The research, published in the Journal of Neurology, comes from the MobilE-TRA 2 cohort, a prospective observational study run at the German Center for Vertigo and Balance Disorders in Munich, a tertiary referral centre that sees more than 3,000 patients a year. The team, led by Sophia P. Schulze and Ralf Strobl of Ludwig-Maximilians-Universität München, followed 337 adults aged 60 and over who had been newly assessed for a vertigo, dizziness, or balance disorder. Just over half were women, and the average age was 71. Each participant underwent a full interdisciplinary work-up—structured medical history, neurological, ocular-motor, and neuro-otological examinations, and where clinically indicated, caloric testing, video head impulse testing, vestibular-evoked myogenic potentials, posturography, and audiometry. Then, at three and twelve months after receiving their individualised treatment recommendations, patients filled in postal questionnaires reporting how often they had actually implemented what had been prescribed. Follow-up rates were impressively high: 88.7 percent at three months and 87.2 percent at twelve.

The researchers drew a deliberate distinction between two categories of non-pharmacological recommendation. The first was specific exercises—balance, gait, or habituation exercises prescribed as part of vestibular rehabilitation, the standard therapy for many vestibular disorders. The second was lifestyle-related recommendations, a composite covering physical activity, general everyday movement, and weight control. This distinction matters because the two types demand different patterns of behaviour. Specific exercises need not be performed daily to be effective, whereas lifestyle changes depend on frequent, near-continuous implementation. Accordingly, the team applied different cut-offs on a five-point self-reported frequency scale, defining adherence to exercises as a score of two or higher and adherence to lifestyle recommendations as three or higher. The framework guiding the analysis was the World Health Organization’s multidimensional model of adherence, which sees the phenomenon as shaped by interacting social and economic, health system-related, condition-related, therapy-related, and patient-related factors.

The headline numbers look reassuring at first glance. Around 80 percent of participants were classified as adherent to each recommendation type at least once during follow-up—79.6 percent for specific exercises among the 216 who reported receiving them, and 80.4 percent for lifestyle recommendations among the 270 who received those. But the longitudinal analysis, using logistic generalised linear mixed-effects models with random intercepts to account for repeated measurements within each person, told a more nuanced story. Adherence to specific exercises dropped markedly between the three-month and twelve-month assessments, with an odds ratio of 0.28 (95 percent confidence interval 0.12 to 0.67). In plain terms, the odds of a patient still performing their prescribed vestibular exercises a year after their initial assessment were less than a third of the odds at three months. Adherence to lifestyle recommendations, by contrast, remained statistically stable over the same period.

Why do the exercises fall away while the lifestyle changes persist? The authors are careful not to interpret the decline as simple failure. In vestibular rehabilitation, symptoms often improve or resolve with treatment, and a patient whose dizziness has faded may genuinely need less practice. Previous research has also documented persistent barriers: symptom provocation during the exercises themselves—which can temporarily make people feel worse—along with time constraints, coexisting impairments, and insufficient guidance or feedback. People with vestibular disorders also report higher fear-avoidance beliefs and lower confidence during balance activities than healthy adults, which can make unsupervised home exercise feel risky. The decline may therefore reflect a mixture of successful recovery, waning motivation, and the well-known difficulty of sustaining self-managed home exercise that has been observed across physiotherapy and chronic disease populations more broadly.

One of the study’s most intriguing findings concerns who stuck with the exercises. Patients with greater perceived dizziness-related handicap at baseline—measured with the validated 25-item Dizziness Handicap Inventory, which scores the functional, physical, and emotional impact of dizziness from 0 to 100—were more likely to adhere to specific exercises, with an odds ratio of 1.03 per point (95 percent CI 1.00 to 1.06). This seems counterintuitive until one considers the psychology of symptom-driven motivation. People whose dizziness seriously disrupts their lives have a powerful, immediate reason to work at their rehabilitation. Those with mild or rapidly improving symptoms, on the other hand, may simply lose the incentive to continue. The same symptom burden can cut both ways, however: in other vestibulopathy subgroups, symptoms provoked by the exercises have been identified as a barrier to adherence. Symptom burden, the authors conclude, appears to influence adherence in ways that are highly context-specific.

The lifestyle recommendations obeyed a different logic altogether. Here, the strongest predictor was self-efficacy—a person’s belief in their own ability to perform specific behaviours, assessed with a three-item General Self-Efficacy Short Scale. Higher self-efficacy was associated with higher adherence (OR 1.65; 95 percent CI 1.02 to 2.66), while male gender was associated with lower adherence (OR 0.37; 95 percent CI 0.16 to 0.88). The self-efficacy finding aligns neatly with systematic reviews in physiotherapy, where low self-efficacy is consistently described as a barrier to home exercise, and with broader behavioural evidence linking confidence to health behaviour change. It also echoes earlier results from the same cohort, in which self-efficacy predicted functioning after specialised care. In a condition where patients must manage dizziness and unsteadiness while simultaneously changing daily habits, the belief that one can cope with difficult situations may be precisely the resource that sustains behaviour over time.

Perhaps the most methodologically interesting part of the study is what did not predict adherence. Drawing on behavioural economics, the team measured two further patient-related traits: time preferences, meaning how much people value future benefits relative to immediate rewards, and health-related risk attitudes, meaning willingness to take risks in health contexts. Both have been linked to health behaviours such as smoking, alcohol consumption, exercise, and diabetes self-management in previous research. Yet in this cohort, neither showed a statistically significant association with adherence to either recommendation type. The finding suggests that the psychological machinery behind keeping up vestibular exercises or lifestyle changes may differ from that behind other preventive health behaviours—or simply that the single-item measures used here lacked the sensitivity to detect weaker effects. Either way, it tempers the assumption that present-oriented, risk-tolerant patients are inevitably the ones who drift away from their treatment plans.

The study has honest limitations that shape how its results should be read. Adherence was self-reported and therefore vulnerable to recall and social desirability bias; the authors emphasise that the figures represent perceived implementation rather than objectively measured behaviour. Adherence measurement in VDB has never been standardised, and the category of specific exercises may have encompassed different exercise types across diagnostic subtypes, which ranged from benign paroxysmal positional vertigo and persistent postural-perceptual dizziness to Menière’s disease, vestibular migraine, and bilateral vestibulopathy. Diagnostic subtype could not be included in the multivariable models because several groups were too small, leaving open the possibility of residual confounding. Sensitivity analyses with alternative cut-offs shifted some estimates—for instance, under a stricter exercise cut-off, multimorbidity emerged as a barrier and self-efficacy as a stronger facilitator—so individual effect estimates warrant caution. Recruitment during the SARS-CoV-2 pandemic, when healthcare access was disrupted, may also have selected a more severely affected population, limiting transferability to primary care.

Even with those caveats, the practical message is clear and potentially actionable. Adherence in older adults with vertigo, dizziness, and balance disorders is not a single behaviour but at least two, with different time courses and different drivers. Exercises decay over the year after prescription, particularly among those whose symptoms were mild to begin with, while lifestyle changes persist—especially in patients with high self-efficacy, and less so in men. For clinicians, that argues against a one-size-fits-all follow-up schedule: patients with low self-efficacy, mild symptoms, or a recent exercise prescription may benefit most from booster contacts, feedback, and structured support in the months after their initial assessment, precisely when the data show adherence beginning to slip. For researchers, the study opens a direct question that it could not answer: why do patients stop? Larger cohorts, objective adherence measures, and primary-care replication will be needed to turn these observational patterns into interventions that keep older people steady on their feet.

Subject of Research: Adherence to non-pharmacological treatment recommendations in older adults with vertigo, dizziness, and balance disorders

Article Title: Adherence to treatment recommendations in older adults with vertigo, dizziness, and balance disorders: the MobilE-TRA 2 cohort study

Article References: Schulze, S. P., Katzenberger, B., Koller, D., Huppert, D., Grill, E., & Strobl, R. (2026). Adherence to treatment recommendations in older adults with vertigo, dizziness, and balance disorders: the MobilE-TRA 2 cohort study. Journal of Neurology, 273(10), Article 649. https://doi.org/10.1007/s00415-026-14195-0

Image Credits: AI Generated

DOI: 10.1007/s00415-026-14195-0

Keywords: vertigo, dizziness, balance disorders, vestibular rehabilitation, treatment adherence, older adults, self-efficacy, geriatrics, cohort study, lifestyle modification, Dizziness Handicap Inventory, neurology

The starting point for the new index was deliberately simple and internationally recognizable: the four cornerstones of health articulated by the World Health Organization. These cornerstones, which cover balanced diet, appropriate physical activity, avoidance of tobacco and rational use of alcohol, served as the dimensional skeleton of the framework. Around that skeleton, the researchers fleshed out a full set of candidate indicators drawn from the contents of China’s own health-related policy documents. This dual anchoring matters. By rooting the index simultaneously in WHO doctrine and in national policy language, the team ensured that the resulting tool speaks both the universal language of global health promotion and the specific administrative vocabulary that Chinese health authorities use when designing campaigns, screening programs and evaluation schemes.

To decide which candidate items deserved a place in the final instrument, the researchers turned to the modified Delphi method, a technique long favored in health services research for distilling expert judgment into measurable consensus. Fifty experts were recruited to the panel and consulted across multiple iterative rounds, each round feeding anonymous feedback back to the group so that opinions could converge without the distortions of face-to-face hierarchy or dominant personalities. The response dynamics across the three consultation rounds tell their own story about engagement: the effective response rates were 60 percent in the first round, rising to 90 percent in the second, and settling at 66.67 percent in the third. That second-round surge suggests the panelists found the evolving framework increasingly worth their time, while the final-round taper reflects the natural completion of consensus once most disagreements have been resolved.

Expert engagement is only meaningful if the experts themselves are credible, and the study quantifies this through the authority coefficient, a composite of each panelist’s judgment basis and familiarity with the topic. The authority coefficients for the three rounds came in at 0.906, 0.899 and 0.904 respectively, figures that sit comfortably in the range conventionally interpreted as high expert authority. In practical terms, the people scoring the indicators were not casual observers but specialists whose self-assessed command of the subject matter remained consistently strong across the entire consultation. Equally important was whether the panel actually converged. The Kendall Harmony Coefficient, a rank-based measure of agreement among raters, reached 0.342 in the third round, indicating statistically meaningful coordination of expert opinion after two rounds of structured feedback.

With consensus achieved on the indicator set, the researchers faced the harder mathematical problem of weighting: not all lifestyle behaviors contribute equally to health outcomes, and an index that treats every item identically would misrepresent reality. Here the team employed the Analytic Hierarchy Process, a structured decision-making technique that decomposes complex judgments into pairwise comparisons and then checks whether those comparisons are internally coherent. The AHP calculations assigned weights to the four dimensions of 0.286, 0.286, 0.286 and 0.143 respectively, a strikingly egalitarian distribution in which three of the WHO cornerstones carry equal weight while the fourth carries half. Every comparison matrix passed the consistency test, meaning the experts’ pairwise judgments did not contradict one another in ways that would undermine the derived weights.

The resulting Chinese Adult Healthy Lifestyle Index System comprises 4 dimensions containing 22 individual items, a granularity fine enough to capture specific behaviors while remaining compact enough for practical deployment in surveys, clinics and community health screenings. But a consensus-built checklist is not automatically a valid measuring instrument, so the team subjected the scale to classical psychometric evaluation using questionnaire data. Exploratory factor analysis identified six robust factors that together accounted for 62.337 percent of the total variance in responses. Intriguingly, this statistical structure did not simply reproduce the four theoretical dimensions. Instead, the dietary and risk behavior domains naturally differentiated into subdomains during the analysis, refining the initial four-dimensional framework in a data-driven way that suggests the underlying behavioral architecture is more layered than the policy categories alone imply.

Reliability testing reinforced the case for the instrument. The Cronbach’s alpha coefficient for the full scale reached 0.819, a value indicating acceptable internal consistency, meaning the items within the scale tend to measure the same underlying construct rather than a grab bag of unrelated behaviors. For a tool intended to be administered across diverse adult populations, from urban office workers to rural residents, that coherence is essential. The study’s procedures were approved by the Medical Ethics Committee of Shanxi Medical University under ethical code 2024020, with informed consent obtained from all individual participants, and the authors declare no competing interests. The research received no specific grant from funding agencies in the public, commercial or not-for-profit sectors, making it an unusually lean affair for an instrument of this ambition.

Why does a Chinese-specific lifestyle index matter when international instruments already exist? The most widely used measure, the Health-Promoting Lifestyle Profile, was developed in a Western context, and its assumptions about diet, social norms and health behaviors do not always translate cleanly across cultures. Dietary patterns in China, the role of traditional foods, the epidemiology of tobacco use, and the policy infrastructure of health promotion all differ from the settings in which imported scales were validated. By grounding each of the 22 items in Chinese policy documents and vetting them through a domestic expert panel, the Shanxi Medical University team has produced a framework whose content validity is anchored in the lived and governed reality of the population it aims to assess. The authors conclude that the index system demonstrates scientific rigor and content validity in its constructed indicators, providing a culturally adapted framework for assessing healthy lifestyle behaviors among Chinese adults.

The potential applications extend well beyond academic measurement. A validated index with transparent weights gives health authorities a quantitative instrument for population surveillance, allowing them to track lifestyle scores over time, identify which behavioral domains lag in which regions, and evaluate whether interventions actually move the needle. Employers, insurers and community health centers could use the 22-item structure for rapid screening, while researchers gain a common metric that makes cross-study comparison feasible in a way that ad hoc lifestyle questionnaires never could. The equal weighting of three dimensions and the half-weighting of the fourth also encode an explicit value judgment that policymakers can debate and adjust, which is precisely what a transparent index is designed to enable.

There are, of course, the usual caveats that accompany any new instrument. The Delphi panel reflected expert consensus rather than direct predictive evidence, so longitudinal studies will be needed to confirm that higher scores on the index correspond to lower morbidity and mortality in Chinese cohorts. The exploratory factor structure, with its six emergent factors, hints that future revisions may reorganize the scale along more empirically natural lines. And the moderate third-round response rate reminds us that even well-designed consensus processes lose participants as they iterate. Still, the study represents a methodical fusion of global health doctrine, national policy content and rigorous psychometrics, and it arrives as China confronts the mounting burden of chronic disease driven by modifiable behaviors. If the index performs as its construction suggests, the humble act of scoring a lifestyle may become as routine in Chinese public health practice as measuring blood pressure.

Subject of Research: Construction and validation of a healthy lifestyle index system for Chinese adults using a modified Delphi method

Article Title: Construction of a healthy lifestyle index system for Chinese adults: a modified Delphi study

Article References: Guo, H., Shi, Y., Zhang, N., Wang, C., Tian, R., Luo, D., & Duan, Z. (2026). Construction of a healthy lifestyle index system for Chinese adults: a modified Delphi study. BMC Public Health. https://doi.org/10.1186/s12889-026-29736-5

Image Credits: AI Generated

DOI: 10.1186/s12889-026-29736-5

Keywords: healthy lifestyle, Delphi method, index system, Chinese adults, public health, Analytic Hierarchy Process, psychometrics, WHO, health promotion, BMC Public Health, lifestyle modification, scale validation

Type-2 diabetes mellitus is a chronic metabolic disorder characterised by elevated blood glucose resulting from insulin resistance and progressive impairment of insulin secretion. Long-term elevation of glucose damages blood vessels and nerves, driving complications that range from kidney failure and vision loss to foot ulcers, stroke and heart disease. Optimal glycaemic control, meaning the maintenance of blood glucose within recommended targets, is therefore the central objective of diabetes management, because it minimises these complications over time. Alongside medication, adherence to a healthy lifestyle, encompassing diet, physical activity, weight management and avoidance of tobacco, is recognised as a cornerstone of diabetic care, and it is precisely this behavioural dimension that the Nigerian team set out to address.

The study was designed as a randomised controlled trial, the most rigorous experimental format for evaluating the effect of an intervention, because random allocation distributes known and unknown confounding factors evenly between groups. It was conducted among patients with Type-2 diabetes over a period of 22 weeks, running from November 2023 to April 2024. Participants were randomly assigned to either an intervention arm or a control arm using block randomisation in blocks of four, with allocation determined by a table of random numbers at a one-to-one ratio. Sixty-three participants were enrolled in each arm, giving a total of 126 patients in the trial. Block randomisation of this kind helps to keep group sizes balanced throughout the recruitment process, which is particularly useful in a clinical setting where enrolment may proceed unevenly.

Data collection relied on an adapted version of the World Health Organization STEPS questionnaire, a standardised instrument widely used in population health research to capture sociodemographic characteristics, clinical features and behavioural risk factors. The researchers administered the questionnaire both before and after the intervention, allowing each participant to serve as their own baseline comparator as well as enabling comparison between the two trial arms. To summarise lifestyle practices in a single interpretable metric, the team employed a composite Health Behaviour Score, which aggregates individual behaviours into an overall measure of how healthy a participant’s daily practices are. This composite approach is valuable because individual behaviours often move in different directions, and a summary score can capture net change more reliably than any single item alone.

The intervention itself was a programme of structured lifestyle modification counselling delivered using the 5 A’s framework, a widely adopted behavioural counselling model that guides clinicians through five sequential steps: assessing the patient’s current behaviour and readiness, advising clear and personalised behaviour change, agreeing on realistic goals collaboratively, assisting the patient with practical strategies and support, and arranging follow-up to sustain momentum. Crucially, the counselling was reinforced by five follow-up telephone reminders containing standard pre-recorded messages delivered in Hausa, the predominant language of the region, and in English. This dual-language, telephone-based reinforcement is a pragmatic adaptation to the realities of Northern Nigerian primary care, where patients may travel long distances, face competing economic demands and cannot easily attend frequent in-person follow-up sessions.

When the researchers compared the two arms after the intervention, the difference in healthy behaviour was striking. Among participants in the intervention group, 73.8 percent showed a post-intervention increase in healthy behaviour scores, compared with just 26.2 percent in the control group. This difference was highly statistically significant, with a chi-squared statistic of 29.3 and a p-value below 0.001, meaning the probability of observing such a difference by chance alone is extremely small. Importantly, the two arms had comparable baseline healthy behaviour scores before the intervention began, with a chi-squared value of 0.145 and a p-value of 0.703, which confirms that the groups started from essentially the same behavioural starting point and strengthens the argument that the counselling, rather than pre-existing differences, drove the change.

The trial also tracked two key biochemical markers of glycaemic control: fasting blood glucose, which measures circulating glucose after an overnight fast, and glycated haemoglobin, or HbA1c, which reflects average blood glucose over the preceding two to three months and is considered the gold standard for assessing long-term glycaemic control. Using the Wilcoxon signed-rank test, a non-parametric statistical method for comparing paired measurements, the team found statistically significant decreases in both markers within each arm after the study period. In the intervention arm, the decrease in median post-intervention fasting blood glucose was significant with a z-statistic of -4.124 and a p-value below 0.001, and in the control arm the decrease was also significant with a z-statistic of -3.225 and a p-value of 0.001. Similarly, post-intervention HbA1c fell significantly in both groups, with the intervention arm showing a z-statistic of -3.774 and a p-value below 0.001, and the control arm a z-statistic of -3.158 and a p-value of 0.002.

However, when the researchers used analysis of covariance, or ANCOVA, to adjust for baseline differences and isolate the specific effect of the counselling intervention on glycaemic control, the picture changed. The effect of counselling on post-intervention fasting blood glucose was not statistically significant, with an F-statistic of 0.000 and a p-value of 0.994, and the effect on post-intervention HbA1c was likewise not significant, with an F-statistic of 1.084 and a p-value of 0.300. In other words, although blood glucose measures improved over the 22 weeks in both groups, the improvement could not be attributed specifically to the counselling programme. Both arms received routine clinical care, and factors such as concurrent medication adjustments, seasonal dietary patterns, or regression to the mean may have contributed to the glucose declines observed in both groups alike.

The authors conclude that structured lifestyle modification counselling significantly improved healthy behaviour among patients with Type-2 diabetes, but produced no significant effect on glycaemic control within the trial’s timeframe. This dissociation between behaviour and biochemistry is not unusual in lifestyle intervention research. Behavioural change is the first link in a long causal chain, and measurable improvements in HbA1c often require sustained change over longer periods, greater intensity of intervention, or larger sample sizes to detect. A 22-week window may simply have been too short for newly adopted dietary and physical activity habits to exert a detectable, group-level effect on glycated haemoglobin, particularly if the magnitude of behavioural change, while statistically robust, was modest in absolute terms.

Nevertheless, the practical implications of the trial are considerable. The researchers suggest that integrating structured lifestyle counselling with telephone reminders may serve as an innovative way to promote healthy lifestyles in busy, resource-limited primary care settings. The approach requires no expensive equipment, no additional clinic visits and no specialist staff beyond trained counsellors, and the use of pre-recorded messages in the local language makes it scalable and culturally accessible. The trial was registered with the Pan African Clinical Trial Registry under number PACTR202601577207835 on 20 January 2026, and the research was fully funded by the authors themselves, with no external funding received. Ethical approval was obtained from the Health Research Ethics Committee of Aminu Kano Teaching Hospital, and all participants provided voluntary written informed consent. As diabetes prevalence continues to climb across sub-Saharan Africa, evidence that a low-cost, telephone-supported counselling model can meaningfully shift patient behaviour represents a promising foundation, and future trials with longer follow-up will be needed to determine whether these behavioural gains can ultimately be converted into the blood sugar improvements that matter most for preventing diabetic complications.

Subject of Research: Effect of structured lifestyle modification counselling on lifestyle practices and glycaemic control in Type-2 diabetes patients in Northern Nigeria

Article Title: Effect of structured lifestyle modification counselling on lifestyle practices and glycaemic control among Type-2 Diabetes patients in Northern Nigeria (SLIC-T2D trial): a randomised controlled trial

Article References: Gana, A. A., Abdulkadir, Z., Damagun, F. M., Ogunyele, T. T., Olawumi, A. L., Iroezindu, G. U., Suleiman, A. K., Kwaku, A. A., Benjamin, T. A., Chinedu, G. M., & Grema, B. A. (2026). Effect of structured lifestyle modification counselling on lifestyle practices and glycaemic control among Type-2 Diabetes patients in Northern Nigeria (SLIC-T2D trial): a randomised controlled trial. BMC Endocrine Disorders. https://doi.org/10.1186/s12902-026-02592-5

Image Credits: AI Generated

DOI: 10.1186/s12902-026-02592-5

Keywords: Type-2 diabetes, lifestyle modification, counselling, randomised controlled trial, glycaemic control, HbA1c, fasting blood glucose, Nigeria, primary care, telephone reminders, Health Behaviour Score, 5 A's framework