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Editorial: Why does discussing lifestyle seem more difficult than prescribing drugs?

Encouraging lifestyle change features first-line in all guidelines on type 2 diabetes, and it is widely described as the cornerstone of diabetes management. Yet most of us find discussing lifestyle and empowering people to make changes more challenging than drug prescribing. In this editorial, Pam Brown discusses why this might be the case, in addition to offering some reading recommendations on the subject of food and diabetes.

This is a busy time of year, with colleagues taking holidays and the ongoing catch-up workload continuing alongside coping with the day-to-day care needs of our population, so thanks for making time to read this issue of the journal.

Lifestyle consultations

Encouraging lifestyle change features first-line in all guidelines on type 2 diabetes, and it is widely described as the cornerstone of diabetes management. Yet most of us find discussing lifestyle and empowering people to make changes more challenging than drug prescribing. Different clinicians may have different reasons underpinning this challenge. Firstly, most of us have had less education around lifestyle than on drug therapy, making us less confident in delivering advice. Secondly, the evidence base is developing just as rapidly as that for drug therapy, but it is usually less publicised and often seems more controversial and confusing, with studies seeming to contradict each other. What we might have recommended at the last consultation we may now perceive as having been overtaken by new research. Thirdly, we often meet stiff resistance to our initial discussion and are less likely to find that people have managed to make changes or get positive feedback at review, resulting in lifestyle discussion feeling less rewarding.

So why are drug and diet discussions different? When helping people make drug therapy decisions in diabetes, we have guidelines to follow, with treatment options reduced to a concise algorithm. The consultation is straightforward – we discuss results; we agree need for treatment intensification; we explore drug options, sharing benefits and potential side effects; the person with diabetes asks questions which we are comfortable answering; they choose their preferred option; and we issue the prescription and help them understand how to optimise the benefits.

Lifestyle discussions, in contrast, are less structured and can feel more challenging. Often we have to find a way to raise lifestyle discussion sensitively, or decide what information and resources to share with people when they ask “What should I eat?” Even if we are happy discussing lifestyle and have questions to better understand why lifestyle change may be important to the person sitting beside us and what they feel willing to change, we have no algorithm or clear-cut guidance to follow, and what we share is left to personal preference.

Some of us are old enough to have grappled with a previous European Association for the Study of Diabetes guideline on type 2 diabetes, which listed all the drug classes as options after metformin, triggering complaints that it was more of a menu than a guideline. That is what discussing lifestyle or consulting the (albeit excellent and evidence-based) Diabetes UK (2018) nutrition guidelines can feel like.

At Diabetes & Primary Care we are always looking for ways to help readers tackle challenging areas of care. Over the coming months we will share a series of At a Glance Factsheets exploring and summarising the latest evidence on lifestyle and type 2 diabetes to help us upskill and hopefully make our discussions easier. We’ll start with an overview of how each aspect of lifestyle impacts on type 2 diabetes and its associated comorbidities, focusing on resources we can use to update our knowledge and share with people with diabetes. We’ll follow with more in-depth summaries of the evidence base for nutrition, physical activity, sleep, stress, risky substances and relationships. Each factsheet will summarise key messages, outline controversies and include links to reviews or key papers to facilitate more in-depth learning for those who want to learn more. If you have been involved in developing lifestyle reviews or resources which you feel would be useful to colleagues, please share them with us at dpc@omniamed.com and we will include as many as we can.

In preparation for writing the factsheet on nutrition, I have just completed the 6-week Plant-Based Nutrition course at the University of Winchester. I enjoyed the scientific rigour, critical thinking and exploring the reading lists. I was reminded of the importance of challenging my own thinking and perspectives, and of being aware of differing viewpoints and how these might influence nutrition guidance. For example, those who are committed to a healthy vegan lifestyle, such as Michael Greger and Plant-Based Health Professionals, will naturally focus on evidence of the benefits of a whole-food, plant-based diet, whereas those who have themselves benefitted from low- or very-low-carbohydrate diets, such as Zoe Harcombe, are more likely to also include studies which demonstrate the benefits of this way of eating. Alongside these viewpoints, we know that not all vegan or low-carb eating patterns are healthy and that many people consume good-quality, healthy omnivorous diets, hence the importance of discussing what people are actually eating and keeping an open mind that no one eating pattern is always best.

In this issue

We all face uncertainties in our diabetes practice and wish we had an expert on hand to answer our questions and offer guidance. Many people with type 2 diabetes have experienced deteriorating glycaemic control during lockdown, resulting in high HbA1c levels. Retinal screening services had to suspend routine work, resulting in a large backlog which they are now working through whilst coping with greatly reduced capacity. A common uncertainty results: in those with high HbA1c values, if we want to prescribe potent glucagon-like peptide-1 receptor agonists, when is it safe to do this and when do we need up-to-date retinopathy screening results? We do not want to restrict drug choice but equally we cannot risk deterioration of existing retinopathy. In this issue of the journal, Professor Steve Bain, an investigator on the LEADER and SUSTAIN trials, who has researched this topic, provides pragmatic guidance and scenarios we can use to test our decision-making in his At a Glance Factsheet.

This is just one of the many questions arising from day-to-day practice which have been raised at our PCDS conferences, and we have commissioned a range of experts to help us evaluate the evidence and provide answers. If you have a question which you would like answered, please email us.

Jane Diggle and Mike Kirby provide practical guidance on two very important aspects of diabetes care in their How to guides on assessing feet to prevent foot ulceration and on diagnosing and managing erectile dysfunction, respectively. As well as commissioning new topics, we are updating previously published How to articles, and on our new website these are all collated in one place, accessible from the journal home page. If you haven’t seen or used the How to’s, click here, browse and download the PDFs. The catalogue is updated each month, so it’s certainly worth bookmarking this section of the site.

Many of you will have already read our ADA news stories that were uploaded to the Early view section immediately after the conference, but if you missed them they have now been collated in this issue, complete with a quick summary of the key trials. In Diabetes Distilled, Kevin Fernando and I take a closer look at some of the papers arising from data presented at the conference, including the SURPASS-2, AMPLITUDE-O and DARE-19 trials, as well as highlighting UK data demonstrating differential rates of statin prescribing and hence missed opportunities in some ethnic groups.

David Morris gives us the opportunity to test our knowledge of both steroid-induced diabetes and hypoglycaemia in two new sets of interactive case scenarios. Su Down, Editor-in-Chief of our sister publication, the Journal of Diabetes Nursing, profiles a new PCDS e-learning resource covering the nine care processes. This month also sees the launch of the first part of the PCDS Mental Health e-learning Hub. Be sure to take a look!

Once again it is time to call on candidates for election to the PCDS Committee. If you think you have the expertise, energy and enthusiasm to help shape the Society going forward, don’t delay in finding out more, as nominations close on 7th September.

Also in this issue, Alison Northern and colleagues provide an update on the digital diabetes education platform MyDESMOND, which has seen its user base skyrocket since the start of the pandemic. This project won the award for best poster at the 2020 PCDS National Conference. If you have been undertaking research with your team, why not submit your own poster to this year’s Conference in November? Details of how to submit your poster abstract are outlined here.

Deckchair reading recommendations

My deckchair reading recommendations provide a range of perspectives on food and diabetes. Professor Mike Lean’s well-written invited review shares the content of his enjoyable Banting Memorial Lecture delivered virtually at Diabetes UK this year (Lean, 2021). As well as the biographical details of his career journey, it outlines remission options and shares examples of Banting’s own paintings. I challenge you not to be re-enthused to actively encourage people to aim for remission after reading it.

The BMJ’s systematic review and meta-analysis of randomised controlled trials of low-glycaemic-index or low-glycaemic-load dietary patterns demonstrates small but clinically significant benefits of these diets (Chiavaroli et al, 2021). The effects of low-GI/GL diets mimic those achieved with acarbose – minus the unpleasant side effects.

Finally, the second part of the National Food Strategy – The Plan – aims to provide “a complete review of England’s food system from farm to fork”, as well as updating on the progress that has been made on the recommendations published in the first part of the strategy last year (Dimbleby et al, 2021). Basing the plan on the Eatwell Guide without this being reviewed and re-evaluated has been criticised, and gaps and missed opportunities in the strategy have been highlighted (Adams, 2021). The summary of recommendations provides a quick read and includes sections such as “Escape the junk food cycle and protect the NHS” – clearly heavily influenced by terms used during the pandemic. The focus on how England can meet its zero-carbon goal by 2050 heavily influences the perspective, so the report is as much about farming as healthy eating. The full report contains some fascinating statistics, graphs and information, and if you would like another perspective, Jean Adams’ BMJ review (Adams, 2021) is one of many comment pieces available. Scotland’s food strategy report is available here, while the Food Standards Agency’s policy for Northern Ireland is outlined here and the updated Welsh Community Food Strategy (available here) is included in the Programme for Government for the 6th Senedd. Enjoy dipping into your deckchair reading, and we look forward to seeing you virtually at the PCDS Northern Ireland Conference on 16th September, the Scottish Conference on 26th October, the National Conference on 18–19th November and the All-Ireland Conference on 27th November.

Adams J (2021) National food strategy: what’s in it for population health? BMJ 374: n1865

Chiavaroli L, Lee D, Ahmed A et al (2021) Effect of low glycaemic index or load dietary patterns on glycaemic control and cardiometabolic risk factors in diabetes: systematic review and meta-analysis of randomised controlled trials. BMJ 374: n1651

Diabetes UK (2018) Evidence-based nutrition guidelines for the prevention and management of diabetes. DUK, London. Available at: https://bit.ly/3y5e7s1 (accessed 23.08.21)

Dimbleby H, Cooper T, Taylor A et al (2021) National Food Strategy: Independent review. The Plan. Available at: www.nationalfoodstrategy.org (accessed 23.08.21)

Lean MEJ (2021)  Banting Memorial Lecture 2021 – Banting, banting, banter and bravado: convictions meet evidence in the scientific process: Diabetes UK Professional Conference, 27 April 2021. Diabet Med 20 Jul [Epub ahead of print]. https://doi.org/10.1111/dme.14643

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