Digital DPPs are turning the tide on prediabetes

With a record 12.7 million people at elevated risk of developing Type 2 diabetes in the UK, the need to help people change their lifestyles en masse has never been more acute.

Patients already diagnosed with Type 2 are typically very aware of the need to move more and eat more healthily, but struggle to translate their intention to change into sustained action. People with prediabetes, on the other hand, can be more difficult for healthcare professionals to engage with a behaviour change intervention.

Their perception of risk is generally lower; the lack of any physical symptoms leads some to question whether they actually have a health issue and whether changes are required at all.

According to one study, people with prediabetes consistently underestimate their probability of developing Type 2; 84% considered themselves at low, very low or negligible risk. Indeed, many people with prediabetes only find out about their condition when they visit a GP with an unrelated issue, rather than on a regular check-up for diabetes as the NHS recommends.

Others are hindered by outcome expectancies. They recognise the need to change, but feel any attempt will be hopeless and so accept that they will simply remain in their current habits and that developing the condition is an inevitability. As food is perceived as a necessity for life, low outcome expectations can be further compounded by feelings of frustration and deprivation when healthcare professionals advise making changes to a dietary intake.

But digital DPPs, often dubbed “Prevention 2.0”, are addressing these challenges. By making support available on a smartphone or tablet, anytime and anywhere, digital DPPs are reducing the “hassle factor”, leading to significantly higher uptake; one digital trial in London’s Waltham Forest, for example, saw a 500% increase in just 14 days.

When a user can work through a DPP in their own home, in their own time, completion rates are much higher too, improving on users’ understanding of how prediabetes affects their health and increasing users’ risk perception of more serious health issues in the future if they don’t act on their healthcare provider’s recommendations.

Trials in behavioural economics have shown that when a complex goal, such eating more healthily, is broken down into a series of easier actions (eg eating five a day), outcome expectancies can be significantly improved. On a digital DPP, participants can set their own clear, achievable short-term goals and can refer back to them on their phone at any time, boosting motivation to sustain a healthier lifestyle over the long term.

Instant, one-click referral systems also reduce wait times between referral and access to just minutes – as opposed to weeks or sometimes months for a face-to-face DPP – minimising drop-offs as people become demotivated over time without support.

Digital DPPs therefore show serious promise in improving access to support – among even the hardest to reach groups – and overcoming the psychological barriers to sustaining lifestyle changes for people with prediabetes. As the NHS scales access to such programmes across the UK, turning the tide on diabetes has never seemed more possible.

Reversing Type 2 diabetes – in 5 steps

Author Holly Hart, MSc, is a qualified Health Psychologist and one of Changing Health’s lifestyle coaches. This article is based on real life case studies, including two users who achieved Type 2 diabetes remission in 10 weeks between April to June, 2018.

People with Type 2 diabetes usually know they need to make a change, and they have the motivation to do so. But their self-efficacy – that is, their beliefs about their capabilities to succeed – is often low; they perceive significant barriers preventing them from sustaining a healthier lifestyle.

There are, however, some useful techniques to help people with diabetes overcome the barriers to change and translate their motivation into action. Here are a few recommendations from my experience supporting people to better manage their condition:

1) Letting people know that good food can be cheap

Many people think fresh, “healthy food” is more expensive (it doesn’t have to be!), while others may be hampered by a lack of social support – often key to success. Some may worry that eating as a family may require the entire family to change their diet, and some may have been disillusioned by a lack of success when trying to make lifestyle changes in the past.

2) Making education simple

People with diabetes report that one of their biggest barriers to making the changes they need to is a lack of access to education and information. Those who do receive guidance from their healthcare provider often tell us that there was too much to take in, too quickly, and they ended up with only a limited understanding of how their condition affects them. We tend to provide links to websites and tell people what to search for online instead, so they can learn at their own pace in their own time.

3) Showing that dieting doesn’t mean no food

A common misconception we find among people with diabetes is the idea that following a diet means cutting out your favourite food and getting up at 4am for an exercise class. In fact, the simplest lifestyle changes are typically the key to successful management or even remission of diabetes. The inspirational success stories you get to hear as a coach are testament to this approach, and communicating to patients that their lifestyle changes don’t need to be radical can transform their outcome expectations.

Debra, a Changing Health user who recently achieved remission in 10 weeks, did so by making only “little swaps”, like pasta for cauliflower rice, so a healthier diet didn’t feel like a chore to maintain. It’s also important to avoid warning people with diabetes about what will happen if they don’t make a change; research has shown this doesn’t work.

Instead, we find that listing the benefits of a healthier lifestyle can be much more effective, particularly those which impact the most on everyday life: improved cognition and memory, better concentration, reduced tiredness and feeling less out of breath when walking the dog or taking the children to the park. focusing on past successes (identifying and emphasising previous, successful attempts to initiate lifestyle change) has been linked to optimal care consultations and better clinical outcomes.

Pairing this with discussions about how to overcome barriers that have occurred in the past, or might come up in the future, enables the patient to think more positively about making a change and this positivity is key.

4) Setting achievable goals from the outset

Healthcare providers can also support patients on their journey towards a healthier lifestyle by encouraging them to set clear short, medium and long-term goals. SMART goals – specific, measurable, achievable, realistic and timely – keep patients focussed every step of the way and have been proven to be effective in improving outcomes.

If patients write these goals down, the chances of success are even higher – up to 42%, according to new research. Changing Health coaches suggest users write down their progress so far on post-it notes and leave them in prominent places around the house, boosting their motivation to keep going when times are tough.

5) Personalising the approach to support

Every individual is at a different stage in their behaviour change journey and so it’s important to take their unique circumstances into account. Ultimately, it’s about re-framing the conversation to focus on their own possibilities of success, rather than the consequences of failure, at every point of contact.

The biggest lesson I’ve learnt, though, is that while people with diabetes don’t often realise that transforming their health can be a straightforward process – once they do, they’re bound to surprise you.

Watch Sheinaz, a GP Practice Manager who achieved diabetes remission with Changing Health, tell the story of her weight loss journey in NHS Digital’s short film here: https://bit.ly/2v67fvR

Government: Take a stand. Stop junk promotions.

With almost two thirds of the UK adult population now either overweight or obese, there’s universal recognition that something must be done to avert a full-blown public health emergency. Many policymakers, on the recommendation of leading public health experts, are looking first to junk food marketing.

It’s clear that marketing has played a central role in our steady weight gain over the years; Public Health England estimates 40% of food bought in the UK is done so at a discount, increasing overall consumption by 22%. That’s more than anywhere else in Europe. Viewers of family TV shows like The Voice see 12 adverts for junk food within an hour.

The Government’s role in averting the obesity crisis, however, is subject to dispute. A number of measures have been floated; alongside the sugar levy, which came into force last month, a cross-party proposal to ban “buy one get one free” offers on junk food is gaining momentum, as is a plan to curb junk food TV advertising before 9pm, while a mandatory traffic light labelling system appears to be almost certain. London mayor Sadiq Khan last week opened consultations on a ban on junk food advertising on London’s public transport network.

But free marketeers argue that such “nannying” by the state restricts consumer choice with no benefit to public health. Some even suggest that obesity figures are artificially inflated to justify these “intrusive” policies. “Who benefits from over-egging childhood obesity rates? As usual, powerful people with killjoy aspirations are the most likely to spread bad data far and wide,” wrote Kate Andrews of the strongly free-market Institute of Economic Affairs (IEA) in City A.M earlier this month.

This is a bit strong: who are these ‘powerful people with killjoy aspirations’? Have Jamie Oliver, Sadiq Khan et al fabricated the obesity epidemic just to spoil the party? Meanwhile, who benefits from suggestions that controlling the marketing of harmful products is detrimental to consumers? For a start, many of the conglomerates that fund the IEA, including British American TobaccoPhilip Morris and Japan Tobacco International, amongst others, although the organisation is notoriously opaque in this regard. Perhaps understandably.

“Such policy proposals make it harder for adults to live their lives freely,” Ms. Andrews continues. Again – questionable. If we can’t make ‘free choices’ without the influence of a marketing campaign, rather than a rational assessment of the facts, aren’t they actually quite the opposite?

Controlling junk food marketing more tightly is about limiting the number of times we’re prompted (be that a supermarket offer, a daytime TV ad, or a billboard on the tube) to buy unhealthy food we don’t need on a whim. The odds of being obese are more than twice as high for young people who report seeing junk food advertising every day. These policy proposals will restrict exposure to such advertising,  but they don’t curtail our freedom to buy what we want to.

The sugar tax doesn’t prevent us from buying six-packs of Coca Cola, but it’s shown promise elsewhere in reducing overall sugar consumption; in Mexico, where 70% of the population is overweight or obese, it’s already driven a 7.6% fall in sales of sugary drinks. If the trend is replicated in the UK, that’s a clear win for public health at very little expense to the everyday consumer.

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Obesity is a multidimensional issue and so must be the approach to reversing current trends. As I argued in a previous blog post, mandating alone will not change behaviour at a national level. A combination of ‘hard’ legislation, ‘soft’ nudges and individual and group interventions are all needed to encourage people to make healthier choices.

What’s certain is this: we’ve been bombarded with junk food promotions for decades. We’re consuming more calories than ever before, with disastrous results. The only real opposition to the proposed regulations comes from those who stand to lose out on profit. Government should boldly ignore the protests of the corporate lobby and curb the constant and ever-present influences to buy high-calorie, sugary foods. To the benefit of us all.

Sleep and diabetes: 7 easy steps for a better night’s rest

Sleep duration and quality are now widely accepted as important factors in the prevention and management of mental health7, cardiovascular,and metabolic conditions including type 2 diabetes1.

Normal sleep is characterised by reduced consciousness, little or no nervous activity and inactivity of nearly all voluntary muscles1. Sleeping for too long, or not enough, poses potential risks of obesity and Type 2 diabetes; optimum sleep should be seven to eight hours each night. There is a 9% relative risk of developing type 2 diabetes for each hour of shorter sleep, and a relative risk of 14% for each hour of longer sleep4.

So do people with Type 2 diabetes get the right amount? Taking a generalised view from available research, the simple answer would be: absolutely not. Sleep impairment is more common in females, but is prevalent among both genders7.

Reasons for this include:

  1. Lifestyle choices: excessive drinking, smoking, inactivity
  2. Societal/economic pressures: Shift work, unemployment, etc5.
  3. Associated medical conditions: Fatigue, depression, neuropathic pain and obstructive sleep apnoea (OSA) 5
  4. Circadian mal-alignment: Some people are either morning types (they find it relatively easy to get up early in the morning but also go to bed early) or evening types (they go to bed later and find it difficult with early starts). However, evening types are twice as likely to develop type 2 diabetes compared to morning types3

 

Here are 7 easy steps to better sleep with Type 2 diabetes:

  1. Get a sleep assist device, like a CPAP (continuous positive airwave pressure) on recommendation from your GP. This can help in reducing blood pressure and HbA1C levels2
  2. Exercise more. If you have problems keeping up with being active due to other associated conditions, speak to a medical professional
  3. Master your body and consult a dietician or nutritionist to help guide you through food choices and meal times that match your body clock.
  4. Speak to your employers about your condition and try to work out productive working times that would not impact on your health negatively.
  5. Stick to a sleep schedule as this can help regulate your body clock. There are medications like exogenous melatonin that help in the management of circadian rhythm disorders6. Speak to a sleep specialist if you have problems sticking to a particular bedtime.
  6. A bed time ritual like mediation could be the key to good sleep
  7. Ensure you sleep in a comfortable room (with appropriate bed, pillows and mattress) devoid of distractions.

References

  1. Brady, E. M. and Hall, A. P. (2016) ‘Sleep and type 2 diabetes mellitus’, Practical Diabetes, 33(1), pp. 23–26. doi: 10.1002/pdi.1993.
  2. Guest, J. F., Panca, M., Sladkevicius, E., Taheri, S. and Stradling, J. (2014) ‘Clinical outcomes and cost-effectiveness of continuous positive airway pressure to manage obstructive sleep apnea in patients with type 2 diabetes in the U.K.’, Diabetes Care, 37(5), pp. 1263–1271. doi: 10.2337/dc13-2539.
  3. Merikanto, I., Lahti, T., Puolijoki, H., Vanhala, M., Peltonen, M., Laatikainen, T., Vartiainen, E., Salomaa, V., Kronholm, E. and Partonen, T. (2013) ‘Associations of chronotype and sleep with cardiovascular diseases and type 2 diabetes’, Chronobiology International, 30(4), pp. 470–477. doi: 10.3109/07420528.2012.741171.
  4. Shan, Z., Ma, H., Xie, M., Yan, P., Guo, Y., Bao, W., Rong, Y., Jackson, C. L., Hu, F. B. and Liu, L. (2015) ‘Sleep duration and risk of type 2 diabetes: A meta-analysis of prospective studies’, Diabetes Care, 38(3), pp. 529–537. doi: 10.2337/dc14-2073.
  5. Vetter, C., Devore, E. E., Ramin, C. A., Speizer, F. E., Willett, W. C. and Schernhammer, E. S. (2015) ‘Mismatch of sleep and work timing and risk of type 2 diabetes’, Diabetes Care, 38(9), pp. 1707–1713. doi: 10.2337/dc15-0302.
  6. Wilson, S., Nutt, D., Alford, C., Argyropoulos, S., Baldwin, D., Bateson, A., Britton, T., Crowe, C., Dijk, D.-J., Espie, C., Gringras, P., Hajak, G., Idzikowski, C., Krystal, A., Nash, J., Selsick, H., Sharpley, A. and Wade, A. (2010) ‘British Association for Psychopharmacology consensus statement on evidence-based treatment of insomnia, parasomnias and circadian rhythm disorders’, Journal of Psychopharmacology, 24(11), pp. 1577–1601. doi: 10.1177/0269881110379307.
  7. Zhu, B., Quinn, L. and Fritschi, C. (2017) ‘Relationship and variation of diabetes related symptoms, sleep disturbance and sleep-related impairment in adults with type 2 diabetes’, Journal of Advanced Nursing, (October), pp. 689–697. doi: 10.1111/jan.13482.
  8. https://sleepfoundation.org/sleep-tools-tips/healthy-sleep-tips