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Letter: Effective lifestyle advice

Dear Editor-in-Chief,

I am writing in response to the article published in the last issue of Diabetes & Primary Care written by Peter et al (2011). The authors are right to conclude that lifestyle advice alone will not produce sustained change. However, this particular study may have been unnecessary to reveal this, since there is an abundance of evidence already published to support the fact that giving advice and its passive receipt is not a useful strategy to influence lifestyle change. This is perhaps best summed up in the views of Knight et al (2006): “rigid dietary instruction and obedience training have no place in modern diabetes education” and “there is a widespread assumption that transferring knowledge will improve health outcomes, but there is very little empirical support for this assertion”.

The recent Health Foundation review (de Silva, 2011) sets out the strategies that are associated with successful changes and self-management, chief among these is involving people in decision-making. Also included are: developing care plans as a partnership between service users [sic] and professionals; goal setting; proactive follow-up; using targeted approaches; emphasising problem solving; and providing opportunities to share and learn from others. It is not clear from this article that any of these were undertaken in the intervention with a dietitian and physiotherapist cited.

In addition, the conclusion that more contact with healthcare professionals is likely to be needed does not give the full picture, since many people with diabetes receive lifestyle advice year in, year out, which makes no difference at all to their self-care behaviour. It is the quality of the contact, rather than the quantity, that has been shown to make the difference. In keeping with the evidence and along with many others, I believe that focusing on healthcare professionals’ skills development for person-centred consultations, and the re-organisation of care for people with diabetes (and other long-term conditions), for example to include care planning, will have many beneficial and cost-effective results for all concerned.

Yours sincerely,
Rosie Walker
Education Director, Successful Diabetes 

Author response
We thank the reader for raising some valid points. Our conclusion that lifestyle advice alone will not produce sustained change, refers not to lifestyle changes alone but also indices of pancreatic beta-cell function and insulin sensitivity. To our knowledge, few studies have looked at the changes in pancreatic beta-cell function using insulin and proinsulin profiles in response to meal tests. Earlier studies have looked at glycaemia in general and HOMA scores and we have included these scores for comparison as pancreatic beta-cell function cannot be assessed in isolation.

We agree there is an abundance of evidence that giving advice and its passive receipt is not a useful strategy to influence change at a behavioural level and also that setting proactive care plans and using targeted approaches may make differences at a metabolic level. We also agree that the quality of the consultation has a better impact on effective change. However, it remains the case that many diabetes clinics still use methods as described in our article and we have demonstrated that these approaches do not make a difference even at the level of the pancreatic beta-cell, which only emphasises the changes that would need to be instituted.

Yours sincerely,
Rajesh Peter

Dear Editor-in-Chief,

I am writing in response to the article published in the last issue of Diabetes & Primary Care written by Peter et al (2011). The authors are right to conclude that lifestyle advice alone will not produce sustained change. However, this particular study may have been unnecessary to reveal this, since there is an abundance of evidence already published to support the fact that giving advice and its passive receipt is not a useful strategy to influence lifestyle change. This is perhaps best summed up in the views of Knight et al (2006): “rigid dietary instruction and obedience training have no place in modern diabetes education” and “there is a widespread assumption that transferring knowledge will improve health outcomes, but there is very little empirical support for this assertion”.

The recent Health Foundation review (de Silva, 2011) sets out the strategies that are associated with successful changes and self-management, chief among these is involving people in decision-making. Also included are: developing care plans as a partnership between service users [sic] and professionals; goal setting; proactive follow-up; using targeted approaches; emphasising problem solving; and providing opportunities to share and learn from others. It is not clear from this article that any of these were undertaken in the intervention with a dietitian and physiotherapist cited.

In addition, the conclusion that more contact with healthcare professionals is likely to be needed does not give the full picture, since many people with diabetes receive lifestyle advice year in, year out, which makes no difference at all to their self-care behaviour. It is the quality of the contact, rather than the quantity, that has been shown to make the difference. In keeping with the evidence and along with many others, I believe that focusing on healthcare professionals’ skills development for person-centred consultations, and the re-organisation of care for people with diabetes (and other long-term conditions), for example to include care planning, will have many beneficial and cost-effective results for all concerned.

Yours sincerely,
Rosie Walker
Education Director, Successful Diabetes 

Author response
We thank the reader for raising some valid points. Our conclusion that lifestyle advice alone will not produce sustained change, refers not to lifestyle changes alone but also indices of pancreatic beta-cell function and insulin sensitivity. To our knowledge, few studies have looked at the changes in pancreatic beta-cell function using insulin and proinsulin profiles in response to meal tests. Earlier studies have looked at glycaemia in general and HOMA scores and we have included these scores for comparison as pancreatic beta-cell function cannot be assessed in isolation.

We agree there is an abundance of evidence that giving advice and its passive receipt is not a useful strategy to influence change at a behavioural level and also that setting proactive care plans and using targeted approaches may make differences at a metabolic level. We also agree that the quality of the consultation has a better impact on effective change. However, it remains the case that many diabetes clinics still use methods as described in our article and we have demonstrated that these approaches do not make a difference even at the level of the pancreatic beta-cell, which only emphasises the changes that would need to be instituted.

Yours sincerely,
Rajesh Peter

de Silva D (2011) Helping People Help Themselves: A Review of the Evidence Considering Whether it is Worthwhile to Support Self-Management. Health Foundation, London
Knight KM, Dornan T, Bundy C (2006) The diabetes educator: trying hard, but must concentrate more on behaviour. Diabet Med 23: 485–501
Peter R, Backx K, Dunseath G et al (2011) Effects of lifestyle advice in people newly disgnosed with type 2 diabetes. Diabetes & Primary Care 13: 276–83

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