Diabetes Management: Why Can’t We Do This with Lifestyle Alone?

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Dr. Kate Rowland

Counseling patients with diabetes on lifestyle change during primary care office visits is motivated by good intentions. We as primary care doctors are interested in prevention, lifestyle changes can positively affect many patients with diabetes, and patients do best when engaged in managing their disease1. But it’s difficult to show with data that brief physician encounters are effective at producing any of these outcomes.

Diabetes self-management education focuses on patient empowerment, knowledge, and skills. Diabetes education is associated with better A1c levels, modest weight loss, and lower healthcare cost2. But the best outcomes are seen with intensive education programs involving at least ten contact hours.  This isn’t surprising, but it’s also clear—this education isn’t something happening in a doctor-patient encounter.

Many of us work with diabetes educators, so that may not be an area that we consider to be “ours.” What about diet? The Academy of Nutrition and Dietetics and the American Diabetes Association recommend three to four encounters with a registered dietician lasting 45-90 minutes each for patients with diabetes, with at least one follow up encounter annually3. Effective nutrition counseling for diabetes isn’t a short-term 15 minute experience either.

Frustrated by lack of success, we have turned to other forms of counseling. Motivational interviewing is a style of patient care in which the physician’s role is to support and direct change, and the patient’s is to identify potential areas of change and their own reasons for change4. The physician no longer threatens the patient with catastrophes that could happen if the patient does not take his metformin; instead, she asks the patient what he has thought about changing, how capable he feels of changing them, and how ready he is to change them. They may set a goal for change, something measurable that the patient is in charge of. Ambivalence is accepted as normal.

Motivational interviewing is associated with somewhat better outcomes than traditional counseling. Patients report perceiving it better than our usual care, which some report as demeaning and critical5. A 2013 meta-analysis looked at 48 RCTs of motivational interviewing for various clinical scenarios and found no evidence that it improved blood sugar levels or medication adherence, but it did show an improvement in weight loss, quality of life, activity level, and other outcomes that we struggle to impact6.

Two significant caveats come out of this article. First, the providers had an average of 18 hours of training in motivational interviewing. Second, the motivational interviewing techniques were only found to be effective when delivered by mental health providers (although physicians provide the intervention in only two of the included studies). Another meta-analysis also found benefit in outcomes like weight loss and blood pressure, but many of the studies had contact time that far exceeded what our healthcare system provides in a typical primary care setting7.

So the evidence says our counseling might not work. Does this mean we don’t have the in-person, face-to-face conversations? Of course not. We still give the handouts and we make the recommendations. We counsel our patients because we want to engage with them. We have information we think they should hear and that we think they would appreciate knowing. If motivational interviewing makes both doctor and patient less frustrated, we should pursue training.

When we sit in the office and talk with our patient about making changes, we should not feel discouraged when they aren’t able to change, and the patient shouldn’t feel discouraged, either. The evidence for physician counseling for lifestyle change is not strong—the evidence for physicians helping patients access intensive, multi-contact programs is much better. If we are really serious about solving “lifestyle” problems with “lifestyle” solutions, we’ll need to rethink our expectations for our healthcare system.

Kate Rowland, MD, is an assistant professor in the department of family medicine at Rush Medical College in Chicago. She is core faculty at the Rush Copley Family Medicine Residency. Dr. Rowland’s clinical interests include applying evidence to practice and medical education. See Dr. Rowland’s publications on PubMed.

References:

  1. Tamhane S, Rodriguez-gutierrez R, Hargraves I, Montori VM. Shared Decision-Making in Diabetes Care. Curr Diab Rep. 2015;15(12):112.
  2. American Diabetes Association. 1. Promoting Health and Reducing Disparities in Populations. Diabetes Care. 2017 Jan;40(Suppl 1):S6-S10.
  3. Evert AB, Boucher JL, Cypress M, et al. Nutrition therapy recommendations for the management of adults with diabetes. Diabetes care. 2014 Jan 1;37(Supplement 1):S120-43.
  4. Miller WR, editor. Enhancing motivation for change in substance abuse treatment. Diane Publishing; 1999.
  5. Dellasega C, Anel-Tiangco RM, Gabbay RA. How patients with type 2 diabetes mellitus respond to motivational interviewing. Diabetes Res Clin Pract. 2012 Jan;95(1):37-41.
  6. Lundahl B, Moleni T, Burke BL, Butters R, Tollefson D, Butler C, et al. Motivational interviewing in medical care settings: a systematic review and meta-analysis of randomized controlled trials. Patient Educ Couns. 2013 Nov;93(2):157-68.
  7. VanBuskirk KA, Wetherell JL. Motivational interviewing with primary care populations: a systematic review and meta-analysis. Journal of behavioral medicine. 2014 Aug 1;37(4):768-80.