Using lifestyle as medicine: Setting up type 2 diabetes lifestyle clinics in West Wales

As a GP, I cannot fail to see how the climate of the NHS is changing. Faced with a wave of chronically ill people combined with ongoing staff shortages, there has been a seismic shift and an enormous mismatch between what people expect and need from their healthcare providers and what can actually be delivered. Lists of up to 50 patients a day have reduced us to little more than prescribing machines that treat the symptoms rather than addressing the root causes of an illness. This is painfully true with type 2 diabetes, a condition for which the cornerstone of management, in all national and international guidelines, is supposed to be diet and lifestyle change.

One morning, in the Spring of 2018, I decided I’d had enough. It seemed to me that, whatever the dose and however many tablets were added, people’s HbA_1c would keep going up and the diabetes complications would slowly manifest, leaving both patient and doctor helpless. I concluded that, unless the patients themselves got a grasp of the effect their BMI was having on their health, we were helpless to make meaningful change, and that prevention is better than cure when it comes to all chronic disease. That was the moment I decided I was going to set up a preventative medicine clinic.

The first steps

The best place to get funding for new projects locally is with Primary Care Cluster funding (equivalent to Primary Care Networks in England), and so I went to the next meeting and, fortunately, was granted £45,000 to hire admin support and a dietitian, and to complete an Obesity and Weight Management diploma.

The clinic started in November 2018 for 10 patients with diabetes. Despite my original ambition to prevent chronic illness in general, I soon realised that the people who most needed help were in fact those with type 2 diabetes. The clinics began as four sessions of an hour’s length to be delivered weekly. They focused on a low-carbohydrate diet, managing stress, improving sleep, learning about time-restricted eating and the gut microbiome. After a year, I added a talk about psychology, creating new habits and aiming for “lifestyle change” rather than an unsustainable “diet”.

Adapting for COVID-19

The advent of the COVID-19 pandemic meant that the clinics had to be transferred online, but this has also come with some advantages; video group consultations with results boards (which review each attendee’s HbA_1c, eGFR, ALT, lipid levels and diabetes medications) are a highlight, and we were fortunate that the Welsh Assembly Government funded training for this in 2020, via the Tec (Technology-enabled care) Cymru initiative. We have also been joined by a Diabetes Specialist Nurse, who shares the clinics with me.

Since then, waiting lists have gone down and I am now developing systems that mean patients can start learning whilst waiting. We also provide monthly drop-in sessions after they have finished the initial six-week programme, and there is no specific discharge date.

The project has evolved since its early days and now includes a clinic for people with type 2 diabetes, one for those with pre-diabetes and one for those who are interested in weight loss. All programmes follow a similar outline (Box 1) and are delivered over a period of 6 weeks via an online platform as part of our website. Patients are also offered group coaching sessions, run alongside, to help with goal setting, eliminating negative self-limiting beliefs and working on a positive mindset.

Outcomes

In 2022, the clinics received 161 referrals (118 women, 43 men), of whom 82 (51%) had type 2 diabetes. Follow-up data were only available for 37 participants, and this may have skewed results. However, among participants with outcome data, after 6 months:

●   In the weight loss clinics:

• Average weight loss was 8.6 kg.
• 71% of participants lost more than 5% of their body weight.

●   In the type 2 diabetes clinics:

• 81% lowered their blood glucose.
• Average waist circumference reduced by 11 cm.
• 40% reduced or stopped their glucose-lowering drugs.

Overall, 98% of those who started the course completed it, and all participants scored the programme content and delivery highly, and all would recommend to a friend or colleague. All felt they had made improvements in their lifestyle and 86% perceived an improvement in energy levels.

We will soon have a new data collection system, which will be able to streamline the process of evaluation. Previously, we have been using four different computer systems to extract clinical data, document patient progress and then to evaluate the outcomes. With the new system (created with funding from the Welsh Health Hack innovation project), we will be able to visualise data much more easily. I am hoping this will really help to evaluate the impact of the service and add to the pool of evidence that lifestyle medicine is highly effective. This will hopefully be ready by the summer.

Reflection

I really was that naïve, to think I could change the face of healthcare in my small network in rural west Wales! Looking back, I am glad I was unaware of all the challenges that lay ahead or I might never have started. I knew I needed funding for the project and I knew I needed administrative support. I also realised that I needed some education on lifestyle change, as medical school seemed to have omitted this training from the curriculum. Fortunately, I was able to convince the Primary Care Cluster of the value of these clinics and was granted funding to hire admin support and a dietitian, and to complete the relevant diploma.

The clinic started with 10 patients with diabetes. And what a delight these people were: they sparked my interest and enthusiasm for this condition, which I had previously always dreaded treating. We were in a surgery waiting room and it was a Saturday morning. I started with just some PowerPoint slides and my dad’s projector from the 1980s! Those poor people – the talks were mainly education and they were left with no actionable points. I soon realised where I could improve.

I was doing groups on Saturday mornings and Wednesday evenings, and each week I would spend hours improving on what I’d done previously. I would tweak, change and remove sections depending on the audience, and the programme I have now is completely different from where it started.

There was a dark side to this project. It required a lot of hours: organising clinics, writing materials, and collecting and evaluating data, as well as doing a diploma and raising young children. I had clinics overlapping and the groups were getting larger. Without the administrative support, I would certainly have sunk. But something kept me going: I started to see results. Participants were coming off gliclazide within 2 weeks and many had a normal blood glucose within a month. Weight, HbA_1c and blood pressure results were plummeting, joint pains were disappearing and we had two pregnancies! But best of all was the change in the patients themselves; they became excited, hopeful and proud of themselves.

And then the pandemic came. I was told to stop the clinics and, in their place, I began to transfer all the material online. I started learning about online courses and revamped the clinics, creating illustrations and handouts and shortening the talks. Four months later, I was given the green light to go ahead, and we started our virtual clinics. Although at the time it was infuriating to stop the clinics, in hindsight this probably prevented my complete burnout. By the time the clinics were ready to go again, I had been approached by a very experienced Diabetes Specialist Nurse, and she has since been able to share the workload.

The results we have had in 2021 and 2022 are so rarely seen with standard care and, in fact, are usually achievable only with bariatric surgery or restrictive shake diets. Yet the programme we have devised is not a drastic overhaul or a “diet”, but rather a series of positive lifestyle changes and patient education.

I believe that, although we will likely run a hybrid model going forward, there is added value with virtual consulting. Participants are able to open up, share and be more vulnerable when they’re in their own home, and as a result they get more from the experience.

Be inspired

It has been a great year for us, although I will not pretend it has been easy. Doing this clinic has been far more rewarding than working as a “normal” GP. I am actually seeing my patients get better and empowering them to do it for themselves. And of course it is not just the diabetes that improves: their whole metabolic health vastly improves alongside. There is nothing more satisfying.

Of course, not all healthcare professionals would be able to devote so much time to clinics such as these. However, for those whose time with patients is limited to a 10-minute consultation, there is still a modest intervention that can help: see Box 2.

The climate is changing; patients are more aware than ever that remission of type 2 diabetes is achievable for many; that is a great motivator. I have many patients asking to do the course who are not within my NHS catchment area, and I hope to inspire other healthcare professionals to start their own lifestyle clinics.

I became a doctor to help people, and I finally feel that I am on the right path. With the NHS under ever greater pressure, now is the time to empower people to take control of their own health. It’s not as hard as it may seem!