'I could have made those changes years earlier': experiences and characteristics associated with receiving a prediabetes diagnosis among individuals recently diagnosed with type 2 diabetes

A critical realist exploration of factors influencing engagement in diabetes prevention programs in rural settings

BACKGROUND

Diabetes prevention programs are intended to reduce progression to type 2 diabetes, but are underutilised. This study aimed to explore people with prediabetes' knowledge and attitudes about prediabetes, and their perceptions about engagement in preventive programs in a rural setting. The findings will inform strategies and recommendations to increase preventive health program engagement.

METHODS

Using a qualitative approach with a critical realist methodology, semi-structured interviews were conducted with 20 rural participants with prediabetes from the Northern New South Wales Local Health District in 2021. Interviews were audio-recorded, transcribed verbatim and thematically analysed. The social-ecological model was used as a framework to interpret and action the study findings.

RESULTS

Factors that empowered participants and facilitated a desire to engage in preventive programs included knowledge about prediabetes, a high level of social support, trusting and supportive relationships with health professionals, and a strong desire not to progress to diabetes. Barriers to program engagement included low health literacy levels, limited support, negative experiences with health services, and social and physical constraints. The factors that influenced engagement with preventive health programs were mapped to an individual, interpersonal, organisational, community and policy level, which highlighted the complex nature of behaviour change and the influence of underlying mechanisms.

CONCLUSIONS

Engagement in diabetes prevention programs was dependent on individual agency factors and structural barriers, each of which related to a level of the social-ecological model. Understanding the perceptions of people with prediabetes will inform strategies to overcome multi-level barriers to preventive health program engagement in rural settings.

Understanding dietary behaviour change after a diagnosis of diabetes: A qualitative investigation of adults with type 2 diabetes

Type 2 diabetes (T2D) is a major public health concern. Optimal management of T2D often requires individuals to make substantial changes to their dietary intake. This research employed a qualitative methodology to examine decision making processes underpinning dietary behaviour change. Semi-structured telephone interviews were conducted on a purposive sample of 21 Australian adults who had recently consulted a dietitian after being diagnosed with T2D. Data were analysed using theoretical thematic analysis and themes were matched deductively with constructs that underpin motivational, volitional, and implicit processes which exist in common models of behaviour change. Influences on motivation, such as a desire to improve health status and making use of valuable support networks featured in participant narratives. Volitional influences included knowing their limits, dealing with falling off the wagon, and learning how their body responds to food. The themes unlearning habits and limit the availability were identified as underpinning implicit influences on dietary change. Individual differences and emotions were constructs additional to the model that influenced dietary change. These findings contribute to a richer understanding of the subjective experiences of adults with T2D regarding dietary change and highlight the multiple processes that guide their decision making in this context.

Analyzing Dietary Behaviors Self-reported by People With Diabetes Using a Behavior Change Technique Taxonomy

OBJECTIVE

We aimed to explore both the dietary-related behavior change techniques (BCTs) adults with type 2 diabetes (T2D) described to enact themselves and the BCTs they perceived their dietitians to enact within consultations.

DESIGN

Qualitative study involving semistructured telephone interviews with adults who consulted with a dietitian after their T2D diagnosis. Participants shared their experience of dietary behavior change and interactions with dietitians.

SETTING

Telephone-based interviews from an Australian university setting.

PARTICIPANTS

Twenty-one adults (12 females and 9 males) aged 36-75 years were self-selected and invited by email.

PHENOMENON OF INTEREST

Dietary behavior changes reportedly enacted after a T2D diagnosis by participants and their dietitians.

ANALYSIS

Transcripts were analyzed through thematic content analysis according to the BCT taxonomy.

RESULTS

Participants described several BCTs such as problem-solving and self-monitoring (behavior), which helped their dietary behavior change. Participants perceived their dietitians to use BCTs, including goal setting (outcome), self-monitoring (behavior), and instruction on how to perform the behavior. These participants who had consulted with a dietitian reported additional techniques than those prescribed in the consultation process.

CONCLUSIONS AND IMPLICATIONS

Adults with T2D undertake a variety of BCTs to support dietary behavior change. Dietitians can draw on behavior change taxonomies to support behavior change in clients.

The Quality in Nutrition Care (QUINCE) model: development of a model based on Australian healthcare consumer perspectives

BACKGROUND

Primary healthcare is the ideal setting to address diet-related disease through delivery of nutrition services. However, quality nutrition care has not previously been defined from the healthcare consumer perspective.

OBJECTIVES

To explore, and develop a theoretical model of, healthcare consumer expectations of quality nutrition care in the primary healthcare setting.

METHODS

A qualitative study design collected data describing healthcare consumer expectations of nutrition care. Consumers were recruited through social media and research networks, screened, and invited to participate in a semi-structured telephone interview. Interviews explored experiences and views of nutrition care. Interviews were thematically analysed, and informed development of a model using an iterative process.

RESULTS

Twenty-three healthcare consumers participated in an interview. Five themes were identified. The Quality in Nutrition Care consumer model developed from these themes comprised 5 interconnected components, these being: (i) quality nutrition care occurs within an integrated societal system; (ii) quality nutrition care is available, accessible, and affordable; (iii) quality nutrition care is up-to-date and evidence based; (iv) quality nutrition care is underpinned by positive relationships; and (v) quality nutrition care is personalized to consumer needs.

CONCLUSIONS

The consumer-derived model of quality nutrition care can be used by providers to inform activities that enhance primary healthcare practice, outcomes, and impact. The model has important implications for primary healthcare system reform and policy. Future research should explore the provision of dietetic services in primary care, with specific focus on factors that influence quality care, and investigate how quality is monitored and improved.

A diagnosis of prediabetes when combined with lifestyle advice and support is considered helpful rather than a negative label by a demographically diverse group: A qualitative study

AIMS

The aim of this study was to explore the experience and perceptions of a diagnosis of prediabetes among a demographically diverse sample of New Zealanders who had, and had not, regressed to normoglycaemia following participation in a primary care nurse-delivered intervention for 6 months. The sample included Indigenous Māori who have high rates of diabetes and associated co-morbidities.

METHODS

A purposefully selected sample of 58 people with prediabetes and BMI >25 kg/m², stratified by male/female, Māori/non-Māori, and those who had/had not regressed to normoglycaemia, after completing 6-months of a prediabetes intervention were interviewed. Interviews were audio-recorded and transcribed. Data were analysed by thematic analysis.

RESULTS

Most participants recalled being shocked when told they had prediabetes, but they did not perceive the diagnosis to be a label in a negative sense, and some, described the diagnosis as helpful. Participants appreciated knowing that prediabetes could be reversed, and the opportunity to be able to take supported action and make lifestyle changes through the nurse-delivered prediabetes lifestyle intervention. Participants' clear preference was to take control and make dietary changes, not to take Metformin.

CONCLUSIONS

Prediabetes was not considered a negative label, but an opportunity, when coupled with a primary care nurse-delivered dietary intervention.

How do patients want to receive nutrition care? Qualitative findings from Australian health consumers

This qualitative descriptive study explored health consumers' preferences for receiving nutrition care in Australian primary care. The study was underpinned by a constructivist research paradigm. Semistructured telephone interviews were conducted with 25 health consumers (age 19-78 years; 19 female) from across Australia between May and August 2020. Content analysis, using an inductive approach revealed emergent themes. was used to reveal emergent themes. Five themes were identified in the data: (1) health consumers want to receive nutrition care from a qualified person; (2) nutrition care is viewed as important, and health consumers want to receive it in a format that meets their needs; (3) nutrition care should be low cost and available to everyone; (4) nutrition care services should be conveniently located; and (5) health consumers want nutrition care to be offered frequently, across their lifespan. Health consumers have a clear idea of how they would like to receive nutrition care in the primary care setting, but reported challenges to receiving this care within the current system. New models of service delivery are needed to meet the needs of health consumers.

Proximal and distal influences on dietary change among a diverse group with prediabetes participating in a pragmatic, primary care nurse-led intervention: a qualitative study

OBJECTIVE

To understand motivators, facilitators and challenges to dietary change amongst a diverse sample of New Zealanders with prediabetes participating in a primary care nurse-led individualised dietary intervention.

DESIGN

A qualitative study involving semi-structured, face-to-face interviews with a stratified sample of adults with prediabetes and BMI ≥ 25 kg/m2, purposefully selected from a larger 2-year primary care-based prediabetes dietary intervention study. Thematic analysis was undertaken. A socio-ecological model guided interpretation.

SETTING

Hawke's Bay, Aotearoa/New Zealand, April 2018-March 2020.

PARTICIPANTS

Fifty-eight people aged 28-69 years, with similar numbers of men and women, indigenous Māori and non-Māori, and those who had and had not regressed to normoglycaemia at 6 months.

RESULTS

Motivators for wanting to make dietary changes were determination not to progress to diabetes; wanting to be healthy and contribute to others and encouragement by others. Facilitators for adopting and maintaining changes were a strong desire to be healthy; personal determination and feeling supported. Challenges were compromised control over life and environmental factors; feeling unsupported by others; social occasions; financial constraints and living with other health conditions. Developing their own strategies to overcome challenges was empowering, enabling a sense of control. These factors were similar across demographic and glycaemic outcome groups.

CONCLUSIONS

Influences on dietary change involved personal, interpersonal, organisational, environmental and policy factors. Although findings appeared similar across groups, dietary interventions need to address the specific ways motivators, facilitators and challenges manifest for individuals and social groups and be tailored accordingly within the context of the wider obesogenic and socio-economic environment.

Co-design of a digital dietary intervention for adults at risk of type 2 diabetes

Background

Co-design has the potential to create interventions that lead to sustainable health behaviour change. Evidence suggests application of co-design in various health domains has been growing; however, few public-facing digital interventions have been co-designed to specifically address the needs of adults at risk of Type 2 diabetes (T2D). This study aims to: (1) co-design, with key stakeholders, a digital dietary intervention to promote health behaviour change among adults at risk of T2D, and (2) evaluate the co-design process involved in developing the intervention prototype.

Methods

The co-design study was based on a partnership between nutrition researchers and designers experienced in co-design for health. Potential end-users (patients and health professionals) were recruited from an earlier stage of the study. Three online workshops were conducted to develop and review prototypes of an app for people at risk of T2D. Themes were inductively defined and aligned with persuasive design (PD) principles used to inform ideal app features and characteristics.

Results

Participants were predominantly female (range 58–100%), aged 38 to 63 years (median age = 59 years), consisting of a total of 20 end-users and four experts. Participants expressed the need for information from credible sources and to provide effective strategies to overcome social and environmental influences on eating behaviours. Preferred app features included tailoring to the individual’s unique characteristics, ability to track and monitor dietary behaviour, and tools to facilitate controlled social connectivity. Relevant persuasive design principles included social support, reduction (reducing effort needed to reach target behaviour), tunnelling (guiding users through a process that leads to target behaviour), praise, rewards, and self-monitoring. The most preferred prototype was the Choices concept, which focusses on the users’ journey of health behaviour change and recognises progress, successes, and failures in a supportive and encouraging manner. The workshops were rated successful, and feedback was positive.

Conclusions

The study’s co-design methods were successful in developing a functionally appealing and relevant digital health promotion intervention. Continuous engagement with stakeholders such as designers and end-users is needed to further develop a working prototype for testing.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12889-021-12102-y.

Short-term improvements in diet quality in people newly diagnosed with type 2 diabetes are associated with smoking status, physical activity and body mass index: the 3D case series study

Background

Dietary intake impacts glycaemic control through its effect on weight and glucose-insulin homeostasis. Early glycaemic control is associated with improved outcomes and reduced mortality for people with type 2 diabetes (T2D). To date, the diet quality of people with T2D has only been studied cross-sectionally. The objective of this paper is to quantify short-term improvements in diet quality and to identify factors associated with improvements after T2D diagnosis among participants in the 3D study.

Methods

This paper presents data from the 3D study of 225 Australian adults, newly diagnosed with T2D. Telephone interviews collected demographic, diet, physical and health data at baseline and 3 months. Diet quality was assessed using the Dietary Approaches to Stop Hypertension (DASH) tool to examine short-term changes in diet quality after diagnosis. Participants were categorised into two groups: those who improved their diet quality by 3 months (increase in DASH score of 3 or more) and those who did not. Factors associated with change in DASH scores were clinically and statistically evaluated.

Results

The 3D cohort was comparable to Australian cohorts with diabetes by gender and body mass index (BMI) but differed by age, remoteness and socioeconomic status. Mean (SD) baseline DASH score was 24.4 (4.7), in the midrange of possible scores between 8 and 40. One third of participants improved their DASH score by 3-months. This group had lower diet quality (p < 0.001), lower BMI (p = 0.045), higher physical activity levels (p = 0.028) and were less likely to smoke (p = 0.018) at baseline.

Conclusions

Diet quality changes after diagnosis do not appear to be associated with demographic characteristics but were associated with lifestyle behaviours. Strategies targeted at better supporting smokers, those with low physical activity and higher BMI are required. Future research should investigate how the diet quality changes people make around time of diagnosis are related to long-term health outcomes.