Observational Study
Copyright ©The Author(s) 2017. Published by Baishideng Publishing Group Inc. All rights reserved.
World J Gastroenterol. Mar 14, 2017; 23(10): 1881-1890
Published online Mar 14, 2017. doi: 10.3748/wjg.v23.i10.1881
Role of illness perception and self-efficacy in lifestyle modification among non-alcoholic fatty liver disease patients
Shira Zelber-Sagi, Shiran Bord, Gali Dror-Lavi, Matthew Lee Smith, Samuel D Towne Jr, Assaf Buch, Muriel Webb, Hanny Yeshua, Assy Nimer, Oren Shibolet
Shira Zelber-Sagi, Assaf Buch, Muriel Webb, Hanny Yeshua, Oren Shibolet, Liver Unit, Department of Gastroenterology, Tel-Aviv Medical Center, Tel-Aviv 6423906, Israel
Shira Zelber-Sagi, Shiran Bord, Gali Dror-Lavi, School of Public Health, University of Haifa, Haifa 3498838, Israel
Matthew Lee Smith, Institute of Gerontology, College of Public Health, The University of Georgia, Athens, GA 30602, United States
Matthew Lee Smith, Samuel D Towne Jr, Texas A&M University, School of Public Health, College Station, TX 77843, United States
Assaf Buch, Muriel Webb, Hanny Yeshua, Oren Shibolet, The Sackler Faculty of Medicine, Tel-Aviv University, Tel-Aviv 6423906, Israel
Hanny Yeshua, Family Medicine Department, Tel-Aviv and Dan Petach-Tikva, Clalit Health Services, Rabin Medical Center, Tel-Aviv 49100, Israel
Assy Nimer, Internal medicine A Galler medical Center, Bar-Ilan University, Ramat-Gan 5290002, Israel
Author contributions: Zelber-Sagi S and Bord S contributed equally to this study; Zelber-Sagi S conceived the study; Zelber-Sagi S, Bord S and Dror-Lavi G designed the study; Zelber-Sagi S, Dror-Lavi G, Buch A, Webb M and Yeshua H performed the data collection; Shibolet O conducted on data collection; Zelber-Sagi S, Bord S, Smith ML and Towne SD Jr wrote the manuscript; Nimer A and Shibolet O critically reviewed the manuscript.
Institutional review board statement: The study was approved by the institutional review board of Tel Aviv medical center.
Informed consent statement: All participants signed an informed consent.
Conflict-of-interest statement: We declare that in this manuscript there was no Conflict of interest and no financial support.
Data sharing statement: Technical appendix, statistical code, and dataset available from the corresponding author at zelbersagi@bezeqint.net.
Open-Access: This article is an open-access article which was selected by an in-house editor and fully peer-reviewed by external reviewers. It is distributed in accordance with the Creative Commons Attribution Non Commercial (CC BY-NC 4.0) license, which permits others to distribute, remix, adapt, build upon this work non-commercially, and license their derivative works on different terms, provided the original work is properly cited and the use is non-commercial. See: http://creativecommons.org/licenses/by-nc/4.0/
Correspondence to: Dr. Shira Zelber-Sagi, RD, PhD, Liver Unit, Department of Gastroenterology, Tel-Aviv Medical Center, Tel-Aviv 6423906, Israe. zelbersagi@bezeqint.net
Telephone: +972-3-6973984 Fax: +972-3-6966286
Received: December 3, 2016
Peer-review started: December 6, 2016
First decision: December 28, 2016
Revised: January 9, 2017
Accepted: February 6, 2017
Article in press: February 8, 2017
Published online: March 14, 2017
Processing time: 100 Days and 14 Hours
Abstract
AIM

To describe the relationships between non-alcoholic fatty-liver disease (NAFLD) patient’s disease consequences and treatment perceptions, self-efficacy, and healthy lifestyle maintenance.

METHODS

A cross-sectional study among 146 ultrasound diagnosed NAFLD patients who visited the fatty liver clinic at the Tel-Aviv Medical Center. Eighty-seven of these individuals, participated in a clinical trial of physical activity and underwent fasting blood tests, analyzed at the same lab. Exclusion criteria included positivity for serum HBsAg or anti-HCV antibodies; fatty liver suspected to be secondary to hepatotoxic drugs; excessive alcohol consumption (≥ 30 g/d in men or ≥ 20 g/d in women) and positive markers of genetic or immune-mediated liver diseases. Patients were asked to complete a self-report structured questionnaire, assembled by the Israeli Center for Disease Control. Nutrition habits were measured using six yes/no questions (0 = no, 1 = yes) adopted from the national survey questionnaire. Participants in the clinical trial completed a detailed semi-quantitative food frequency questionnaire (FFQ) reporting their habitual nutritional intake during the past year. Self-efficacy was assessed by the Self-Efficacy Scale questionnaire, emotional representation, degree of illness understanding, timeline perception, treatment perception and symptoms were measured by the Brief Illness Perception questionnaire. Illness consequences were measured by the Personal Models of Diabetes Interview questionnaire. A path analysis was performed to describe the interrelationships between the patients’ illness perceptions, and assess the extent to which the data fit a prediction of nutritional habits.

RESULTS

The study sample included 54.1% men, with a mean age of 47.76 ± 11.68 years (range: 20-60) and mean body mass index of 31.56 ± 4.6. The average perceived nutrition habits score was 4.73 ± 1.45 on a scale between 0-6, where 6 represents the healthiest eating habits. Most of the study participants (57.2%) did not feel they fully understood what NAFLD is. Better nutritional habits were positively predicted by the degree of illness understanding (β = 0.26; P = 0.002) and self-efficacy (β = 0.25; P = 0.003). Perceptions of more severe illness consequences were related with higher emotional representation (β = 0.55; P < 0.001), which was related with lower self-efficacy (β = -0.17; P = 0.034). The perception of treatment effectiveness was positively related with self-efficacy (β = 0.32; P < 0.001). In accordance with the correlation between self-efficacy and the perceived nutrition habits score, self-efficacy was also correlated with nutrient intake evaluated by the FFQ; negatively with saturated fat (percent of saturated fat calories from total calories) (r = -0.28, P = 0.010) and positively with fiber (r = 0.22, P = 0.047) and vitamin C intake (r = 0.34, P = 0.002). In a sub analysis of the clinical trial participants, objectively measured compliance to physical activity regimen was positively correlated with the self-efficacy level (r = 0.34, P = 0.046).

CONCLUSION

Self-efficacy and illness understanding are major determinants of lifestyle-modification among NAFLD patients. This information can assist clinicians in improving compliance with lifestyle changes among these patients.

Keywords: Non-alcoholic fatty-liver disease; Physical activity; Diet; Illness perception; Self-efficacy

Core tip: Dietary modification is a main route of treatment in non-alcoholic fatty liver disease (NAFLD), however it is difficult to maintain in the long term and better ways for implementation are needed. Higher perceptions of understanding the illness and a higher self-efficacy are positively related to better nutritional habits, and therefore its enhancement should be part of the behavioral treatment. Emphasizing to patients that although NAFLD is a chronic condition, it is effectively treatable by diet, increases their self-efficacy. “Scaring” the patients and leading them to believe that NAFLD has severe consequences may lead to the undesirable outcome of reduced self-efficacy and worse dietary habits.