Feasibility of using telehealth to deliver an exercise and nutrition intervention to people with non-alcoholic fatty liver disease

This is a 12-week pilot randomized controlled trial designed to investigate the feasibility of using telehealth as an approach to remotely deliver an exercise and dietary program for middle-aged and older adults (aged 45 years and over) with diagnosed non-alcoholic fatty liver disease (NAFLD). Specifically, the program will focus on lifestyle strategies aimed to promote regular muscle strengthening training, increased dietary protein intake (predominantly from plant-based sources) and promote healthy eating behaviours to optimise body composition, muscle strength and function. Following baseline assessments, participants will be randomised (1:1 ratio) to receive either usual care or the telehealth lifestyle intervention. Those participants allocated to the telehealth intervention will be prescribed a 12-week muscle strengthening program by a qualified accredited exercise physiologists (EP) using a commercially available (and free) web-based exercise prescription platform and app (TeleHab) accessible via a smart device (phone or tablet). TeleHab is a digital platform specifically designed for health professionals to prescribe exercise programs to participants remotely that can also track and monitor progress, provide regular feedback and assess particpant adherence via app analytics. Selecting from a library of >5,000 exercises, the EP will design an individualised program for each participant including the training dose (frequency, sets, repetitions) for each exercise. The participant can set reminders for exercise times, record exercise completion (sets, repetitions) and rate their perceived exertion and any pain for each exercise. Exercise prescription will be personalised based on the participant’s baseline assessment, medical and physical activity history, and the EP’s clinical judgement. Participants will be prescribed a 25 minute muscle strengthening program consisting of 6-8 exercises utilising major muscle groups (2 sets of 10-12 repetitions) at a moderate intensity to be completed thrice weekly (on non-consecutive days). Some examples of the exercises to be prescribed include squats, lunges, hip abduction/adduction, bench stepping, bent over row, press ups, triceps dips, calf raises, lying back extension and core postural exercises (eg. plank). At week 6, the EP will prescribe (via Telehab) a new set of exercises for the remaining 6 weeks of the intervention. In addition, participants will be instructed to engage in regular aerobic activity (e.g., brisk walking) for at least 30 minutes at least twice per week, which they will record in a calendar. Prior to commencing the study, participants will receive education on the TeleHab app and safety by the EP and prescription of their individualised exercise program via video (zoom) consultation. In weeks 2 and 6 participants will attend small group (~5 participant, ~30-60 min sessions) video consultations with the EP. These sessions will be used to respond to any questions, modify the exercise program if required and promote motivation and a sense of community for participants. Participants will also receive a healthy eating plan devised by a dietitian/nutritionist. It is hypothesized that it will emphasize a protein intake of 1.2-1.5 g/kg/day from predominately plant-based (legumes, tofu, nuts, peanuts, nut paste, peas, beans), as well as white meat and fish sources. Participants will follow the healthy eating plan during the 12-week intervention. Participants will receive dietary information via a video (zoom) consultation by the dietitian/nutritionist at baseline to outline the healthy eating plan, focusing on a high protein intake and more broadly how different protein sources (e.g., plant-based) can be incorporated into the diet. These recommendations will be based on a heart healthy, modified Mediterranean style dietary pattern informed by current clinical guidelines for NAFLD which incorporate increasing intakes of mono and polyunsaturated fats, vegetables, legumes, fruit, wholegrains, nuts and seeds and reducing intakes of processed sugars, red and processed meats. Additionally, participants will attend small group (~5 participants) video (zoom) consultations with the dietitian/nutritionist conducted in weeks 2 and 6 to provide information and tips on increasing protein intake, provide feedback on protein checklists, and promote motivation for participants and in week 12 to conduct semi-qualitative interviews to assess participants perceptions of the program. Changes in macro and micronutrient intakes and food groups will be assessed via three separate 24-hour records conducted at baseline, 6 and 12 weeks collected via a web-based dietary app. Nutrition information will be analysed using Foodworks nutrient analysis software (Xyris, Brisbane, Queensland, Australia). Additionally, online protein checklists will be completed at weeks 0, 2, 6, 9 and 12 weeks to further assess adherence to the higher protein intake from predominantly plant-based sources. In addition to the regular support from the EP and dietitian/nutritionist, participants will receive regular push notifications (4-5 messages/week, approximately 30 sec read per message) with health focused messages to support behavioural change including reminders and tips for increasing daily serves of protein (predominately plant-based) and physical activity/movement tips and motivational messages.