol development, felt strongly that participants would not respond well to strangers, so researchers needed to establish good rapport with the participants before beginning the interviews. Participant engagement with the intervention was impacted by their mental health symptoms. Although this population voluntarily reside in the CRC with mostly stabilized medication and symptoms, they were still in a transitional phase of stabilizing mental health symptoms and developing independent living skills. For some participants, involvement in the intervention was periodically impacted by the relapse of mental health symptoms, which affected the intervention outcomes. However, this needs to be considered as a reality of developing and implementing interventions with this population group. Importantly, this should not detract from the necessity and significance of providing lifestyle intervention at this point of their rehabilitation. CONCLUSIONS This pilot study provides support for the feasibility and effectiveness of a dietary intervention using Mediterranean diet principles, implemented within a real world mental health rehabilitation setting, for improving dietary behaviours, cooking skills, self-efficacy and confidence preparing foods in people with SMI. We observed preliminary indicators that these changes in behaviours and self-efficacy may lead to improved cardiovascular health of participants with SMI. A randomized controlled wait-list trial in rehabilitation centres is required to further investigate these findings, and support a recent call to include dietitians into the multi-disciplinary teams responsible for the routine care of people with SMI to prevent induced weight gain in first-episode psychosis (Teasdale et al., 2015). ACKNOWLEDGEMENTS We gratefully acknowledge the CRC staff and residents who took part in this study and not only made it possible but provided significant input and support. FUNDING N.P (formerly Sinn), D.Z., A.W. and K.O.D. are supported by National Health and Medical Research Council Programme Grant funding (no. 320860 and 631947). S.B. is supported by Australian Research Council DECRA funding (no. DE130101577). Fish oil capsules were provided by Vifor Pharma. SUPPLEMENTARY MATERIAL Supplementary material is available at Health Promotion International online. REFERENCES Bach-Faig A., Berry E. M., Lairon D., Reguant J., Trichopoulou A., Dernini S., et al.   ( 2011) Mediterranean diet pyramid today. Science and cultural updates. Public Health Nutrition , 14, 2274– 2284. Google Scholar CrossRef Search ADS PubMed  Bushe C., Haddad P., Peveler R., Pendlebury J. ( 2005) The role of lifestyle interventions and weight management in schizophrenia. Journal of Psychopharmacology , 19, 28– 35. Google Scholar CrossRef Search ADS PubMed  Colton C. W., Manderschied R. W. ( 2006). Congruencies in increased mortality rates, years of potential life lost, and causes of death among public mental health clients in eight states. Preventing Chronic Disease , 3, A42. Google Scholar PubMed  Cooke L. ( 2007). The importance of exposure for healthy eating in children. Journal of Human Nutrition and Dietetics , 20, 294– 301. Google Scholar CrossRef Search ADS PubMed  de Lorgeril M., Salen P., Martin J.-L., Monjaud I., Delaye J., Mamelle N. ( 1999). Mediterranean diet, traditional risk factors, and the rate of cardiovascular complications after myocardial infarction: final report of the Lyon Diet Heart Study. Circulation , 99. 779– 785. Google Scholar CrossRef Search ADS PubMed  Dickson-Swift V., James E. L., Kippen S., Liamputtong P. ( 2007). Doing sensitive research: what challenges do qualitative researchers face? Qualitative Research , 7, 327– 353. Google Scholar CrossRef Search ADS   Drewnowski A., Maillot M., Rehm C. ( 2012). Reducing the sodium-potassium ratio in the US diet: a challenge for public health. American Journal of Clinical Nutrition , 96, 439– 444. Google Scholar CrossRef Search ADS PubMed  Estruch R., Ros E., Salas-Salvado J., Covas M.-I., Corella D., Aros F.et al.   ( 2013) Primary prevention of cardiovascular disease with a Mediterranean diet. The New England Journal of Medicine , 368, 1279– 1290. Google Scholar CrossRef Search ADS PubMed  Gale N. K., Heath G., Cameron E., Rashid S., Redwood S. ( 2013) Using the framework method for the analysis of qualitative data in multi-disciplinary health research. BMC Medical Research Methodology , 13, 117. Galletly C. L., Murray L. E. ( 2009) Managing weight in persons living with severe mental illness in community settings: A review of strategies used in community interventions. Issues in Mental Health Nursing , 30: 660– 668. Google Scholar CrossRef Search ADS PubMed  Hanks A. S., Just D. R., Smith L. E., Wansink B. ( 2012) Healthy convenience: nudging students toward healthier choices in the lunchroom. Journal of Public Health , 34, 370– 376. Google Scholar CrossRef Search ADS PubMed  Lambert T. J. R., Chapman L. H. ( 2004) Diabetes, psychotic disorders and antipsychotic therapy: a consensus statement. Medical Journal of Australia , 181, 544– 548. Google Scholar PubMed  Liu S. K., Chiu C.-H., Chang C.-J., Hwang T.-J., Hwu H.-G., Chen W. J. ( 2002) Deficits in sustained attention in schizophrenia and affective disorders: stable versus state-dependent markers. American Journal of Psychiatry , 159, 975– 982. Google Scholar CrossRef Search ADS PubMed  Malik S., Wong N. D., Franklin S. S., Kamath T. V., L’Italien G. J., Pio J. R. et al.   ( 2004) Impact of the metablic syndrome on mortality from coronary heart disease, cardiovascular disease, and all causes in United States adults. Circulation , 110, 1245– 1250. Google Scholar CrossRef Search ADS PubMed  Mashiach-Eizenberg M., Hasson-Ohayon I., Yanos P. T., Lysaker P. H., Roe D. ( 2013). Internalized stigma and quality of life among persons with severe mental illness: The mediating roles of self-esteem and hope. Psychiatry Research , 208, 15– 20. Google Scholar CrossRef Search ADS PubMed  Mausbach B. T., Harvey P. D., Goldman S. R., Jeste D. V., Patterson T. L. ( 2007). Development of a brief scale of everyday functioning in persons with serious mental illness. Schizophrenia Bulletin, , 33, 1364– 1372. Google Scholar CrossRef Search ADS   McCreadie R. ( 2003) Diet, smoking and cardiovascular risk in people with schizophrenia: descriptive study. British Journal of Psychiatry , 183, 534– 539. Google Scholar CrossRef Search ADS PubMed  Meneton P., Lafay L., Tard A., Dufour A., Ireland J., Menard J., et al.   ( 2009). Dietary sources and correlates of sodium and potassium intakes in the French general population. European Journal of Clinical Nutrition , 63, 1169– 1175. Google Scholar CrossRef Search ADS PubMed  Mente A., de Koning L. D., Shannon H. S., Anand S. S. ( 2009). A systematic review of the evidence supporting a causal link between dietary factors and coronary heart disease. JAMA Internal Medicine , 169: 659– 669. National Vascular Disease Prevention Alliance. ( 2012) Guidelines for the management of absolute cardiovascular disease risk. http://www.cvdcheck.org.au/index.php?option=com_content&view=article&id=47&Itemid=27 (7 July 2016, date last accessed). Newcomer J. W. ( 2005). Second-generation (atypical) antipsychotics and metabolic effects: A comprehensive literature review. CNS Drugs , 19, 1–93. Google Scholar CrossRef Search ADS PubMed  Newcomer J. W. ( 2007). Metabolic syndrome and mental illness. The American Journal of Managed Care , 13,: S170– S177. Google Scholar PubMed  Nordmann A. J., Suter-Zimmermann K., Bucher H. C., Shai I., Tuttle K. R., Estruch R.et al.   ( 2011). Meta-analysis comparing Mediterranean to low-fat diets for modification of cardiovascular risk factors. The American Journal of Medicine , 124, 841– 851. Google Scholar CrossRef Search ADS PubMed  Ory M. G., Jordan P. J., Bazzarre T. ( 2002). The Behaviour Change Consortium: setting the stage for a new century of health behaviour-change research. Health Education Research , 17, 500– 511. Google Scholar CrossRef Search ADS PubMed  Osborn D. P. ( 2001). The poor physical health of people with mental illness. Western Journal of Medicine , 175, 329– 332. Google Scholar CrossRef Search ADS PubMed  Osborn D. P. J., Nazareth I., King M. B. ( 2007). Physical activity, dietary habits and Coronary Heart Disease risk factor knowledge amongst people with severe mental illness. Social Psychiatry and Psychiatric Epidemiology , 42: 787– 793. Google Scholar CrossRef Search ADS PubMed  Pallanti S., Quercioli L., Hollander E. ( 2004) Social anxiety in outpatients with schizophrenia: a relevant cause of disability. American Journal of Psychiatry , 161, 53– 58. Google Scholar CrossRef Search ADS PubMed  Parks J., Svendsen D., Singer P., Foti M. E. ( 2006). Morbidity and mortality in people with serious mental illness. National Association of State Mental Health Program Directors Medical Directors Council 2006. http://tinyurl.com/nyyqn6s. Parletta N., Aljeesh Y., Baune B. T. (under review). Health behaviours, knowledge, life satisfaction and wellbeing in people with mental illness across four countries and comparisons with normative sample. Parletta N., Milte C. M., Meyer B. ( 2013). Nutritional modulation of cognitive function and mental health. Journal of Nutritional Biochemistry , 24, 725– 743. Price J., Riis J. ( 2012). Behavioural economics and the psychology of fruit and vegetable consumption. Journal of Food Studies , 1, 1– 13. Google Scholar CrossRef Search ADS   Prochaska J. O., DiClemente C. C. ( 1994). The Transtheoretical Approach: Crossing Traditional Boundaries of Therapy . Krieger, US. Reinaerts E., de Nooijer J., Candel M., de Vries N. ( 2007). Explaining school children's fruit and vegetable consumption: the contributions of availability, accessibility, exposure, parental consumption and habit in addition to psychosocial factor. Appetite , 48, 248– 258. Google Scholar CrossRef Search ADS PubMed  Shai I., Schwarzfuchs D., Henkin Y., Shahar D. R., Witkow S., Greenberg I.et al.   ( 2008) Weight loss with a low-carbohydrate, Mediterranean, or low-fat diet. New England Journal of Medicine , 359, 229– 241. Google Scholar CrossRef Search ADS PubMed  Shiner B., Whitley R., Van Citters A. D., Pratt S. I., Bartels S. J. ( 2008). Learning what matters for patients: qualitative evaluation of a health promotion program for those with serious mental illness. Health Promotion International , 23, 275– 282. Google Scholar CrossRef Search ADS PubMed  Sinn N., Howe P. R. C. ( 2008). Mental health benefits of omega-3 fatty acids may be mediated by improvements in cerebral vascular function. Bioscience Hypotheses , 1, 103– 108. Google Scholar CrossRef Search ADS   Smith J., Firth J. ( 2011). Qualitative data analysis: the framework approach. Nurse Researcher , 18, 52– 62. Google Scholar CrossRef Search ADS PubMed  Strassnig M., Brar J. S., Ganguli R. ( 2003). Nutritional assessment of patients with schizophrenia: a preliminary study. Schizophrenia Bulletin , 29, 393– 397. Google Scholar CrossRef Search ADS PubMed  Teasdale S. B., Rosenbaum S., Watkins A., Curtis J., Kalucy M., Samaras K., Ward P. B. ( 2015). Preventing antipsychotic‐induced weight gain in first‐episode psychosis: transitioning dietitians into routine care. Nutrition and Dietetics , 2015. DOI: 10.1111/1747-0080.12211. Wallendorf M., Belk R. ( 1989). Assessing trustworthiness in naturalistic consumer research. In Hirschman E. C.(ed), Interpretive Consumer Research . Association for Consumer Research, Provo, UT, pp. 69– 83. Wansink B., Sobal J. ( 2007). Mindless eating the 200 daily food decisions we overlook. Environment and Behaviour , 39, 106– 123. Google Scholar CrossRef Search ADS   Wardle J., Cooke L. J., Gibson L., Sapochnik M., Sheiham A., Lawson M. ( 2003). Increasing children's acceptance of vegetables: a randomized trial of parent-led exposure. Appetite , 40, 155– 162. Google Scholar CrossRef Search ADS PubMed  Wilton R. D. ( 2003). Poverty and mental health: a qualitative study of residential care facility tenants. Community Mental Health Journal , 39, 139– 156. Google Scholar CrossRef Search ADS PubMed  Wirshing D. A., Smith R. A., Erickson Z. D., Mena S. J., Wirshing W. C. ( 2006). A wellness class for inpatients with psychotic disorders. Journal of Psychiatric Practice , 12, 24– 29. Google Scholar CrossRef Search ADS PubMed  Yang Q., Liu T., Kuklina E. V., Flander W. D., Hong Y, Gillespie C., et al.   ( 2011). Sodium and potassium intake and mortality among us adults: prospective data from the third national health and nutrition examination survey. Archives of Internal Medicine , 171, 1183– 1191. Google Scholar CrossRef Search ADS PubMed  © The Author 2016. Published by Oxford University Press. All rights reserved. For permissions, please e-mail: journals.permissions@oup.com

Journal

Health Promotion InternationalOxford University Press

Published: Feb 1, 2018

There are no references for this article.

You’re reading a free preview. Subscribe to read the entire article.


DeepDyve is your
personal research library

It’s your single place to instantly
discover and read the research
that matters to you.

Enjoy affordable access to
over 18 million articles from more than
15,000 peer-reviewed journals.

All for just $49/month

Explore the DeepDyve Library

Search

Query the DeepDyve database, plus search all of PubMed and Google Scholar seamlessly

Organize

Save any article or search result from DeepDyve, PubMed, and Google Scholar... all in one place.

Access

Get unlimited, online access to over 18 million full-text articles from more than 15,000 scientific journals.

Your journals are on DeepDyve

Read from thousands of the leading scholarly journals from SpringerNature, Elsevier, Wiley-Blackwell, Oxford University Press and more.

All the latest content is available, no embargo periods.

See the journals in your area

DeepDyve

Freelancer

DeepDyve

Pro

Price

FREE

$49/month
$360/year

Save searches from
Google Scholar,
PubMed

Create lists to
organize your research

Export lists, citations

Read DeepDyve articles

Abstract access only

Unlimited access to over
18 million full-text articles

Print

20 pages / month

PDF Discount

20% off