*3.3. Results Analyses of Adherence to the Mediterranean Diet, Satisfaction, and Adherence to the Reintervention*

Regarding adherence to the Mediterranean diet, *t*-tests showed that there were no statistically significant differences (*p* = 0.100) between the time before (Time 1: 8.2 ± 2.1) and immediately after the reintervention (Time 2: 8.8 ± 1.7). Furthermore, participants reported a higher level of satisfaction with the program after the second intervention compared to the first one, although these findings did not reach statistical significance (first intervention: 6.8 ± 2.3, second intervention: 8.0 ± 1.4; *p* = 0.080). With regard to adherence to the reintervention, seven patients withdrew before completing the first module, 66% of the 29 participants had looked at more than half of the program (at least 5 of the 9 modules), and 38% had completed all of it. Finally, at Time 0, the comparison between the 29 volunteers who agreed to participate in the reintervention and the 76 participants excluded from the study showed no statistically significant differences in any of the studied variables (*p* > 0.29), except for the BMI, which was higher in the excluded patient group (29.0 ± 2.5 and 30.2 ± 2.8, respectively; *p* = 0.033). However, a subsequent analysis verified that the differences had already existed before the first intervention between these two groups (29.3 ± 2.6 versus 30.5 ± 2.6; *p* = 0.033).


**Table 2.**

Comparisons

 for Time 0 versus Time 1 versus Time 2.

presented as mean (SD). c Time 1: average values prior to patient reintervention, presented as mean (SD). d Time 2: average values post patient reintervention,presented as mean (SD). e Difference was calculated as Time 1 (PRE-reintervention) minus Time 0 (1st intervention FOLLOW-UP). f Difference was calculated asTime 2 (POST-reintervention) minus Time 1 (PRE-reintervention). \* *p* ≤ 0.05; \*\* *p* ≤ 0.01.

### **4. Discussion**

This study indicates that the 29 hypertensive overweight or obese patients enrolled in the reintervention had maintained long-term benefits in terms of reduced BMI and BP at a 3-year follow-up after having completed the 'Living Better' online intervention [16,17]. Likewise, our results show that these variables significantly improved after the same group of patients repeated the program a second time (reintervention). To the best of our knowledge, this is the first work using a web-based program aimed at promoting a healthy lifestyle based on psychoeducation, regular engagement in PA, and the establishment of healthy eating behavior with such a long-term follow-up time. It is also the first study to describe the effects of a reintervention in patients with an OB-HTN phenotype.

Our results did not show any significant changes in any of the study variables (SBP, DBP, BMI, antihypertensive drugs, or eating behavior) at the 3-year follow-up, compared to the first intervention in 2018, with the exception of the level of PA, which had significantly worsened. This decline may have been because of the restrictions to movements and access to sports spaces imposed by governmental authorities as a result of the COVID-19 pandemic at the time of this work. In this sense, recent research indicates that there was a significant decrease in PA at this time, accompanied by an increase in sedentary habits, due to these restrictions [10,11]. Also of note, the eating behavior of the study patients did not significantly worsen during that time. Indeed, the 'Living Better' program has already been shown to effectively improve emotional eating and other psychological variables related to eating and quality of life (anxiety and stress) [16]. These results are consistent with the absence of significant changes in BP and BMI, together indicating the long-term effectiveness of the 'Living Better' program.

To help deal with the possible negative lifestyle effects of the COVID-19 pandemic on patients with the OB-HTN phenotype (for example, decreased PA), we decided to implement a second intervention with the same program. Given the self-administered, interactive, multimedia, and web-based nature of the platform, we hypothesized that repeating this program could reinforce and enhance the knowledge that the patients had acquired after the first intervention, helping them to face the barriers and thereby perhaps minimizing the negative impact of the situation on their lifestyle and health.

The results that we obtained after administering the reintervention confirmed our hypothesis. Thus, despite the restrictions imposed by the pandemic, the participants had significantly increased their levels of PA—after 3 months of reintervention—by approximately 30%, or around 900 METs-min/week. In addition to the improvements in PA, as already demonstrated in the first intervention in 2018 [16], reintervention with the 'Living Better' program also positively influenced emotional eating and external eating. In fact, one of the goals of this program is to change eating behavior (generating a more conscious and less impulsive eating style) by using psychoeducation, eating tricks, and self-control strategies. This finding is relevant because eating styles are considered to be multi-dimensional, stable, and related to OB [26]. The latter is important in the context of the negative emotions such as anxiety and panic generated by the COVID-19 pandemic, which have been associated with unhealthy eating behavior in populations with higher rates of OB [27,28]. Furthermore, adherence to the Mediterranean diet before reintervention was close to the upper limit of the 'medium adherence' range (8.2 points on the MEDAS questionnaire) [25], perhaps because of the effect of the first intervention. Nonetheless, the reintervention still produced a slight increase in the score by 0.6 points.

Therefore, presumably as a consequence of improvements in PA and eating behavior after the reintervention, the participants had reduced their body weight by an average of 2 kg, which translated into a significant reduction in BMI by 0.7 kg/m2. Of special note, this BMI reduction was even higher than that achieved after the first intervention in 2018 (0.4 kg/m2) [17]. In addition, the literature also reflects the direct impact that weight loss has on BP values [29]. In this sense, compared to our first study [17], the SBP and DBP of the reintervened patients also decreased further, possibly as a consequence of the greater BMI reduction. In these patients, SBP and DBP decreased by 4.7 and 3.5 mmHg, respectively

(*p* = 0.017 and *p* = 0.009), compared to the non-significant reduction in SBP (−2.6 mmHg, *p* = 0.15) and the lower reduction in DBP (−2.2 mmHg, *p* = 0.05) that we reported after the first intervention in 2018. These post-reintervention improvements also exceeded those reported in the meta-analysis by Liu et al. on Internet-based lifestyle counselling [30], in which SBP and DBP were reduced by a mean of 3.8 mmHg and 2.1 mmHg, respectively. Likewise, it is important to note that the improvements that we found in this research were not the result of a change in medication, because no significant differences were reported by the participants at any of the timepoints examined in the number of antihypertensive drugs used.

In terms of program engagement [31], the percentage of participants who completed our entire program was lower (38%) than in our first intervention [17] or similar e-counselling lifestyle interventions [32]. The low completion rate for the whole program during the reintervention may have been partly because of the limitations caused by the COVID-19 pandemic, perhaps forcing the population to adapt their working hours and spaces, as well as reducing the availability of personal time and resources [33,34]. This phenomenon may also have been because the participants had remembered some of the educational content from the first intervention, leading them to complete only the modules that they considered necessary. Indeed, two thirds of the participants completed at least half of the 'Living Better' program (five or more modules). Moreover, the mean participant satisfaction with the reintervention was 1.2 points (out of 10) higher than the average from the first study [17], although this did not reach statistical significance. This difference may be because of the alterations we made to the program presentation by including more audiovisual content [35,36], as suggested by the patients after the first intervention.

At this point, it is important to highlight that the Internet has been shown as an effective means to promote healthy lifestyles in order to help prevent and treat chronic diseases. This is because it can reach more people (including those with limited access to health services or low levels of social support) and it can provide patients with more intensive contact with clinicians at a lower economic cost than conventional face-to-face programs [37,38]. Additionally, Internet-based platforms can provide immediate, easily accessible, individually tailored (one-on-one), and permanent (accessible at any time) support to patients in the comfort of their own homes. All these advantages were especially relevant in the context of the COVID-19 pandemic, which was ongoing while this study was implemented. Therefore, the long-term effects of the web-based 'Living Better' program and those obtained after a reintervention with the same program were remarkable and should be scientifically valued. They minimized the profound negative impact of COVID-19 on the health of these patients—who all had an OB-HTN phenotype—and even managed to improve their health profiles.
