Beyond Diet and Exercise: Understanding Patients with Prediabetes

Maya is a 46-yr old lady attending for blood results. She’s in a rush to get back home, as she’s had to leave her elderly parents alone to attend and it’s not long before the school run. You note her HbA1c has climbed from 41 to 45mmol/mol, now in the category of pre-diabetes, or non-diabetic hyperglycaemia as it is officially termed. 

Currently in the UK, 5 million people have a diagnosis of diabetes, with around 10% of the NHS budget spent on diabetes and related care (BJGP). An additional 4 million people are estimated to be at high risk of developing T2DM, just like Maya. 

So how do we best intervene? What can we learn from people who have experienced a diagnosis of prediabetes about what helps and hinders change?

Current prevention strategy centres around supporting people to manage their weight, eat healthily and increase physical activity. In positive news, the NHS Diabetes Prevention Programme reports that those who complete their lifestyle change programme reduce their risk of T2DM by 1/3^rd. However, despite the success of the NDPP, rates of T2DM continue to rise, and not everyone is benefiting equally from the scheme. People living in areas of high deprivation, women and individuals from diverse ethnic groups are less likely to be referred or engage with the programme (BJGP). 

What factors may underly this difference? A new primary care based qualitative study published in the BJGP used narrative interviews to explore how people reacted to the diagnosis of prediabetes, and how the interplay of wider socioeconomic and environmental factors affected likelihood of lifestyle change. Although a small study of 25 patients, it raised interesting points about factors impacting an individual’s capacity to adopt the recommended lifestyle changes.

Uncertainty

Participants reported that their ability to make lasting change was hindered by uncertainty about what level of change was needed and ambiguity about the level of risk posed. ‘They tell you it’s above the completely normal range but it’s not ... at a level that requires any intervention ... it’s sort of an amber light where you’ve got to be a bit more careful’.

On the flip side participants were very positive about F2F consultations, where clinicians took the time to explore their circumstances and provide tailored advice. Interestingly telephone consultations were not valued in the same way, viewed as ‘anonymous’.

Home and family

Dynamics within the immediate social circle of home and family strongly influenced eating habits. Support from family members enabled change. However, many prioritised the needs of family members above their own health, especially if caring for children or elderly relatives. There was a recurrent theme of gendered expectations of caregiving, with women particularly reporting limited ability to focus on their own health due to competing demands.

Wider societal norms 

Social gatherings, celebrations and religious festivals are often associated with high calorie foods. The desire to take part, and risk of social exclusion often took precedence over the theoretical risk of developing a health condition. Food was also seen as part of relationship building in the workplace. Some felt that opting out of ‘cake culture’ or disclosing their health concerns could negatively affect their workplace relationships and career prospects. 

Structural influences 

Those living in low-income areas described a prevalence of fast-food outlets and scarcity of healthy alternatives. One participant noted that it was cheaper to buy processed food than the ingredients to make an equivalent meal. Housing stress and lack of access to safe green spaces negatively also impacted capacity to focus on healthy lifestyle choices. 

What can we take away from this study? First and foremost a reminder that individuals do not develop diabetes in a vacuum, there is a complex interplay of socioeconomic factors that impact health related behaviours. A diagnosis of NDH can be confusing and unsettling. Patients value clinicians that take time to understand their social context and agree on realistic goals. For Maya, it was vital that someone understood her caring commitments and helped think through practical options for support. 

More broadly, there is evidence that diabetes prevention programmes are effective and we should continue to promote these. Also remember that when patients are unable to participate in intensive lifestyle change programmes, or their HbA1c increases despite participation, NICE and recent SIGN guidelines encourage us to consider pharmacological measures such as metformin, and incretin-based therapies if eligible.