Testing a new approach to dietary changes for type 2 diabetes
There are only around 9,000 registered dietitians in the UK and not all have expertise in the prevention and management of diabetes. Dr Anne Haase and Dr Clare England developed a specific approach to help set relevant goals and to support diet behaviour change for type 2 diabetes patients.
Dietitians and registered nutritionists use in-depth dietary assessment to give targeted advice and to help set specific dietary goals. However, there are only around 9,000 registered dietitians in the UK and not all have expertise in the prevention and management of diabetes. In practice people with type 2 diabetes often receive dietary advice from health professionals who do not have specialist nutrition training: the system often produces generic advice which those at risk of diabetes or suffering from it, say is not relevant to them and that they don’t know how to put it into practice.
Dr Anne Haase and Dr Clare England developed a specific approach to help set relevant goals and to support diet behaviour change for type 2 diabetes patients. Their UK Diabetes and Diet Questionnaire (UKDDQ) assesses and scores diet quality, scoring items and habits of particular relevance to the prevention and management of type 2 diabetes. The UKDDQ is supported by the Talk2Change approach, based on motivational interviewing techniques to promote behavioural changes and encourage a decision to eat differently.
Haase and England’s research had shown that a combination of the UKDDQ and Talk2Change method could help practitioners hold more successful conversations with patients in motivating dietary change. Combining the two could potentially enable dietary advice to be delivered by front-line staff without specific expertise in nutrition and behaviour change.
By 2017 the new approach had been promoted to local and national health professionals, researchers and patients via professional and patient networks, and was well-received. It had also been downloaded numerous times. And Birmingham CCG, a demonstrator site for the NHS Diabetes Prevention Programme, had used the UKDDQ to measure dietary change and was actively evaluating it.
However, both academics recognised that changing practitioner behaviour and introducing new tools into existing services is not straightforward. Many lifestyle interventions are successful in a research setting but not subsequently taken up. The combination of reasons often includes poor targeting, no buy-in from the target group(s), impracticality or simply lack of awareness. To prevent this, Haase and England successfully applied for ESRC IAA exploratory funding to identify key providers and partners and what was needed for them to introduce the techniques into their service. They were also interested in whether (and why) existing tools to promote lifestyle change were used or not.
The funding enabled them to commission an experienced market research consultant to work with potential providers, practitioners and partners. They wanted to identify environments where the intervention had potential to achieve high impact, and in what practical form it would be useful eg. paper- or web-based, with on-line training etc. The resulting Report would determine the best route forward and possibly an application for funding that could lead to a full-scale feasibility trial.
Meetings and discussions with dietitians and nurses about their advice delivery programmes, and how the combined tool might fit with their support for people with diabetes, proved very positive. In one example, the North Somerset Specialist Diabetes nurses and Bristol Community Health dietitians were trained in the combined approach and actively explored introducing it into their own practice. Practitioners valued the training: they have subsequently maintained an interest in the project and continue to use the UKDDQ with specific patients.
However, although the results showed a positive response to the new approach, the Report could not provide any straightforward way to implement it into the current fragmented delivery systems. Structural barriers to introducing the new approach within existing practices included the difficulties of ensuring clients received and completed the questionnaire in advance, or the lack of flexibility in consultation times.
Given the limitations of exploratory funding, the team focused on obtaining enough information to guide refinement of the intervention and to suggest improvements in the delivery pathways, while recognising its potential impact on support workers’ and dietitians’ workload. And although the project partners expressed an active interest in promoting and using the intervention, their motivation was undermined by the lack of NHS funding for it. Combined with this was the expectation by external organisations and potential investors that this should, as a public health issue, be supported by funded health groups, charities or local authorities.
Despite these difficulties, the project outcomes were promoted through the Bristol Biomedical Research Centre (BRC) and through an online Report. The Report itself became a Paper for Health Services Research, promoted through social media.
The project was also reported in Diabetes UK group sessions, and across the NHS Bristol, North Somerset and Gloucester CCG (BNSSG) via dietitians’ newsletters and social media. Information was also provided to general practices to highlight for people at risk or with type 2 diabetes, and the team were invited to promote the project at the BNSSG Diabetes conference for GPs, nurses and other health professionals.