Research Article
Efficacy of Cognitive Behavioral Therapy in Adherence to the Mediterranean Diet in Metabolic Syndrome Patients: A Randomized Controlled Trial

https://doi.org/10.1016/j.jneb.2018.06.003Get rights and content

Abstract

Objective

Verify the efficacy of cognitive behavioral therapy (CBT) in adherence to the Mediterranean diet (MedDiet) in metabolic syndrome (MetS) patients.

Design, Setting, Participants, and Intervention

In the Multimodal Intervention Program for Patients with Metabolic Syndrome clinical trial, 79 MetS patients completed the intervention. Of those, 48 belonged to the experimental group and 31 to the control group. The intervention received by the experimental group was CBT; the control group followed usual care and attended a workshop on healthy lifestyle.

Main Outcome Measure(s) and Analysis

Anthropometric, biochemical, psychological, and lifestyle measures were taken before and after the intervention at 3 and 6 months. Analyses included paired t tests, ANOVA, and ANCOVA.

Results

The ANOVA results showed a statistically significant interaction between the 2 groups in waist circumference (P = .009), triglycerides (P = .015), and adherence to the MedDiet (P = .026). The ANCOVA results indicated between-group difference in waist circumference (P = .026 and .062 at 3 and 6months, respectively), in triglycerides (P = .009 and .860 at 3 and 6 months, respectively), and in MedDiet (P = .024 and .273 at 3 and 6 months, respectively).

Conclusions and Implications

In interventions in which CBT was applied, significant improvements were observed in MetS patients, especially in adherence to the MedDiet.

Introduction

Metabolic syndrome (MetS) is the clustering of cardiovascular risk factorssuch as central obesity, atherogenic dyslipidemia, high blood pressure (BP) and hyperglycemia.1 The best therapeutic strategy for MetS patients is the use of therapies that seek to reduce all risk factors simultaneously, such as lifestyle therapy.2 Studies in this area indicate that behavioral intervention programs designed to promote healthy lifestyles, including physical exercise, nutritional education, and group dynamics are not only effective in producing changes in lifestyle but also directly influence biochemical outcomes.3

Lifestyle modification based on cognitive behavioral therapy (CBT) is 1 of the most important and effective strategies for managing MetS, especially when specific recommendations regarding diet and exercise are combined with behavioral and cognitive strategies. The main challenge of this treatment lies in helping patients maintain healthy behavioral changes over the long term.4

Effective educational, behavioral, and motivational techniques are thus necessary to help patients achieve real change in the way theyeat. The use of moderate energy-deficitdiets combined with reasonable long-term weight loss goals and increased physical activity is probably the most viable intervention method for reducing body weight. Cognitive behavioral techniques such as self-control, stimulus control, cognitive restructuring, relapse prevention, and the continuation of successful changes are critical to successful treatment.5

In this regard, interventions focusing on adherence to the Mediterranean diet (MedDiet) are especially interesting. This diet is characterized by a high intake of fruits, vegetables, legumes, whole (minimally processed) foods, fish, and unsaturated fatty acids (especially olive oil); moderate consumption of alcohol (mainly wine, preferably consumed with food); and a low consumption of meat (particularly red meat), dairy products, and saturated fatty acids.3

The Prevention with Mediterranean Diet study revealed that participants with greater adherence to the MedDiet had higher levels of high-density lipoprotein cholesterol (HDLc) and lower levels of triglycerides. It has been found that greater adherence to the MedDiet significantly lowers the likelihood of MetS in a population with a high risk for cardiovascular diseases (CVDs)6 and can counteract the effects of increased adiposity on CVD risk.7 Focusing on MetS patients, a few studies evaluated the effect of adherence to the MedDiet, including a clinical trial in which improvements were observed in the intervention group in weight, high-sensitivity C-reactive protein, and insulin resistance.8 It would thus seem that adherence to the MedDiet is effective in reducing the prevalence of MetS and associated cardiovascular risk.8

Despite these findings, to the authors’ knowledge, no studies have performed a follow-up on the efficacy of CBT in increasing adherence to the MedDiet in MetS patients. This study was thus undertaken with a twofold objective: (1) to verify the efficacy of CBT in increasing adherence to the MedDiet, and (2) to study the cardiovascular risk factors modified as a consequence of implementing thistherapeutic approach in a group of MetS patients, with a follow-up of 6months.

Section snippets

Design, Setting, and Participants

In the Multimodal Intervention Program for Patients with Metabolic Syndrome (clinical trial registered at clinicaltrials.gov, No. NCT02949622), 143 subjects who met the diagnostic criteria for MetS according to the National Cholesterol Education Program1 were randomized to begin the intervention. Figure1 shows a flowchart illustrating the progress of the patients over the course of the trial. Using intention-to-treat analysis, possible differences between subjects who completed the intervention

Description of the Sample

The groups were comparable in terms of the main demographic variables, components of MetS, and pharmacotherapy, with the exception of waist circumference for women, as shown in Table1. The mean time since initial diagnosis (in years) was 4 (SD, 5) for fasting glucose, 8 (SD, 8) for hypertension, and 5 (SD, 6) years for dyslipidemia, respectively.

Intention-to-Treat Analysis

The results showed a statistically significant interaction between the groups for waist circumference (F1,133 = 4.872; P = .011), triglycerides (F1.125

Discussion

The aim of this study was to verify the efficacy of CBT in promoting adherence to the MedDiet and in reducing cardiovascular risk factors in patients with MetS. The results indicated differences between the EG and CG after treatment with CBT in some of the MetS criteria, such as the reduction in waist circumference and triglycerides for the EG. Regarding lifestyle variables, the EG also showed greater adherence to the MedDiet than did the CG after treatment.

Cognitive Behavior Therapy improved

Implications for Research and Practice

The results of this study highlight the value of CBT as a tool to change dietary habits, especially those related to adherence to the MedDiet, and consequently to reduce cardiovascular risk factors. At the public health level, the cost of prevention and treatment (the number of medical visits or operations performed on patients with high cardiovascular risk) could be reduced. Therefore, CBT in a group format and with a multidisciplinary team can have positive implications for the

Acknowledgments

Thank you to Coordenação de Aperfeiçoamento de Pessoal de Nível Superior (CAPES) for awarding a grant for this work (No. 5566-10-0) and to the Department of Internal Medicine and Rheumatology of the University Hospital Virgen de las Nieves.

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    Conflict of Interest Disclosure: The authors have not stated any conflicts of interest.

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