Lifestyle intervention studies such as the Diabetes Prevention Program (DPP) and the Diabetes Prevention Study have shown that lifestyle interventions have beneficial effects on risk factors for cardiometabolic diseases and reduce the development of type 2 diabetes mellitus( Reference Tuomilehto, Lindstrom and Eriksson 1 – Reference Ratner, Goldberg and Haffner 3 ). The success of these studies has led to the adaptation of these lifestyle interventions towards several different target groups and settings( Reference Johnson, Jones and Freeman 4 – Reference Ramachandran, Snehalatha and Mary 9 ).
In the Netherlands, the Study of Lifestyle intervention and Impaired glucose tolerance Maastricht (SLIM) also showed that a combined diet and physical activity intervention reduces diabetes risk( Reference Mensink, Feskens and Saris 10 ). The SLIM study was a randomised controlled trial studying the effectiveness of a lifestyle intervention on glucose tolerance in persons with impaired glucose tolerance. Participants in the lifestyle intervention received 1 h of individual dietary advice every 3 months and one group session per year, lasting 90 min, led by a dietitian. In addition, they could participate in a weekly supervised aerobic and resistance training programme at the university fitness centre( Reference Mensink, Corpeleijn and Feskens 11 ). In that trial, individuals with low socio-economic status (SES) were more likely to drop out than individuals with higher SES( Reference Roumen, Feskens and Corpeleijn 12 ). This is unfortunate, as in general the prevalence of CVD and type 2 diabetes mellitus is relatively high among individuals with low SES( Reference Dalstra, Kunst and Borrell 13 ). Others have also shown that this group is less likely to participate in lifestyle interventions and more likely to drop out early( Reference Lakerveld, IJzelenberg and van Tulder 14 – Reference Moroshko, Brennan and O’Brien 16 ). Similar patterns, with respect to both the higher prevalence of cardiometabolic diseases and the high dropout rates, have been observed in ethnic minorities living in the Netherlands( Reference Uitewaal, Manna and Bruijnzeels 17 – Reference Uitewaal, Bruijnzeels and De Hoop 20 ). Therefore, this group forms an important target group for lifestyle interventions.
In order to tackle the under-representation of socio-economically disadvantaged individuals and ethnic minorities in health promotion activities, adapted methods are necessary to reach and retain this group effectively( Reference Liu, Davidson and Bhopal 21 – Reference Cleland and Ball 23 ). For this reason, we adapted the SLIM study to the needs and preferences of low-SES individuals of Dutch, Turkish and Moroccan origin (the three largest ethnic groups in the Netherlands) based on the findings of preceding research( Reference Bukman, Teuscher and Feskens 22 , Reference Teuscher, Bukman and van Baak 24 , Reference Teuscher, Bukman and Meershoek 25 ). This adapted study was named MetSLIM.
Following the preferences of the target group, adaptations included additional group meetings about topics relevant for the target group; involving ethnicity- and gender-matched research assistants, dietitians and sports instructors; activities provided for women and men separately; and all activities provided in participants’ own neighbourhood. Study design, setting and measurements were chosen to minimise the burden of participation. A detailed overview of the choices and considerations in the adaptation process from SLIM to MetSLIM is described elsewhere( Reference Teuscher, Bukman and Meershoek 25 ). The aim of the present study was to evaluate whether the adapted lifestyle intervention was successful in improving waist circumference and other cardiometabolic risk factors, lifestyle behaviour and quality of life among low-SES individuals of Dutch, Turkish and Moroccan origin.
Methods
Study design
MetSLIM was a quasi-experimental study running from January 2013 until June 2015 in two cities in the Netherlands. Participants were invited to either the intervention group or the control group. Measurements were not taken blinded; researchers knew which group the participants belonged to. Participants were blinded to the study design; participants knew that the effect of the programme was being evaluated, however, they were not aware of the existence of a comparison group receiving a different programme. All participants gave their written informed consent before the start of the study. The design of the MetSLIM study has been published in more detail previously( Reference Teuscher, Bukman and Meershoek 25 ).
Recruitment
Individuals of Dutch, Turkish and Moroccan origin, aged 30–70 years, were recruited in socio-economically deprived neighbourhoods. Intervention group participants were recruited in different neighbourhoods from control group participants to avoid dissatisfaction and spill-over. The aim was to achieve similar numbers of participants for each ethnicity (frequency matching) in the intervention and control groups. Two recruitment strategies were used. First, participants were recruited via general practices that either were situated in socio-economically deprived neighbourhoods or had a broad spectrum of low-SES patients or ethnic minority patients. General practitioners made a selection of potential participants in their database based on the inclusion criteria that were available in their registry, such as age, medication use and postal code (as an indicator for neighbourhood). General practitioners were asked to select only patients from Dutch, Turkish and Moroccan origin who were physically and mentally able to participate in the intervention. Second, participants were recruited in community centres involving community health workers (e.g. social workers), local health professionals and other local contacts. Interested persons were asked to fill out a screening questionnaire to check whether they fulfilled the inclusion or the exclusion criteria.
The inclusion criteria were: (i) waist-to-height ratio (WHtR) >0·5; (ii) aged between 30 and 70 years; (iii) no medication for hypertension, hypercholesterolaemia, CVD, diabetes mellitus or/and renal failure at baseline; (iv) living in a socio-economically deprived neighbourhood; and (v) Dutch, Turkish or Moroccan ethnic origin. Following the definitions of Statistics Netherlands, persons with both parents born in the Netherlands are considered to be Dutch( 26 ) and persons who have at least one parent born in Morocco/Turkey are considered to be Moroccan/Turkish( 27 ). However, if persons signed up for the study from neighbourhoods close by or of another ethnic background, they were also accepted for participation in the study as it was considered unethical and undesirable (for social cohesion) to exclude them. Exclusion criteria were: (i) having a mental or physical disability that made participation in a lifestyle intervention impossible; (ii) already participating in a lifestyle programme targeting weight loss; and (iii) pregnant or lactating.
Based on the results of the screening questionnaire, eligible participants were invited for baseline measurements. The appointment for baseline measurements took place at a community or health-care centre in participants’ own neighbourhood. At the beginning of this appointment, participants gave written informed consent. At the end of the appointment, participants received a referral letter to the medical laboratory for blood withdrawal and instructions for the start of the intervention or control programme. During the inclusion period (January 2013 to June 2014), 220 participants with elevated WHtR enrolled in the study, of whom 117 participated in the intervention group and 103 in the control group.
Intervention and control groups
The intervention group participated in a 12-month lifestyle intervention that promoted lifestyle change and weight loss through increased physical activity and changes in dietary habits following the general Dutch public health recommendations( 28 ) (see the online supplementary material, Supplemental File 1). The lifestyle intervention was provided in a community setting and consisted of three components: four group meetings, 4 h of individual dietary advice and weekly sports lessons. All group meetings on nutrition were provided separately for Dutch, Turkish and Moroccan participants. The individual dietary advice (maximum 4 h) was divided over a flexible number of consultations and was given by a dietitian who was ethnicity-matched to the Dutch, Turkish and Moroccan participants. Dietitians tailored their advice, based on the national guidelines on healthy nutrition( 28 ), to the needs of each participant. Additionally, participants were invited to join the four group meetings (90 min). The first was an introductory meeting, guided by the researcher, in which participants got to know the dietitian, the sports instructor and other study participants. The other three group meetings were about nutrition and were guided by the dietitian. The group meeting focused on label reading, social occasions and price concerns (supermarket tour). Because of a lack of interest or other thematic priorities, the meeting on price concerns was in some cases replaced by a meeting about ‘Staying motivated’ or ‘Ramadan’. The dietary advice and the group meetings were, if preferred, given in participants’ native language. The physical activity lessons (60 min) were set up especially for the study participants and were tailored to the needs and preferences of the sports groups. Sports instructors provided a variety of activities such as basketball, circuit training, core stability, zumba and walking. The physical activity classes for ethnicities other than Dutch were provided separately for women and men with gender-matched sports instructors. Participants were allowed to bring friends and family along to the physical activity lessons if that was feasible given the space of the physical activity location.
The participants in the control group received only one group meeting (90 min) guided by a dietitian, together with, if necessary, a language assistant with a dietetic background. The dietitian provided the group with general information about a healthy diet. Additionally, participants received information leaflets on the benefits of healthy nutrition and increased physical activity.
The intervention programme was promoted as ‘TogetherLongerHealthy’ and the control programme as ‘Health check’. Both groups participated in the same measurements. All participants received the results of their own measurements. Measurement results were also sent to the general practitioners.
Outcome measures
To evaluate the effectiveness of the lifestyle intervention programme, data were collected at baseline and after 12 months. Participants underwent physical examinations and were asked to fill in questionnaires, either alone or together with a research assistant speaking their native language. Standardised measurement procedures were followed, which were described in protocols. Height was measured without shoes to the nearest millimetre. Body weight and body fat percentage were measured with a Tanita BC-418 bioimpedance scale (Tanita Corporation, Tokyo, Japan). Waist circumference was determined midway between the lowest rib and the iliac crest, and hip circumference was measured at the widest portion of the buttocks. Both were measured twice to the nearest 0·5 cm and averaged. Blood pressure was measured six times (with 2 min of rest in between) in a seated position with an Omron 705CP (Omron Healthcare Co., Kyoto, Japan). The mean was calculated from the last five measurements. Blood samples were taken after at least 10 h of fasting to measure fasting glucose, HDL cholesterol, total cholesterol, TAG, HbA1c (glycated Hb), fasting insulin, liver function enzymes, creatinine and uric acid. A fasting spot urine sample was collected to measure albumin and creatinine. Analyses were performed at either SHO laboratory in Velp or Maxima Medisch Centrum laboratory in Veldhoven, the Netherlands, depending on the location of the blood sampling. For fasting insulin, all blood samples were analysed at SHO laboratory in Velp.
Albuminuria was determined by the ratio between urinary concentrations of albumin and creatinine, with a cut-off of >2·5 mg/mmol for men and >3·5 mg/mmol for women( Reference Bermúdez, García and Surribas 29 ). LDL cholesterol was calculated using the Friedewald formula( Reference Friedewald, Levy and Fredrickson 30 ). Metabolic syndrome was defined by the revised National Cholesterol Education Program Adult Treatment Panel III criteria as the presence of three or more of the following five cardiometabolic risk factors: (i) increased waist circumference (men ≥102 cm, women ≥88 cm); (ii) low HDL cholesterol (men <1·03 mmol/l, women <1·29 mmol/l or on drug treatment for reduced HDL cholesterol); (iii) high TAG level (≥1·69 mmol/l or on drug treatment for elevated TAG); (iv) increased blood pressure (systolic ≥130 mmHg and/or diastolic ≥85 mmHg or on antihypertensive drug treatment); and (v) impaired fasting glucose (≥5·6 mmol/l or on drug treatment for elevated glucose)( Reference Grundy, Cleeman and Daniels 31 ). For participants with both parents born in Asia (except for countries in the Middle East), cut-off values of 90 cm (men) and 80 cm (women) for waist circumference were used( Reference Grundy, Cleeman and Daniels 31 ).
Physical activity was measured with the Short Questionnaire to Assess Health-enhancing physical activity (SQUASH)( Reference Wendel-Vos, Schuit and Saris 32 ). Dietary intake was assessed with ethnic-specific FFQ( Reference Dekker, Snijder and Beukers 33 ) and calculated using the 2013 Dutch food composition database( 34 ). Adherence to a healthy diet was assessed by the Dutch Healthy Diet index (DHD-index)( Reference van Lee, Geelen and Hooft van Huysduynen 35 , Reference van Lee, Feskens and Hooft van Huysduynen 36 ). The original DHD-index consists of ten components, representing the Dutch Guidelines for a Healthy Diet( 28 ). Eight of the ten components were measured in the MetSLIM study (physical activity, vegetables, fruit, fibre, fish, SFA, trans-fatty acids and alcohol). Participants could score between 0 and 10 points, resulting in a total maximum score of 80 points. A higher score represents better adherence to the Dutch Guidelines for a Healthy Diet. Quality of life was assessed in different health domains with the 36-Item Short Form Health Survey (SF-36) questionnaire( Reference Ware and Sherbourne 37 ).
Statistical analysis
It was calculated that a sample size of 252 participants would be required to detect a change in waist circumference of 1·1 cm, assuming α of 0·05, power of 80 % and a dropout rate of 25 %( Reference Teuscher, Bukman and Meershoek 25 ). Eventually, 220 participants could be enrolled in the MetSLIM study during an intensive recruitment period of 17 months (see Fig. 1).
Flow diagram of the MetSLIM study. *Invitation letters were sent to individuals assumed to be Dutch (n 450), Turkish (n 423) or Moroccan (n 70)
Participants who became pregnant during the study (n 5) were excluded from the analyses. Furthermore, participants with missing data on waist circumference (the primary outcome measure) at 12 months were considered dropouts and excluded from the analyses; these participants missed data on the other measures as well (n 66). As a result, data collected from 149 participants were used for statistical analysis. Participants with a C-reactive protein concentration >10 mg/l were excluded from the analysis regarding C-reactive protein, because these concentrations reflect acute rather than chronic inflammation( Reference Pearson, Mensah and Alexander 38 , Reference Ridker 39 ). Participants who skipped whole sections of the FFQ or reported a consumption of less than 2092 kJ/d (500 kcal/d) or 3347 kJ/d (800 kcal/d), for women and men respectively, were excluded from the analyses for dietary intake (n 5)( Reference Willett 40 ). Excessive alcohol consumption was classified as more than 21 consumptions/week for men and more than 14 consumptions/week for women.
Data were analysed with the statistical software package IBM SPSS Statistics version 22. Significance level was set at 0·05. All analyses were performed according to the intention-to-treat principle, where participants were analysed in the groups for which they were recruited, regardless of whether they actively participated in that group. Continuous variables are presented as mean and sd, and categorical variables as number and percentage. Baseline characteristics were compared between participants in the intervention and the control group, and between completers and dropouts, with χ 2 tests, independent-samples t tests or Mann–Whitney tests. For each outcome variable, baseline results are described for those participants who had data for that variable at baseline and after 12 months. Changes in prevalence of metabolic syndrome and albuminuria were compared within the intervention and the control group with McNemar’s tests. Changes in continuous effect outcomes over time were compared between the intervention and the control group by ANCOVA, with change after 12 months as the outcome variable, adjusted for the mean value of the measurements at baseline and 12 months for the respective variable( Reference Oldham 41 ) and ethnicity. Although general practitioners and researchers screened for relevant medication during recruitment, a few medication users were enrolled in the study. Excluding users of medication for glucose (n 2), cholesterol (n 5) or blood pressure (n 2) from those analyses that could be influenced by medication use resulted in similar results, except for HbA1c. Medication users were therefore included in the analyses.
The effect of the treatment was compared between participants of Dutch and Turkish origin (the two largest ethnic groups in the study). To test the interaction between treatment and ethnicity, an interaction term was added to the model. For the interaction term between treatment and ethnicity, a P value of 0·20 was considered relevant( Reference Selvin 42 ). The effect of the treatment on dietary intake was not compared between Dutch and Turkish participants, because dietary intake was known for only a small number of Turkish participants in the control group (n 6).
Results
Baseline characteristics and programme attendance
Participants who dropped out (n 66, 31 %) did not differ in baseline characteristics from the completers, except that they were more often smokers and had more often been recruited via their general practitioner (Table 1). The most important reasons for dropout were lack of time (30 %), lack of interest (26 %) and lost contact (20 %; Fig. 1).
Comparison of baseline characteristics between completers and dropouts in the MetSLIM study targeting individuals of low socio-economic status and different ethnic origins with elevated waist-to-height ratio, the Netherlands, January 2013–June 2015
* Employment status: completer n 148, dropout n 58; household situation: completer n 147, dropout n 57; smoking status: completer n 148, dropout n 58; alcohol consumption: completer n 126, dropout n 53; metabolic syndrome: completer n 141, dropout n 54; family history of type 2 diabetes in first-degree relative: completer n 146, dropout n 58.
† Data are expressed as n and % for categorical variables; or mean and sd for continuous variables.
‡ P value of χ 2 tests or independent-samples t tests.
Completers attended more often the introduction meeting of the intervention programme (76 v. 51 %) and more often one or more of the three dietary group meetings than dropouts (85 v. 29 %). Completers also made more use of the individual dietary advice (155 (sd 52) v. 53 (sd 54) min). Participation in physical activity lessons was unfortunately incompletely registered by sport instructors; however, the lessons that were registered showed higher attendance among completers compared with dropouts in the physical activity lessons as well.
The baseline characteristics of the 149 participants who completed the study are presented in Table 2. In general, baseline characteristics were similar between the intervention and the control group. On average, the completing participants were 47·5 (sd 9·2) years old. Most of them were of Dutch (40 %) or Turkish origin (48 %) and female (83 %). Thirty-eight per cent of them had completed no education or primary school only, and 56 % had no paid job. The latter were mostly househusband/housewife (35 %), disabled (18 %) or unemployed/looking for a job (15 %).
Baseline characteristics of participants (n 149) in the MetSLIM study targeting individuals of low socio-economic status and different ethnic origins with elevated waist-to-height ratio, the Netherlands, January 2013–June 2015
INT, intervention group; CON, control group.
* Employment status: INT n 79, CON n 69; household situation: INT n 78, CON n 69; smoking status: INT n 79, CON n 69; alcohol consumption: INT n 63, CON n 63; metabolic syndrome: INT n 74, CON n 67; metabolic syndrome components: INT n 74, CON n 67; family history of type 2 diabetes in first-degree relative: INT n 78, CON n 68; history of hypercholesterolaemia: INT n 79, CON n 69; history of hypertension: INT n 75, CON n 67.
† Data are expressed as n and % for categorical variables; or mean and sd for continuous variables.
‡ P value of χ 2 tests or independent-samples t tests.
Intervention effects on cardiometabolic risk factors
After 12 months, beneficial intervention effects were observed for cardiometabolic risk factors (Table 3). Mean difference in change in waist circumference was −3·3 cm (95 % CI −4·7, −1·8) between the two groups. Also, greater reductions were observed in weight (β=−2·2 kg, 95 % CI −3·7, −0·8), BMI (β=−0·8 kg/m2, 95 % CI −1·3, −0·3), WHtR (β=−0·020, 95 % CI −0·028, −0·011) and fat percentage (β=−0·9 %, 95 % CI −1·8, −0·1) in the intervention group compared with the control group.
Changes in cardiometabolic risk factors from baseline to 12 months among participants (n 149) in the MetSLIM study targeting individuals of low socio-economic status and different ethnic origins with elevated waist-to-height ratio, the Netherlands, January 2013–June 2015Footnote *
INT, intervention group; CON, control group; HbA1c, glycated Hb; HOMA-IR, homeostatic model assessment of insulin resistance.
* Date are expressed as mean and sd; or β and 95 % CI.
† Body fat: INT n 76, CON n 69; fasting insulin: INT n 71, CON n 61; HbA1c: INT n 70, CON n 60; HOMA-IR: INT n 71, CON n 61; TAG: INT n 72, CON n 60; alanine aminotransferase: INT n 71, CON n 61; aspartate aminotransferase: INT n 71, CON n 60; γ-glutamyl transferase: INT n 71, CON n 61; uric acid: INT n 71, CON n 61; C-reactive protein≤10 mg/l: INT n 61, CON n 56.
‡ P value for difference between treatment groups in ANCOVA test, adjusted for ethnicity and individuals’ mean value of the measurements at baseline and 12 months for the respective variable.
§ Excluding participants using relevant medication (n 2) from the analysis resulted in a P value of 0·044.
Apart from waist circumference, no significant improvements were observed for other components of the metabolic syndrome. Metabolic syndrome prevalence did not change significantly in either the intervention group (from 18/68 to 18/68 after 12 months; P=1·00) or the control group (from 16/60 to 20/60 after 12 months; P=0·29). The intervention group had greater improvements in total cholesterol (β=−0·33 mmol/l, 95 % CI −0·56, −0·10) and LDL cholesterol (β=−0·35 mmol/l, 95 % CI −0·56, −0·14) compared with the control group. Albuminuria was rare in both the intervention group (from 1/73 to 3/73 after 12 months; P=0·50) and the control group (from 1/58 to 2/58 after 12 months; P=1·00).
Intervention effects on dietary intake and physical activity
After 12 months, the intervention group reported an increased fibre intake compared with the control group (β=1·5 g/4184 kJ (1000 kcal), 95 % CI 0·3, 2·7; Table 4). The intervention group also reported a reduction in energy intake (β=–1359 kJ, 95 % CI –3082, 363 (β=−325 kcal, 95 % CI −736, 87), P=0·12). Additionally, the intervention group reported a decrease in total minutes of physical activity compared with the control group (β=−573 min/week, 95 % CI −1126, −21).
Changes in dietary intake (n 98) and physical activity (n 125) from baseline to 12 months among participants in the MetSLIM study targeting individuals of low socio-economic status and different ethnic origins with elevated waist-to-height ratio, the Netherlands, January 2013–June 2015Footnote *
INT, intervention group; CON, control group.
* Data are expressed as mean and sd; or β and 95 % CI.
† Dutch Healthy Diet index: INT n 60, CON n 36.
‡ P value for difference between treatment groups in ANCOVA test, adjusted for ethnicity and individuals’ mean value of the measurements at baseline and 12 months for the respective variable.
§ Significantly different between INT and CON at baseline.
Intervention effects on quality of life
The intervention group after 12 months showed greater improvement in the domains ‘health transition’ (i.e. self-rated health compared with 1 year ago) and ‘general health’ (i.e. their own self-reported health and their self-rated health compared with that of others) compared with the control group (P<0·001). Other changes within domains of quality of life were not different between the groups (Table 5).
Changes in quality of life from baseline to 12 months among participants (n 129) in the MetSLIM study targeting individuals of low socio-economic status and different ethnic origins with elevated waist-to-height ratio, the Netherlands, January 2013–June 2015Footnote *
INT, intervention group; CON, control group.
* Data are expressed as mean and sd; or β and 95 % CI.
† Health transition: INT n 63, CON n 65; general health: INT n 62, CON n 63; physical functioning: INT n 61, CON n 65; role physical: INT n 60, CON n 62; role emotional: INT n 57, CON n 62; bodily pain: INT n 63, CON n 65; vitality: INT n 62, CON n 65; mental health: INT n 62, CON n 65.
‡ P value for difference between treatment groups in ANCOVA test, adjusted for ethnicity and individuals’ mean value of the measurements at baseline and 12 months for the respective variable.
Intervention effects among different ethnic groups
In general, the intervention effects were more beneficial among participants of Dutch origin than among participants of Turkish origin, especially for the different measures of obesity (see online supplementary material, Supplemental Tables 1 to 3). Intervention effect on waist circumference (P for interaction=0·14) among participants of Dutch origin was −4·8 cm (95 % CI −7·7, −2·0) compared with −2·7 cm (95 % CI −4·2, −1·2) among participants of Turkish origin. For total physical activity (P for interaction=0·018) and light-intensity physical activity (P for interaction=0·006), the intervention effect was disadvantageous for participants of Turkish origin only (β=−1215 min/week, 95 % CI −2039, −390 for total amount of physical activity; β=−1030 min/week, 95 % CI −1761, −299 for light-intensity physical activity).
Discussion
The results of this 1-year intervention study that targeted low-SES individuals of different ethnic origins are promising and show that a lifestyle intervention carried out in socio-economically deprived neighbourhoods can be successful. The lifestyle intervention significantly improved obesity-related measures such as waist circumference, WHtR, body weight, fat percentage and BMI. The lifestyle intervention did not affect prevalence of metabolic syndrome or components of metabolic syndrome, apart from waist circumference, within 12 months. However, total cholesterol and LDL cholesterol did improve significantly. Significant changes in lifestyle were observed for fibre intake (relative intake increased in the intervention group) and total minutes of self-reported physical activity (reduced in the intervention group) only. The intervention group also showed, although not significantly, a reduction in energy intake. With regard to quality of life, participants in the intervention showed improvements in ‘general health’ and ‘health transition’. Overall, our data support an improvement in cardiometabolic risk and quality of life in the intervention group compared with the control group.
Our study, an adapted version of the SLIM study, was targeted at persons with low SES of different ethnic origins( Reference Teuscher, Bukman and Meershoek 25 ). In the SLIM study, weight loss and reduction in waist circumference were significantly different after 12 months between the intervention and the control group (−2·7 kg, −3·5 cm in the intervention group and −0·2 kg, −1·4 cm in the control group)( Reference Mensink, Feskens and Saris 10 ). This is comparable with our findings. The achieved reduction of waist circumference in our intervention group is also comparable to the results of a primary-care-based intervention study based on the DPP by Ma et al. ( Reference Ma, Yank and Xiao 43 ) among participants with predominantly high SES. Our findings of reduction in weight and total cholesterol are comparable with another effect study of the DPP intervention translated to a community setting (i.e. the YMCA)( Reference Ackermann, Finch and Brizendine 44 ). We did not reproduce the beneficial results with regard to blood pressure, HDL cholesterol, TAG and fasting glucose after 12 months reported in other studies based on the DPP( Reference Boltri, Davis-Smith and Seale 5 , Reference Laatikainen, Dunbar and Chapman 7 , Reference Kramer, Kriska and Venditti 45 ), or the reduction in fasting insulin levels after 12 months in the SLIM study( Reference Mensink, Feskens and Saris 10 ). However, in those studies, participants were selected on the basis of having pre-diabetes, metabolic syndrome or impaired glucose tolerance, or on the basis of being at high risk of developing diabetes (risk score tool), whereas participants in our study were included on the basis of elevated WHtR only. Because medication users were excluded during recruitment, a relatively healthy population was enrolled in our study. This might explain why we found no significant changes in blood pressure, HDL cholesterol, TAG and fasting glucose. Only 28 % of the participants in the MetSLIM study had metabolic syndrome; this is comparable to data on the general Dutch population aged 30–70 years (34 % of men and 24 % of women)( Reference Blokstra, Vissink and Venmans 46 ). Furthermore, the cut-off value of 0·5 might have been too low to select participants with metabolic syndrome, especially for the younger adults. A recent study identified a WHtR cut-off value of 0·580 as optimal for discriminating individuals with metabolic syndrome among younger adults( Reference Bohr, Laurson and McQueen 47 ).
Despite the beneficial changes in obesity measures, the intervention group did not report significant improvements in energy intake and physical activity. One would expect improvements in obesity measures to result from positive lifestyle changes. As obesity measures are expected to be more objective than self-reported lifestyle data, one could debate whether the self-reported lifestyle data in the current study were completely reliable. Questionnaire data can be subject to socially desirable answers and depend on participants’ literacy skills, which might be relatively low in our target group. In this case, it could be that the intervention group got a more realistic view of their PA level and reported less PA, whereas the control group gave socially desirable answers and reported to engage in more PA.
In general, intervention effects were more beneficial among participants of Dutch origin than among participants of Turkish origin. However, these two groups were not completely comparable in the present study as they differed in, among other things, age, education level and intervention location (see Supplemental Table 1). Therefore, the results cannot be attributed to ethnicity only. In any case, the results imply that the intervention was less effective in the Turkish group that was reached in the present study and, in order to achieve greater effects, further adaptations for this group should be considered.
In the present study, low SES was determined by neighbourhood. A disadvantage of selecting participants on the basis of the neighbourhood they lived in was that higher educated persons were also able to participate in the study. However, when we included only the participants with a low educational level in our analyses, this did not change our conclusion significantly. In fact, the intervention effects seemed slightly better when excluding the higher educated participants (data not shown).
The dropout rate in MetSLIM (31 %) was relatively high compared with SLIM (10 % after the first year), but comparable to dropout rates in similar studies among low-SES populations( Reference Carroll, Winters and Fiscella 48 ) or ethnic minorities( Reference Uitewaal, Bruijnzeels and De Hoop 20 , Reference Admiraal, Vlaar and Nierkens 49 ). It can be questioned whether dropout can be reduced by further adaptations to the intervention study protocol. Reasons for dropout that were quite often mentioned were ‘no time’ and ‘no interest’. Participants elaborated on this by mentioning that they had conflicting issues to worry about in life, for example sick relatives. Other researchers have reported that ‘life stressors’ can interfere with participation in a lifestyle intervention( Reference Carroll, Winters and Fiscella 48 ). Such dropout is hard to prevent in a lifestyle intervention focusing exclusively on diet and physical activity. Furthermore, some of the reasons for dropout (e.g. moving to another area) or exclusion from the analyses (e.g. pregnancy) cannot be prevented by adaptation measures.
A limitation of our study was that some participants did not fill in the questionnaires or did not go for their blood test at the medical laboratory. For future studies, it could help to limit the number of measurements (several participants expressed dissatisfaction about the large burden of the measurements) and focus on completing the most important measurements. It would also be advisable to combine measurements; that is, have all measurements at the same time and location. However, that may be practically challenging in community settings.
Another limitation is the low number (19 %) of male participants in the MetSLIM study. Other lifestyle intervention studies also report low participation rates among men( Reference Johnson, Jones and Freeman 4 , Reference Hossain, Yuginovich and Lambden 50 ). The MetSLIM study focused on individuals of Dutch, Turkish and Moroccan origin. However, we did not succeed in recruiting many participants of Moroccan origin. This could possibly have been because we found especially good contact persons within the Dutch and Turkish communities, for example ethnicity-matched general practitioners and a Turkish research assistant with contacts at the intervention locations. Other researchers have concluded that ethnicity-matched recruiters result in better reach to the target group( Reference Hartman, Nierkens and Cremer 51 ). We will investigate this issue further in the process evaluation of the MetSLIM study (forthcoming).
Finally, the quasi-experimental design could be considered a limitation. However, although randomised controlled trials are highly valued, it is debateable if randomised controlled trials are the appropriate research method to evaluate complex interventions( Reference Bothwell, Greene and Podolsky 52 ). In our case, it was considered that randomisation would not be feasible, and even undesirable. As most persons in our target group are probably unfamiliar with research and randomisation, it could have easily provoked dissatisfaction and non-participation if participants were randomly allocated to intervention and control groups, especially within one community. A selective response could therefore be expected with a randomised controlled trial, which would have threatened the recruitment of the target group and the external validity of the study.
Conclusions
In conclusion, the current study showed that the adapted SLIM lifestyle intervention targeting low-SES individuals of different ethnic origins is effective in improving waist circumference, total and LDL cholesterol, and quality of life after 12 months. Future research is required to investigate whether further adaptations to the lifestyle intervention may be necessary to enhance its effectiveness among different ethnic minorities and to investigate how men and persons of Moroccan origin can be more successfully reached for this lifestyle intervention.
Acknowledgements
Acknowledgements: The authors thank all the participants and health-care professionals who were involved in the MetSLIM study. Financial support: This work was supported by LekkerLangLeven (cooperation between the Dutch Diabetes Research Foundation, the Dutch Kidney Foundation and the Dutch Heart Foundation; grant number 2009.20.021). LekkerLangLeven had no role in the design, analysis or writing of this article. Conflict of interest: None. Authorship: A.J.B. and D.T. contributed equally to this work. A.J.B. and D.T. designed the evaluation study, collected and processed all data, and drafted the manuscript. E.J.M.F. and M.A.v.B. helped to analyse the data and to revise the manuscript. R.J.R. and A.M. were involved in reviewing and improving the manuscript. All authors were involved in designing the MetSLIM protocol and approved the final manuscript. E.J.M.F. is the guarantor of this work and, as such, had full access to all data in the study and takes responsibility for the integrity of the data and the accuracy of the data analysis. Ethics of human subject participation: This study was conducted according to the guidelines laid down in the Declaration of Helsinki and all procedures involving human subjects were approved by the Medical Ethical Committee of Wageningen University. Written informed consent was obtained from all subjects. The study was registered at the Netherlands Trial Register as NTR3721.
Supplementary material
To view supplementary material for this article, please visit https://doi.org/10.1017/S1368980017001458
