Metabolic improvement after intervention focusing on personal understanding in type 2 diabetes

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Abstract

The aim of this study was to evaluate, whether an educational intervention, focusing on patients’ personal understanding of their illness, was more effective than care given according to national guidelines for diabetes care. Methods: An intervention group (n = 44), with type 2 diabetes was compared with a control group (n = 60), with HbA1c as the primary outcome. The intervention included ten group sessions addressing themes related to the patients’ personal understanding of their illness. The diabetes nurses involved were educated in theories about illness/wellness experiences and participated in group sessions where various caring strategies related to the patients’ individual needs and understanding were reflected upon. Results: At 1-year follow-up the intervention group showed lower HbA1c levels (mean difference 0.94%; P < 0.001), lower triglycerides (mean difference 0.52 mmol/l; P = 0.002) and higher high-density lipoprotein (mean difference 0.15 mmol/l; P = 0.029) and treatment satisfaction than did the control group. The differences remained when adjusting for age, gender, body mass index or changed treatment during the intervention period. Within the intervention group, BMI and treatment satisfaction were also improved. Conclusion: The intervention, which focused on patients’ personal understanding of illness, was found to be effective in terms of metabolic control and treatment satisfaction.

Introduction

In recent years the long-term health consequences of type 2 diabetes have become well established [1], [2], [3]. The UK Prospective Diabetes Study, (UKPDS) [1] which enrolled individuals newly diagnosed with type 2 diabetes, conclusively, showed that improved blood glucose control lower the risk of diabetes-related complications. The preliminary conclusion of the 5-year Post Study Monitoring programme of the UKPDS was that benefits of improved glucose control, as obtained during the trial, appear to persist even in the longer term [4]. Thus, improved metabolic control is an important goal in diabetes care; another goal is to minimize the impact of the disease on daily life, which is emphasized by the World Health Organization (Europe) and International Diabetes Federation (Europe) [5].

Diabetes education of health care professionals and those affected by diabetes in order to facilitate self-management of the disease plays a key role in the prevention of diabetes related complications. The effect of educational and psychosocial interventions aimed at self-management on glycemic control is uncertain, and the long-term effects are often discouraging and need further studies [6], [7], [8], [9], [10]. Brown [6] among others argues that, a major problem is that only a few of the educational studies meet criteria for inclusion in meta-analysis. Furthermore, HbA1c is reported to improve 1–6 months after education, but deteriorates to 1-month levels after 6 months, a result that was not influenced by the amount of education given. Rubin and Peyrot [10] have shown that education could be effective in promoting self-monitoring of blood glucose, and insulin adjustment, but not lifestyle changes. Funnell [11] found education to be unsuccessful on lifestyle changes such as dietary adjustments unless the education were very intense and continued over long periods of time. However, in a current review, Ellis et al. [12] concludes that face-to-face interaction, a cognitive reframing teaching method, and self-management programmes which include exercise are likely to be successful in improving metabolic control. Other reviews likewise, report self-management programs to have a great beneficial impact on psychological well-being and quality of life, although without long-term improvements in metabolic control [10], [13].

Paterson [14] has in “The shifting perspectives model of chronic illness”, based on a meta-synthesis of 292 reports of qualitative studies, described the patients’ various shifts in perspective between “wellness in the foreground” and “illness in the foreground”. According to Paterson, a “wellness in the foreground” perspective is assumed during periods when the individual is focusing on emotional, spiritual and social aspects of life rather than the diseased body. During other periods, an “illness in the foreground” perspective is assumed, which allows the individual to focus on the illness and its burden, that is, the physical symptoms and the need to attend to the illness. The perspective can help him or her to reflect on the disease and come to terms with it, but also, to conserve energy and other resources.

Current research emphasizes that health care providers need to adopt a more person/patient-centred counselling style [15], [16]. Cradock [17] states that since increased knowledge does not lead to changes in behavior, diabetes education should be seen as a collaboration between equals designed to help patients to make informed decisions about self-management. In US, the National Standards for Diabetes Self-Management Education, explain patient education as an exchange of knowledge, tools and practices that will address the client's needs. Ellis et al. [12] argue that this definition is non-specific, and encourages educational processes that are adaptable and individualized but it also leaves room for a process that is difficult to define and describe. A central assumption of the person-centred approach is that patients can be trusted to find their own way. The counsellor's task is to encourage a relationship, which provides the patient with a feeling of safety and capability. Mearns and Thorne [18] say that person-centred counsellors should “wear” their expertise like an invisible garment if they are to be effective. This counselling approach differs from the traditional or conventional diabetes consultation, which emphasizes the professional's “expert” role and concentrates on imparting information to patients, providing instructions for change, assuming that people want and are able to make those changes [17]. Supporting people with illness to make sense of their experiences has in some studies been shown to be effective. By discussing concerns and personal understanding of illness in support groups, patients with prostate cancer felt they had a better understanding of their illness and perceived themselves as more involved in their treatment than before. Sharing their experiences with others gave them reassurance, helped alleviate their anxiety, and provided them with a more positive outlook [19]. O’Neill [20] found that patients with asthma struggled not only with dyspnea and fatigue, but with depression, loss of social support and intimacy, and stigma, and that breathing techniques, medication, rest, and avoidance measures were the most frequently used coping strategies. O’Neill's findings suggest that supporting patients in finding ways to deal with social and psychologic isolation would enhance their coping with illness. According to Skinner and Hampson, in patients with diabetes, beliefs and personal understanding of illness and treatment are considered to be key factors influencing self care, emotional well-being and glycemic control [21]. Consequently, it is important to develop interventions that help people with diabetes to reflect upon their illness and thereby enhance their coping with illness. Further investigations are needed to evaluate types of programmes, which encourage adults with type 2 diabetes to effectively manage their disease without negative impact on their well-being.

The aim of this study was to evaluate whether a person centred intervention, which focuses on patients’ personal understanding of their illness is more effective than is conventional diabetes care, with regard to metabolic control, well-being, and treatment satisfaction in a group of patients diagnosed with type 2 diabetes during the previous 2 years.

Section snippets

Study design and settings

The design of the study is shown in Fig. 1. The intervention was conducted in a health care district with 1 37 000 inhabitants, including a midsize town and a rural area in northern Sweden. The population is quite homogenous with almost no homeless or very poor people. Furthermore, primary health care in the actual district is run by the county council, following national (built on the St. Vincent declaration) guidelines for diabetes care (22). No private clinics were included in the study.

Results

The mean participant attendance rate for the 10 group sessions was 74%. At baseline no significant differences were found between the intervention and control groups concerning sex, type of treatment, age, HbA1c, BMI, BP, cholesterol, HDL, LDL and triglycerides. Nor were there any significant initial differences between the groups concerning, treatment satisfaction, well-being, or diabetes symptoms (Table 1).

At follow-up, significant changes were seen within the groups regarding HbA1c, BMI,

Improvements after intervention

The study results indicate improved metabolic control among patients with type 2 diabetes at 1-year follow-up of an intervention programme that focused on their personal understanding of the illness. Significant improvements were seen in HbA1c, BMI, cholesterol, and treatment satisfaction in the intervention group while HbA1c increased in the control group.

The difference in HbA1c between the groups was 1%, and was not due to enhanced metabolic treatment during the intervention. We believe that

Acknowledgments

This study was funded by the Swedish Diabetes Association, the County Council of Västerbotten, and the Medical Faculty of Umeå University, Umeå, Sweden. We are thankful to these organisations and also to the patients and nurses who participated in this study.

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