Diet planning as conversation, not monologue

Implementing shared decision making in nutrition clinical practice: A theory-based approach and feasibility study
Original source: Implementation Science 2008, 3:48
Authors: Sophie Desroches (corresponding author), Sylvie Tapp, Marie-Pierre Gagnon, and France Legare
Publication date: 5 November 2008
DOI (digital document ID): 10.1186/1748-5908-3-48
Requires subscription? No
Publicly-available abstract: Yes

Synopsis:
Shared decision making is one of several methods that a health professional can use to help us change our eating habits to better control diabetes and other chronic illnesses. The investigators are looking primarily at dietary approaches to lower cholesterol levels.

The traditional low-fat/low-saturated fat strategy to lower cholesterol is perceived as restrictive, leading to a tendency for people to either "cheat" or to not follow the diet at all. Recently, a number of different dietary approaches have been shown effective in lowering cholesterol -- but the variety, added to the many diet systems discussed in the popular media, can leave the general public confused. Shared decision is a method in which the dietician works collaboratively with the patient, taking into account his cultural and financial perferences, to create a healthy diet that the patient is willing to follow. The process includes explaining the best evidence of the risks and benefits of different dietary models, and explicitly states that the method does include some uncertainties.

The authors of this investigation found no formal studies supporting the use and training of a shared decision making approach using evidence-based practice, and note that some dieticians have reported difficulty in suggesting and implementing this approach.

In this paper they propose a study to learn how shared decision-making is currently used in the field of nutritional consultation, to assess dieticians' intention to adopt two specific behaviors related to shared decision making using the Theory of Planned Behavior, and to learn what the obstacles are to dieticians adopting this approach. Their proposed protocol includes the education of dieticians, the introduction of the Theory of Planned Behavior, focus group discussions in which the dieticians' views and issues are discussed, and audiotaped observation of the dieticians' interactions with patients.

The proposed research project is expected to provide preliminary data about the adoption of shared decision making by dieticians and their patients, look at dieticians' beliefs regarding their intention to adopt shared decision making behaviors and comparing their actions to their intentions, and develop questionnaires to measure this information. The researchers hope that the results generated by the proposed research project will help improve the rate at which dieticians adopt a shared decision-making approach.

Reliability:
The initial study is intended to cover only 40 dieticians, but this is considered mostly as a focus group from which the parameters of a larger study can be planned.

Practical Applications:
The end goal of this research is to increase the adoption of shared decision making in the field of nutritional consulation. Having our dieticians engage us actively, and pay attention to our input, will help us find diets we can -- and will -- live with.

This synopsis was based on the entire article.

Primary Care Physicians as point-of-care for Type 2 diabetes

Family physician and endocrinologist coordination as the basis for diabetes care in clinical practice
Original source: BMC Endocrine Disorders 2008, 8:9
Authors: Alejandra Duran, Isabelle Runkle, Pilar Matía, Maria P de Miguel, Sofia Garrido, Emilio Cervera, Maria D Fernandez, Pilar Torres, Tomas Lillo, Patricia Martin, Lucio Cabrerizo, Nuria Garcia de la Torre, Jose R Calle, Jose Ibarra, Aniceto L Charro, and Alfonso L Calle-Pascual (corresponding author)
Publication date: 31 July 2008
DOI (digital document ID): 10.1186/1472-6823-8-9
Requires subscription? No
Publicly-available abstract: Yes

Synopsis:
The investigators looked at diabetes patients with peripheral circulation and capillary circulation issues and sought to find out whether there was any measurable difference in the results whether the patient was treated by a primary care physician (PCP) or an endocrinologist.

One of the issues surrounding diabetes care in Spain is that primary care physicians (PCPs) may not be as aggressive in treating multiple risk factors and signs of complications of diabetes as a hospital-based endocrinology team. A program in which PCPs are trained to address all these factors and to consult with the hospital-based team was instituted. This study attempts to evaluate the effectiveness of this program.

In the "Area 7" section of Madrid, Spain, 126 patients with Type 2 diabetes and peripheral circulation issues were studied over a 30-month period. After an initial three-month period of treatment by the Diabetes team at St Carlos Hospital, the patients were broken up into two groups: one to continue care at St Carlos, the other to return to their program PCPs for diabetes care. Nine patients moved out of district over the period of the study, leaving 117 patients from which to evaluate this program.

The investigators looked at the folloiwng markers as indicators of care effectiveness: HbA1c (%); Total Cholesterol, HDL cholesterol, LDL cholesterol, and triglycerides; blood pressure; albumine-to-creatinine excretion ratio (ACR); body mass index (BMI) and waist circumference (WC); anti-aggregation treatment; and smoking status.

At the end of the follow up, no differences were found between the groups for the following counters:

• more than 37% of diabetic patients achieved a HbA1c <>
• more than 50% a ACR <>
• more than 80% reached low risk values for cholesterol, LDL cholesterol, triglycerides, and diastolic blood pressure
• more than 80% were on aspirin therapy against platelet aggregation
• 12% remained smokers.

On the other hand,

• less than 45% achieved a systolic blood pressure <>
• only 49% of the men and 30% of the women had a waist circumference of low risk.

The largest difference between the groups is that while 23% of the patients cared for by the diabetes care team achieved a BMI less than 25, less than 12% of the patients cared for by family physicians achieved this level. Neither of these results was considered satisfactory and were attributed to focus on risk factors other than overweight.

The investigators concluded that good metabolic control can be achieved at the primary care level, if the PCP coordinates patient care with the endocrinologist. This will result in better results than being treated by an untrained primary care physician without endocrinological support.

Reliability:
The study was small enough that it could be a pilot project -- evaluation of a small-scale implementation before bringing this program to all of Madrid, or to all of Spain. The follow-up time was 2.5 years, which is an intermediate timeframe. Two of the authors work at the St Carlos hospital and clinic; the third is associated with the evaluation of primary care in the "Area 7" section of Madrid. The research was published in a peer-reviewed journal, which suggests a level of reliability to the results.

Practical Applications:
Moving Type 2 diabetes follow-on care out to the primary care practitioner can simplify care delivery from the patient's point of view. It also allows the PCP to do a better job of treating the entire patient, rather than a single aspect of that patient's care. In addition, teaching PCPs more about diabetes, and giving them consultation access to endocrinologists, can improve both initial diagnosis and ongoing diabetes care.


This synopsis was based on the entire article.

How "Bedside Manner" affects Self Care in Type 2 diabetes

The emotional context of self-management in chronic illness - A qualitative study of the role of health professional support in the self-management of type 2 diabetes
Original source: BMC Health Services Research 2008, 8:214
Authors: John Furler (corresponding author), Christine Walker, Irene Blackberry, Trisha Dunning, Nabil Sulaiman, James Dunbar, James Best, Doris Young
Publication date: 17 October 2008
DOI (digital document ID): 10.1186/1472-6963-8-214
Requires subscription? No
Publicly-available abstract: Yes

Synopsis:
One role of health-care professionals is to support patients with regard to both the clinical and emotional aspects of living with diabetes. The authors of this study tried to find approaches to make these professionals more effective at this task. They asked patients with Type 2 diabetes how they took care of their diabetes and how their relationships with their support teams affected this. They looked at groups who had been telephoned by nurses in the patients' general practitioners' offices to "coach" them about their diabetes and encourage them to become more actively-engaged their own health care and in their relationship with their family doctors. Their goal is to make these nurses more effective in this mission.

A total of 52 patients, ranging in age from 50-80, were split into four focus groups. Most of the participants were either unemployed or retired, and had had at least one visit with a diabetes educator. There were two English-language focus groups, plus one in Arabic and one in Turkish -- the two main languages of lower-income immigrants in the Melbourne, Australia urban area.

The groups focused on the role of personal control of diabetes and how one's relationships with one's healthcare team influenced this.

The investigators found that overall, the English speakers tended to see diabetes as life-limiting, almost punitive, and requiring self discipline. Dietary changes were viewed in terms of sacrifice -- for example, "having to give up" one's favorite foods. They looked at their entire care team as separate but equally important entities. They were more likely to "shop around" to find professionals who would give them "the right answers"; they needed information to be able to exert control their conditions.

Arabic and Turkish speakers saw diabetes as an integrated part of life, possibly indicative of stress. They saw self-management techniques as part of an integrated effort to restore personal calm. Dietary changes were put in a positive light -- using higher-quality foods rather than lesser quality ones, for example. They also relied primarily on their relationship with their General Practitioner, expecting him to provide them with all the information necessary to care for themselves. When they attended education sessions, or saw specialists, it was only upon the strong recommendation of their primary care physicians.

The investigators saw in the English-speakers the emerging concept of "patienthood", and doctor-patient relationships evolving to the ideal of the actively-engaged patient. (This is the model that is fostered by medical professional societies and by health insurers.) In contrast, they felt there was a potential danger in being completely uncritical of one's primary care physician, with the potential for insufficiently aggressive care and poorer long-term outcomes. The authors believe their findings suggest that a patient will see better results if his or her health-care professionals take the time to understand their patients' social, cultural, and emotional contexts and work from there to help them develop an effective approach to self care.

Reliability:
The study size was very small. The authors note that several aspects of its design could have skewed the results, and their specific results are not applicable outside of the particular community studied. The authors are a multidisciplinary group of professionals in medical practice, medical education, public health, and patient advocacy. The research was published in a peer-reviewed journal. The information should be considered more as a start-off point for your own relationships with your health-care team -- or if you are a practitioner, your patients.

Practical Applications:
There are many reasons that one's social and cultural background can either help or hinder self-care. I've often stated -- and even blogged -- that being willing to learn about the beliefs and cultural contexts of others, and by using those contexts as a starting point, the information or discussion you provide will be more easily understood, more appropriate to that other person, and where health information is concerned, more likely to get a positive response. I am encouraged to see this approach, and hope that it will improve diabetes care not just in Melbourne, but throughout the world.

This synopsis was based on the entire article.