Wales has the highest prevalence of diabetes in the UK. In 2016, 7.3% of the adult population had a diagnosis of diabetes (Welsh Government, 2016). The National Survey for Wales, undertaken between April 2019 and March 2020, found that 61% of Welsh adults were classified as overweight or obese, only 25% of the Welsh population had eaten five or more portions of fruit and vegetables the previous day, and 10% followed fewer than two healthy behaviours (Welsh Government, 2021). The Diabetes Delivery Plan for Wales 2016–2020 was designed to address these contributing health behaviours, to reduce the rise in rates of type 2 diabetes and to continue to improve key outcomes and complication rates for all people with diabetes (Welsh Government, 2016).
The role of the All Wales Diabetes Implementation Group (AWDIG) is to oversee the national plan and support health boards to deliver their service improvement plans for diabetes. The implementation group brings together the key stakeholders, including all the health boards, informatics and the third sector (not-for-profit, non-governmental organisations), primary care and secondary care, government and managers, to work collaboratively. The delivery plan offered a great opportunity for Wales to forge ahead in diabetes care and support.
AWDIG decides its priority areas annually, and three of its key strands have been: meeting national standards in both primary and inpatient care; supporting people to manage their conditions through structured diabetes education (SDE) programmes; and creating a more integrated primary and specialist provision. A number of national roles, including a clinical lead, podiatry lead and my role as the dietetic lead, have been appointed to help drive improvement and implementation across Wales.
Type 2 diabetes has been deemed a largely preventable disease, with obesity and inactivity being major risk factors. The Global Report on Diabetes states that diabetes is a public health problem and has been set as one of four priority non-communicable diseases targeted for action, the others being cardiovascular disease, cancer and chronic respiratory disease (World Health Organization, 2016). All four have the potential to cause premature death as a result of increased exposure to tobacco use, unhealthy diets, physical inactivity and the harmful use of alcohol.
In Wales, there is currently no national diabetes prevention programme. An effective intervention to reduce the number of people with prediabetes going on to develop type 2 diabetes has been identified by the Welsh Government as a high priority. Public Health Wales is currently working with health boards to develop, implement and evaluate an All Wales Diabetes Prevention Programme.
Health behaviour change
Health behaviour is influenced by a multitude of different factors within various levels. The environmental level captures cultural, social and physical factors (e.g. access to health care, nutritious foods and physical activity opportunities, and level of education) and on an individual level includes biological factors (e.g. emotions and the ability to self-regulate health-related behaviours). These non-medical factors that influence health outcomes are known as the social determinants of health. For health behaviour change to occur, there is a fundamental need for the self-regulation of behaviours at an individual level.
There is recognition that social factors cut across these determinants and contribute to individuals from poorer backgrounds experiencing worse health outcomes than those from more affluent areas. In response to the increasing demand on the NHS, both prevention and treatment is required if the increasing rates of obesity and type 2 diabetes are to be reversed. When facilitating health behaviour change, all the determinants of health need to be considered when trying to understand the reasons behind what has contributed to an individual’s obesity. The aim of behaviour change interventions (SDE being one of these) is to try and change behaviour by taking into account these wider determinants. As healthcare professionals, do we consider these when we talk to our patients about their weight, lifestyle and eating habits? An evidence-based understanding of nutrition and its role in diabetes management is essential for all healthcare professionals. A key principle of prudent health care is to do no harm by ensuring that any negative consequences of treatment, both dietary and pharmaceutical, are avoided.
Delivering education and support in a pandemic
With all the evidence and backing behind the need to address the growing public health issue of both type 2 diabetes and obesity, the importance of self-management and individuals taking responsibility for their own health remains an ongoing concern. Self-management refers to the ability of the individual to adapt their lifestyle to aid management of their health condition (Randall and Ford, 2011). There has been ongoing development of self-management education programmes for adults with type 2 diabetes in Wales.
Diabetes care changed dramatically when the COVID-19 pandemic hit in March 2020. People living with type 2 diabetes across Wales have had the opportunity of attending SDE, such as X-PERT, facilitated by dietitians and diabetes specialist nurses (DSNs), for many years. These all came to an abrupt stop when we went into lockdown. We had to think outside the box to provide support to those in our care.
AWDIG investigated the availability of digital solutions and, subsequently, commissioned myDesmond. Digital access via myDesmond has provided the potential for everyone living with type 2 diabetes to access support at any time and from any place – before, during and after traditional clinical interventions.
We are, however, mindful that not everyone has the ability or opportunity to access online support. Dietitians across Wales have adapted to provide a blended approach to their intervention style, moving from face-to-face to telephone or video consultations and conducting group sessions via one of the digital platforms, such as Zoom or Teams. This has enabled people to continue to access support and ensured that we are providing a patient-centred approach to diabetes care, with shared decision-making around the approach that best suits the individual and with consideration of their own circumstances.
Dietitians have continued to provide medical nutritional therapy to ensure individualised care – treating the whole person, not just their diabetes – while taking into consideration comorbidities such as obesity, mental health problems, COPD and fertility issues. How do these impact nutritional requirements? One size does not fit all!
Type 2 diabetes remission
Until recently, type 2 diabetes had been considered a long-term health condition. Together with the Association of British Clinical Diabetologists, the Primary Care Diabetes Society released a position statement in June 2019 supporting the statement that it is possible to achieve remission in type 2 diabetes, with weight loss being the primary driver (Nagi et al, 2019). In January 2020, AWDIG funded the real-world implementation across four health boards in Wales of a very low energy, total diet replacement, dietary approach to support people living with diabetes to lose weight and achieve remission.
Commencing this just as the pandemic hit was a huge challenge. Many people coped extremely well with the enormous change in their daily eating habits, while many struggled. The dietitians continued to provide their regular support, switching to remote consultations throughout the lockdowns and ever-changing landscape.
The programme has gained further funding in order to be rolled out across Wales. The future diabetes remission programme will be led by specialist dietitians to support people towards their achieving remission, utilising a menu of dietary approaches. This dietary approach should be seen as an active treatment and one that is acceptable to the individual. Self-efficacy is the overall belief in one’s own ability to succeed. The need for an individual to have the confidence in themselves to achieve change is essential throughout their diabetes remission journey.
Future plans and considerations for diabetes care
Work is ongoing to develop diabetes care pathways to standardise care across Wales. Food and nutrition play a huge role within diabetes treatment and management, and should not be undervalued. However, all services should be aware of the effort that is needed to lose weight and the stigma participants may have previously experienced. The issue of weight bias and stigma has come to light over recent years, where overweight individuals are exposed to negative attitudes that lead to them experiencing discrimination and prejudice in a variety of situations, such as healthcare and employment. The effects of weight bias are widespread and have been associated with poor body image, low self-esteem, low self-confidence, feelings of worthlessness, suicidal thoughts, depression and disordered eating patterns (World Health Organization, 2017). The possible vulnerability of a person struggling with their weight and diabetes management should never be underestimated.
Clinical judgement should be used when making a decision regarding whether an individual is suitable for SDE and which service is most appropriate. The particular needs of each person should be considered. There needs to be clarity between lay-led and healthcare professional-led services, including ensuring that referrers are aware of the clinical decision-making skills the dietitians and DSNs possess, which the lay facilitator will not. This places the dietitian and DSN in a more advanced practitioner role than the lay educator, mitigating any possible risks of unintended consequences owing to dietary and lifestyle changes.