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How motivated are patients with type 2 diabetes to change their lifestyle? A survey among patients and healthcare professionals
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Primary Care Diabetes journal homepage: http://www.elsevier.com/locate/pcd
Original research
How motivated are patients with type 2 diabetes to change their lifestyle? A survey among patients and healthcare professionals Joris J. Linmans ∗ , J. André Knottnerus, Mark Spigt CAPHRI School for Public Health and Primary Care, Department of General Practice, Maastricht University, PO Box 616, 6200 MD Maastricht, The Netherlands
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a b s t r a c t
Article history:
Aim: It is unknown to what extend patients with type 2 diabetes mellitus (T2DM) in primary
Received 25 October 2014
care are motivated to change their lifestyle. We assessed the level of motivation to change
Received in revised form
lifestyle and the agreement for that level between patients and healthcare professionals.
5 February 2015
Methods: Patients with T2DM (150) filled in a questionnaire to assess the level of motivation
Accepted 8 February 2015
to change their lifestyle, using a single question with three answer options. We investigated
Available online xxx
the agreement for this level between these patients and their healthcare professionals (12 professionals). In addition, we investigated and compared the level of physical activity as
Keywords:
indicated by the patients and the healthcare professionals.
Diabetes mellitus, type 2
Results: A large part of the patients reported to have a deficient physical activity level (35%
Life style
according to patients, 47% according to healthcare professionals, kappa 0.32) and were not
Motivation
motivated to change their lifestyle level (29% according to patients, 43% according to health-
Primary health care
care professionals, kappa 0.13). Patients tended to overestimate their physical activity and their motivation to change in comparison with their healthcare professionals. Conclusions: Patients with T2DM in primary care should increase their physical activity level. Healthcare professionals often do not know whether patients are motivated to change their lifestyle, and should therefore assess motivation regularly to optimize lifestyle management. © 2015 Primary Care Diabetes Europe. Published by Elsevier Ltd. All rights reserved.
1.
Introduction
An unhealthy lifestyle is one of the most important etiologic factors of type 2 diabetes (T2DM) and for that reason one of the most important targets in therapy [1–3]. Lifestyle programs in controlled settings have been proven effective in reducing the
∗
incidence of T2DM in individuals with impaired glucose tolerance [4], but in routine practice achieving similar results seems difficult [5,6]. Meanwhile, the threat of a diabetes pandemic has not decreased [7,8]. Given this pandemic, lifestyle behavior change is crucial in the management of T2DM in primary care. Success in achieving sustainable behavior change depends on the motivation of the patient [9,10]. It has also been
Corresponding author. Tel.: +31 0 43 388 4186; fax: +31 0 43 3619344. E-mail address: [email protected] (J.J. Linmans).
http://dx.doi.org/10.1016/j.pcd.2015.02.001 1751-9918/© 2015 Primary Care Diabetes Europe. Published by Elsevier Ltd. All rights reserved.
Please cite this article in press as: J.J. Linmans, et al., How motivated are patients with type 2 diabetes to change their lifestyle? A survey among patients and healthcare professionals, Prim. Care Diab. (2015), http://dx.doi.org/10.1016/j.pcd.2015.02.001
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shown that patient motivation is a key element for successful self-management [11]. Because of the importance of patient motivation, the level of the motivation should be assessed, for example to be able to target counseling. However, is has been shown that GP’s assess the patients’ readiness to change their lifestyle with low accuracy [12]. Previous research found that patients were generally not motivated to self-manage their diabetes [13]. In addition, a study showed that patients with T2DM follow exercise recommendations only in 34% of the time and follow diet recommendations in 59% [14]. Another study [15] found that obese patients were only slightly motivated to lose weight (6.6 on 10-point scale), but their physicians were even less optimistic (an average 4.7). Research also suggests that the majority of patients with T2DM were not physically active [16] and were not motivated to become active in the next six months [16,17]. The extent to which patients with T2DM in primary care are motivated to change their lifestyle is a crucial factor in diabetes management. However, we could not find any study on the motivation for lifestyle changes in patients with T2DM in primary care and the agreement between patients and health professionals. Therefore, the aim of this study was to investigate the motivation to change lifestyle in patients with T2DM in primary care and to assess whether patients and health professionals had similar motivation estimates. In addition, we investigated the agreement between patients and health professionals for physical activity and for lifestyle topics discussed during the consultations.
2.
Method
2.1.
Procedure
We contacted 10 primary healthcare centers in the southern part of the Netherlands based on our existing research network. Diabetes care in the Netherlands is organized according to a diabetes management program (DMP). Within this DMP, the patient has four consultations every year with a diabetes practice nurse (DPN) supervised by the general practitioner. When necessary, extra consultations can be scheduled. All DPNs were asked to randomly include patients who visited the general practice for a regular diabetes check-up during two successive weeks. To be able to answer our research questions using this observational study, we aimed to included 150 patients. DPNs were provided with coded patients and DPN questionnaire sets. Patients who were willing to participate were asked the fill in a questionnaire after the consultation with the DPN. The DPN was also asked to fill in a questionnaire for each patient after the consultation. Data were collected from December 2013 until June 2014. The Medical Ethical Committee of Maastricht University Medical Centre has approved this study (number: METC 134-093). All patients signed an informed consent form.
Dutch language and were not physically disabled for any reason, could participate.
2.3.
The questionnaire contained several items. The patient was asked to provide information on a number of individual characteristics (e.g. age, gender, how many years of diabetes, weight, length, type of medication, Dutch Standard for Healthy Physical activity (exercising at moderate intensity at least half an hour for five or more days a week: deficient, sufficient, sportive), following a physical activity programs and/or diet program). Regarding lifestyle assessment, we are aware that there are several important aspects of lifestyle. However, for pragmatic purposes, in this study we focused on physical activity and diet. The question about the patients’ motivation for lifestyle change was derived from the motivation to stop scale: one question with seven answer options of motivation to stop smoking with accurate predictive value [18]. We adapted this question for two reasons. First, to be able to implement the question in usual care, it should be as short, practical and as little time consuming as possible. Second, in future practice we would want to be able to tailor care to the level of motivation of the patient. However, to tailor lifestyle management to seven different levels is unfeasible. Therefore, we developed a three level motivation scale. Participants were asked: ‘which of the following describes you best’. The three answer options were: 1—I don’t want to improve my lifestyle (healthier diet and/or improve physical activity), 2—I want to improve my lifestyle (healthier diet and/or improve physical activity), but don’t know when I will, 3—I really want to improve my lifestyle (healthier diet and/or improve physical activity) and I want to start now. For now, we chose to ask whether patients wanted to change their lifestyle in general and decided not to split lifestyle motivation into more questions. We did this because we believe this is, also in real-world care, the most efficient first step. Later, healthcare professionals could explore in more detail what part of lifestyle patients want to change. In addition, we asked the patients whether lifestyle was discussed during the consultation and whether the patient received advice on how to improve their physical activity and/or diet. Biomedical data (blood pressure, BMI, medication usage, cholesterol, kidney function, retinopathy, Dutch Standard for Healthy Physical activity, smoking status, risk of diabetic foot ulcers, abdominal circumference, glucose and HbA1c levels), were derived from the electronic medical records. To be able to investigate the agreement between the patient and the DPN for the level of motivation of the patient, the DPN was asked to answer the single-item motivation question about the patient directly after the consultation. In addition, DPNs were asked whether they discussed lifestyle during the consultation and whether they gave advice on how to improve physical activity and/or diet.
2.4. 2.2.
Measurements
Data analyses
Study population
All patients in primary care with type 2 diabetes who had a regular quarterly consultation with the DPN, who could read
We used descriptive statistics to describe the study population of participants. Agreement was quantified using Cohen’s kappa coefficient. The nesting of patients within practices
Please cite this article in press as: J.J. Linmans, et al., How motivated are patients with type 2 diabetes to change their lifestyle? A survey among patients and healthcare professionals, Prim. Care Diab. (2015), http://dx.doi.org/10.1016/j.pcd.2015.02.001
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was taken into account in the computation of the agreement standard error by using the method of Yang and Zhou [19]. Because in the Netherlands patients with T2DM with a BMI ≥ 25 are advised to lose weight [20], the agreement between patients and DPN for this subpopulation was analyzed separately. According to Fleiss [21] there is excellent agreement beyond chance when kappa is higher than 0.75, there is reasonable to good agreement when kappa is between 0.40 and 0.75 and poor agreement when kappa is lower than 0.40. The descriptive analyses were conducted using SPSS 21 and the agreement analyses were conducted using the statistical software R.
3.
Results
Twelve DPNs from 10 practices participated in this study and they asked 150 patients to participate. Nine patients were invited to participate, but did not return the questionnaire. Patient characteristics are shown in Table 1. The mean age was 64 years and 64% was male and 36% female. The mean BMI was 29.2 kg/m2 . According to the patients’ perception, the level of their physical activity was deficient in 35% (49 patients) (see Table 2), and deficient in 47% (66 patients) according to the DPNs. Patients were more positive in 28% (18 + 8 + 13 = 39) of the cases compared with 16% (5 + 4 + 14 = 23) of the cases where DPNs were more positive. Agreement for physical activity rating between patient and DPN was seen in 56% (79 cases) and kappa was low (0.32, p < 0.0001). Patients also tended to be more positive about their motivation to change in comparison with DPNs (Table 2). A large group of patients, 43% (61 patients), were not motivated to change according to the DPN, while 29% (41 patients) of the patients reported to be not motivated to change their lifestyle. Patients were in 35% (22 + 16 + 11 = 49) more positive about their motivation to change than DPNs (24%, 8 + 10 + 16 = 34). Only in 41% (58) of the cases, patient and DPN agreed upon the level of motivation. Cohen’s kappa for motivation was very poor (kappa 0.13, p = 0.11). Interestingly, 16 patients said they were really motivated to change their lifestyle immediately, while the DPN stated that these patients were not motivated at all. Similar results were found in the subgroup of patients with a BMI ≥ 25 (Table 3). A large number of patients did not have sufficient exercise (48% according to DPNs and 37% according to patients). For both physical activity and motivation, patients were more positive than DPNs (34% vs. 15% and 39% vs. 23%, respectively). For physical activity, patients and DPNs agreed in 59% (73 cases), with a low kappa of 0.36 (p < 0.0001). Agreement for motivation to change was very poor with a kappa of 0.084 (p = 0.32) and agreement was only observed in 38% (47 cases). Again for this subgroup, 15 patients said to be really motivated for lifestyle change immediately, while the DPN said they were not motivated at all. According to DPNs, 44% was not motivated to change, while patients said in 27% not to be motivated. In a large number of cases (78%, 109 cases) patients and DPNs agreed that physical activity was discussed (Table 4). Also for diet, they agreed in 69% (96 cases) that this was
Table 1 – Patient characteristics. Characteristics
N = 141
Age (years) Years of T2DM Gender Male Female Smoking Weight (kg) Length (cm) BMI (kg/m2 ) Abdominal circumference (cm) Systolic blood pressure (mmHg) Diastolic blood pressure (mmHg) Fasting glucose (capillary) (mmol/l) HbA1c (%) Total cholesterol (mmol/l) LDL cholesterol (mmol/l) HDL cholesterol (mmol/l) Triglycerides (mmol/l) Plasma creatinine (mol/l) Renal function (GFR) under 60 ml/min Microalbuminuria Macroalbuminuria Diabetic retinopathy Risk for foot ulcers (0–3) Oral blood glucose lowering drugs Insulin Antihypertensive drugs Lipid lowering drugs
64.2 (10.5) 7.6 (5.8) 91 (64.5%) 50 (35.5%) 16 (11.3%) 86.7 (17.3) 170.5 (17.3) 29.2 (4.2) 102.6 (14.7) 135.8 (15.2) 78.5 (8.7) 7.9 (6.1) 6.7 (1.0) 4.4 (1.1) 2.3 (0.9) 1.3 (0.4) 1.8 (1.1) 83.5 (19.3) 19 (13.5%) 14 (9.9%) 0 10 (7.1%) 0.4 (0.6) 114 (80.9%) 20 (14.2%) 100 (70.9%) 113 (80.1%)
T2DM, type 2 diabetes mellitus; BMI, body mass index; HbA1c, glycated haemoglobin; LDL, low-density lipoprotein; HDL, highdensity lipoprotein; GFR, glomerular filtration rate. A GFR below 60 ml/min is considered as a diminished renal function. However, can be acceptable depending on age. Microalbuminuria: males 2.5–25 mg albumin/mmol creatinine, females 3.5–35 mg albumin/mmol creatinine. Macroalbuminuria: males >25 mg albumin/mmol creatinine, females >35 mg albumin/mmol creatinine. Risk for foot ulcers according to the SIMM’s classification [20]: diabetic foot risk classification system: 0 = no higher risk; 1 = slightly higher risk, loss of sensibility or signs of peripheral arterial disease; 2 = high risk, a combination of loss of sensibility and/or signs of peripheral arterial disease and/or signs of elevated pressure; 3 = ulcer or amputation in history. Data are presented as means (SD), unless otherwise stated.
discussed. Because kappa is a measure to indicate differences (compared with the agreement based on chance), the relatively low kappa (0.32 and 0.076) can be explained by this homogenous group where both parties answered with ‘yes’ (unbalance in the marginal totals). While patients and DPN agreed on the fact that lifestyle had been discussed during the consultation, Table 5 shows that they did not agree on whether advice had been given. In total, 34% disagreed for advice given about physical activity (kappa 0.32, p < 0.0001) and 44% disagreed for advice given about diet (kappa 0.14, p = 0.0002).
4.
Discussion
4.1.
Summary of main findings
In our study, many patients with T2DM reported that they were physically inactive and were not motivated to change
Please cite this article in press as: J.J. Linmans, et al., How motivated are patients with type 2 diabetes to change their lifestyle? A survey among patients and healthcare professionals, Prim. Care Diab. (2015), http://dx.doi.org/10.1016/j.pcd.2015.02.001
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Table 2 – Agreement between patient and DPN for motivation and physical activity. All patients. Patient (N = 141) Deficient
Sufficient
Sportive
Total (%)
Ä (CI)
p-Value
40 5 4 49 (34.8) No 23 8 10 41 (28.1)
18 31 14 63 (44.7) Maybe 22 17 16 55 (39.0)
8 13 8 29 (20.6) Yes 16 11 18 45 (31.9)
66 (46.8) 49 (34.8) 26 (18.4) 141
0.32 (0.16–0.47)
<0.0001
61 (43.3) 36 (25.5) 44 (31.2) 141
0.13 (−0.027–0.28)
0.11
Physical activity DPN Deficient Sufficient Sportive Total (%) Motivation to change No Maybe Yes Total (%)
Physical activity level: Sufficient: exercising according to the Dutch Standard for Healthy Physical activity (exercising at moderate intensity at least half an hour for five or more days a week). Deficient: exercising less than those with a sufficient level. Sportive: exercising more than those with a sufficient level. The level of motivation for lifestyle change according to three options: No (1), I don’t want to improve my lifestyle (healthier diet and/or improve physical activity), Maybe (2), I want to improve my lifestyle, but don’t know when I will, Yes (3), I really want to improve my lifestyle and I want to start from now on. DPN = diabetes practice nurse.
Table 3 – Agreement between patient and DPN for motivation and physical activity. Patients with a BMI ≥ 25. Patient (N = 124) Deficient Physical activity DPN Deficient Sufficient Sportive Total (%) Motivation to change No Maybe Yes Total (%)
38 4 4 46 (37.1) No 17 8 8 33 (26.6)
Sufficient
Sportive
Total (%)
Ä (CI)
p-Value
15 28 11 54 (43.5) Maybe 22 15 13 50 (40.3)
7 10 7 24 (19.4) Yes 15 11 15 41 (33.1)
60 (48.4) 42 (33.9) 22 (17.7) 124
0.36 (0.20–0.41)
<0.0001
54 (43.5) 34 (27.4) 36 (29.0) 124
0.084 (−0.080–0.25)
0.32
Physical activity level: Sufficient: exercising according to the Dutch Standard for Healthy Physical activity (exercising at moderate intensity at least half an hour for five or more days a week). Deficient: exercising less than those with a sufficient level. Sportive: exercising more than those with a sufficient level. The level of motivation for lifestyle change according to three options: No (1), I don’t want to improve my lifestyle (healthier diet and/or improve physical activity), Maybe (2), I want to improve my lifestyle, but don’t know when I will, Yes (3), I really want to improve my lifestyle and I want to start from now on. DPN = diabetes practice nurse.
Table 4 – Agreement between patient and DPN for discussing physical activity and diet during consultation. Patient (N = 140)
Physical activity DPN No Yes Total (%) Diet No Yes Total (%)
No
Yes
Total (%)
Ä (CI)
p-Value
8 14 22 (15.7)
9 109 118 (84.3)
17 (12.1) 123 (87.9) 140
0.32 (0.16–0.47)
<0.0001
6 17 23 (16.4)
21 96 117 (83.6)
27 (19.3) 113 (80.7) 140
0.076 (−0.080–0.23)
0.34
DPN = diabetes practice nurse.
Please cite this article in press as: J.J. Linmans, et al., How motivated are patients with type 2 diabetes to change their lifestyle? A survey among patients and healthcare professionals, Prim. Care Diab. (2015), http://dx.doi.org/10.1016/j.pcd.2015.02.001
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Table 5 – Agreement between patient and DPN for giving advice about physical activity and diet during consultation. Patient (N = 140)
Physical activity DPN No Yes Total (%) Diet No Yes Total (%)
Total (%)
Ä (CI)
No
Yes
p-Value
41 15 56 (40.0)
33 51 84 (60.0)
74 (52.9) 66 (47.1) 140
0.32 (0.21–0.44)
<0.0001
34 20 54 (38.6)
41 45 86 (61.4)
75 (53.6) 65 (46.4) 140
0.14 (0.067–0.22)
0.0002
DPN = diabetes practice nurse.
their lifestyle. There was poor agreement between patients and DPNs for the level of physical activity of the patients, and for the motivation of the patients to change their lifestyle. Patients were generally more positive about their level of physical activity compared to DPNs, and they also were more positive about their motivation to change their lifestyle. Patients and DPNs generally agreed that physical activity and diet was discussed during the consultation. However, in general, they did not agree that DPNs gave advice to patients about physical activity and diet.
4.2.
Comparison with existing literature
Sufficient physical activity is an essential part of the management of T2DM. We found however, that 47% of patients with T2DM reported insufficient physical activity. This is in line with previous studies [6,22–24] that found that the level of activity was deficient in 51–82%. Oftedal et al. [23] showed that patients with T2DM believed they had the ability to start exercise and diet management, but less than 10% exercised daily and 25% adhered to their diet daily. In addition, our results showed that patients tended to overestimate their physical activity level compared with DPNs. These results are consistent with previous research [25,26]. Therefore, increasing physical activity in patients with T2DM will still be a challenging task [27,28], especially in overestimators [29]. Motivation is a key element for behavior change. Our results show that 28% of the patients were not motivated to change their lifestyle, but this concerned 43% of the patients according to the DPNs. These results are in agreement with studies that used the stages of change by Prochaska and DiClemente [30] to indicate patients’ readiness to change their behavior. These studies found that among different groups of patients in primary care a large proportion (29–41%) was not motivated (precontemplators) to change their lifestyle [12,22]. In addition, we also found that a large group of patients with a BMI ≥ 25 (27%) were not motivated to change their lifestyle. These people might even benefit most from improving their lifestyle. Several barriers have been identified for lifestyle behavior change. Some of these are: patients do not regard diabetes as a serious disease [31], misperception of the patients’ actual lifestyle behavior [32], decrease in wellbeing [33], asymptomatic disease, increased costs, cultural background [11], patients are satisfied with their behavior [34], frustration from lack of success [35], physical limitations, lack
of time [36] and interference with work [37]. In the end however, without being motivated, acquiring and maintaining a healthy lifestyle will probably be impossible. When healthcare professionals do not know the patients’ motivation or do not agree with patients, they are unable to level to the needs of the patients and provide patient-centered care. Patient-centeredness is associated with increased patient satisfaction and improved health outcomes [13,38]. The results of this study showed that there is little agreement between patients and DPNs. Agreement for motivation for lifestyle change was only seen in 41% of all cases (kappa 0.13). The DAWN-study [39] showed that healthcare professional estimates of success in treatment adherence were much lower than patient estimates of success, especially for lifestyle behaviors (diet and exercise). A study by Befort et al. [15] found that GPs were less optimistic about weight loss than obese patients themselves. Patients reported in 26% to be completely motivated, whereas GPs rated these patients in 3% being completely motivated. Little agreement about the level of motivation may impede good communication and therefore good lifestyle management for patients with T2DM. Besides, management can be targeted at the wrong patients.
4.3.
Limitations
Patients were selected by their own DPNs, which could have resulted in selection bias. However, it is more likely that DPNs selected patients of whom they knew the lifestyle habits and motivation to change. Therefore, if this resulted in selection bias, our results, showing poor agreement, probably tends towards an overestimation of the true agreement. Because questionnaires were filled-in directly after the consultation, we could minimize recall bias as much as possible. Knowing the content of the questionnaire however, may have caused the DPNs to give extra attention to motivation and lifestyle during subsequent consultations. On the other hand, evidence showed that research within real-world medical practice influenced the behavior of healthcare professionals very little during a study [15,40]. Our question to assess motivation was not validated in previous research. We adapted the question from the validated motivation to stop smoking scale [18]. Our question however, is a very pragmatic approach to asses not so much only the motivation to change lifestyle, but rather to assess the agreement between DPNs and patients. Whether the
Please cite this article in press as: J.J. Linmans, et al., How motivated are patients with type 2 diabetes to change their lifestyle? A survey among patients and healthcare professionals, Prim. Care Diab. (2015), http://dx.doi.org/10.1016/j.pcd.2015.02.001
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question we used accurately measures the motivation to change lifestyle could be investigated in future research. Nevertheless, assessing the motivation for lifestyle change in a structural manner is for now not a topic within the DMP and implementing such a question might already be a substantial improvement. We did not measure the actual level of physical activity. Therefore, we cannot clearly proof whether the level of physical activity reported by the patient or by the DPN is correct. Our results show that patients report a higher level than DPNs. Because patients tend to report a higher level of physical activity than the actual measured level [25,26], we believe we can describe that patients tended to overestimate their physical activity level compared with DPN’s. Kappa is a widely used statistical measure to assess the agreement between two raters. However, kappa is sometimes a less practical method; for example, when the distribution of the marginal totals is unbalanced. Therefore, an observed high agreement with a low kappa can be found [41]. We also encountered this problem when calculating the agreement for discussing physical activity and diet during consultation, as we described in Section 3. The marginal totals for the other calculations were more in balance. In this analysis, we chose not to account for the differences of the degree of disagreement (weighted kappa) between different subgroups. For now, we were interested in the level of disagreement between patients and DPNs in general. However, we did account for the nesting of data using the method of Yang and Zhou [19].
4.4.
Implications for clinical practice
To be able to assist the patient with T2DM with the struggle of lifestyle management, healthcare professionals and patients should cooperate at the same level. Not only for the actual behavior of the patient (e.g. physical activity), but also for the motivation to change that behavior. Assessing the motivation of the patients to change their lifestyle in a structural way can assist health professionals to adapt to the needs of the patient. We suggest investigating the possibilities to adopt the motivation question within the everyday lifestyle management for patients with T2DM in usual care.
5.
Conclusion
Patients with T2DM in general practice should increase physical activity toward a sufficient level. Since motivation plays a key role in behavior change, we need pragmatic tools to gain insight into the patients’ motivation to change lifestyle. The question about the motivation for lifestyle change as we proposed in the manuscript is a practically useful tool and may help patients and primary healthcare professionals in such a way that lifestyle management can be targeted and optimized in general practice.
Conflict of interest The authors declare that they have no conflicts of interest.
Acknowledgements The authors would like to thank Dr. S. Vanbelle for her help with the data analyses.
references
[1] N. Boulé, E. Haddad, G. Kenny, G. Wells, R. Sigal, Effects of exercise on glycemic control and body mass in type 2 diabetes mellitus: a meta-analysis of controlled clinical trials, JAMA 286 (10) (2001) 1218–1227. [2] L.M. Delahanty, D.M. Nathan, Implications of the diabetes prevention program and Look AHEAD clinical trials for lifestyle interventions, J. Am. Diet. Assoc. 108 (4 Suppl 1) (2008) S66–S72. [3] D.E. Thomas, E.J. Elliott, G.A. Naughton, Exercise for type 2 diabetes mellitus, Cochrane Database Syst. Rev. 3 (2006) CD002968. [4] C.L. Gillies, K.R. Abrams, P.C. Lambert, N.J. Cooper, A.J. Sutton, R.T. Hsu, et al., Pharmacological and lifestyle interventions to prevent or delay type 2 diabetes in people with impaired glucose tolerance: systematic review and meta-analysis, BMJ 334 (2007) 299. [5] M. Cardona-Morrell, L. Rychetnik, S.L. Morrell, P.T. Espinel, A. Bauman, Reduction of diabetes risk in routine clinical practice: are physical activity and nutrition interventions feasible and are the outcomes from reference trials replicable? A systematic review and meta-analysis, BMC Public Health 10 (2010) 653. [6] J.J. Linmans, W. Viechtbauer, T. Koppenaal, M. Spigt, J.A. Knottnerus, Using electronic medical records analysis to investigate the effectiveness of lifestyle programs in real-world primary care is challenging: a case study in diabetes mellitus, J. Clin. Epidemiol. 65 (7) (2012) 785–792. [7] G. Danaei, M.M. Finucane, Y. Lu, G.M. Singh, M.J. Cowan, C.J. Paciorek, et al., National, regional, and global trends in fasting plasma glucose and diabetes prevalence since 1980: systematic analysis of health examination surveys and epidemiological studies with 370 country-years and 2·7 million participants, Lancet 378 (9785) (2011) 31–40. [8] S. Wild, G. Roglic, A. Green, R. Sicree, H. King, Global prevalence of diabetes. Estimates for the year 2000 and projections for 2030, Diabetes Care 27 (5) (2004) 1047–1053. [9] M.K. Baker, K. Simpson, B. Lloyd, A.E. Bauman, M.A.F. Singh, Behavioral strategies in diabetes prevention programs: a systematic review of randomized controlled trials, Diabetes Res. Clin. Pract. 91 (1) (2010) 1–12. [10] E. Deci, R. Ryan (Eds.), Intrinsic Motivation and Self-Determination in Human Behavior, Plenum, New York, NY, 1985. [11] J.B. Brown, S.B. Harris, S. Webster-Bogaert, S. Wetmore, C. Faulds, M. Stewart, The role of patient, physician and systemic factors in the management of type 2 diabetes mellitus, Fam. Pract. 19 (4) (2002) 344–349. [12] M.W. Verheijden, J.C. Bakx, I.C.G. Delemarre, A.J. Wanders, N.M. van Woudenbergh, B.J. Bottema, et al., GPs’ assessment of patients’ readiness to change diet, activity and smoking, Br. J. Gen. Pract. 55 (2005) 452–457. [13] J. Moran, H. Bekker, G. Latchford, Everyday use of patient-centred, motivational techniques in routine consultations between doctors and patients with diabetes, Patient Educ. Couns. 73 (2008) 224–231. [14] D.J. Toobert, S.E. Hampson, R.E. Glasgow, The summary of diabetes self-care activities measure: results from 7 studies and a revised scale, Diabetes Care 23 (2000) 943–950.
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[15] C.A. Befort, K.A. Greiner, S. Hall, K.M. Pulvers, N.L. Nollen, A. Charbonneau, et al., Weight-related perceptions among patients and physicians: how well do physicians judge patients’ motivation to lose weight, J. Gen. Intern. Med. 21 (2006) 1086–1090. [16] A.F. Kirk, N. Mutrie, P.D. Macintyre, M.B. Fisher, Promoting and maintaining physical activity in people with type 2 diabetes, Am. J. Prev. Med. 27 (2004) 289–296. [17] E. Centis, M. Trento, A. Dei Cas, A.E. Pontiroli, P. De Feo, A. Bruno, et al., Stage of change and motivation to healthy diet and habitual physical activity in type 2 diabetes, Acta Diabetol. 51 (2014) 559–566. [18] D. Kotz, J. Brown, R. West, Predictive validity of the motivation to stop scale (MTSS): a single-item measure of motivation to stop smoking, Drug Alcohol Depend 128 (2013) 15–19. [19] Z. Yang, M. Zhou, Kappa statistic for clustered matched-pair data, Stat Med 33 (2014) 2612–2633. [20] G. Rutten, W. De Grauw, G. Nijpels, S. Houweling, F. Van de Laar, H. Bilo, et al., NHG-Standaard diabetes mellitus type 2 (derde herziening), Huisarts Wet 56 (10) (2013) 512–525. [21] J. Fleiss, Statistical Methods for Rates and Proportions, Wiley, New York, NY, 1981. [22] G. Grandes, A. Sánchez, J. Torcal, R.O. Sánchez-Pinilla, K. Lizarraga, J. Serra, Targeting physical activity promotion in general practice: characteristics of inactive patients and willingness to change, BMC Public Health 8 (2008) 172. [23] B. Oftedal, E. Bru, B. Karlsen, Motivation for diet and exercise management among adults with type 2 diabetes, Scand. J. Caring Sci. 25 (2011) 735–744. [24] K. Vähäsarja, S. Salmela, J. Villberg, P. Rintala, M. Vanhala, T. Saaristo, et al., Perceived need to increase physical activity levels among adults at high risk of type 2 diabetes: a cross-sectional analysis within a community-based diabetes prevention project FIN-D2D, BMC Public Health 12 (2012) 514. [25] L. Lechner, C. Bolman, M. Van Dijke, Factors related to misperception of physical activity in The Netherlands and implications for health promotion programmes, Health Promot. Int. 21 (2006) 104–112. [26] G. Ronda, P. Van Assema, J. Brug, Stages of change, psychological factors and awareness of physical activity levels in The Netherlands, Health Promot. Int. 16 (2001) 305–314. [27] D. Simons-Morton, S. Blair, A. King, T. Morgan, W. Applegate, M. O’Toole, Effects of physical activity counseling in primary care: the Activity Counseling Trial: a randomized controlled trial, JAMA 286 (6) (2001) 677–687. [28] N.H. Williams, M. Hendry, B. France, R. Lewis, C. Wilkinson, Effectiveness of exercise-referral schemes to promote physical activity in adults: systematic review, Br. J. Gen. Pract. 57 (545) (2007) 979–986.
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[29] E.M. van Sluijs, S.J. Griffin, M.N. van Poppel, A cross-sectional study of awareness of physical activity: associations with personal, behavioral and psychosocial factors, Int. J. Behav. Nutr. Phys. Act. 4 (2007) 53. [30] J.O. Prochaska, C.C. DiClemente, Stages and processes of self-change of smoking: toward an integrative model of change, J. Consult. Clin. Psychol. 51 (3) (1983) 390–395. [31] M. Clark, S.E. Hampson, Comparison of patients’ and healthcare professionals’ beliefs about and attitudes towards type 2 diabetes, Diabet. Med. 20 (2003) 152–154. [32] R. Jansink, J. Braspenning, E. Keizer, T. van der Weijden, G. Elwyn, R. Grol, Misperception of patients with type 2 diabetes about diet and physical activity, and its effects on readiness to change, J. Diabetes 4 (2012) 417–423. [33] M. Wermeling, U. Thiele-Manjali, J. Koschack, G. Lucius-Hoene, W. Himmel, Type 2 diabetes patients’ perspectives on lifestyle counselling and weight management in general practice: a qualitative study, BMC Fam. Pract. 15 (2014) 97. [34] P.W. Vermunt, I.E. Milder, F. Wielaard, C.A. Baan, J.D. Schelfhout, G.P. Westert, et al., Behavior change in a lifestyle intervention for type 2 diabetes prevention in Dutch primary care: opportunities for intervention content, BMC Fam. Pract. 14 (2013) 78. [35] J. Nagelkerk, K. Reick, L. Meengs, Perceived barriers and effective strategies to diabetes self-management, J. Adv. Nurs. 54 (2006) 151–158. [36] G.R. Dutton, J. Johnson, D. Whitehead, J.S. Bodenlos, P.J. Brantley, Barriers to physical activity among predominantly low-income African-American patients with type 2 diabetes, Diabetes Care 28 (2005) 1209–1210. [37] E. Hansen, B.J. Landstad, O. Hellzén, S. Svebak, Motivation for lifestyle changes to improve health in people with impaired glucose tolerance, Scand. J. Caring Sci. 25 (2011) 484–490. [38] M. Stewart, J.B. Brown, A. Donner, I.R. McWhinney, J. Oates, W.W. Weston, et al., The impact of patient-centered care on outcomes, J. Fam. Pract. 49 (2000) 796–804. [39] M. Peyrot, R.R. Rubin, T. Lauritzen, F.J. Snoek, D.R. Matthews, S.E. Skovlund, Psychosocial problems and barriers to improved diabetes management: results of the Cross-National Diabetes Attitudes, Wishes and Needs (DAWN) Study, Diabet. Med. 22 (2005) 1379–1385. [40] E.F. Ellerbeck, W.S. Choi, K. McCarter, D.G. Jolicoeur, A. Greiner, J.S. Ahluwalia, Impact of patient characteristics on physician’s smoking cessation strategies, Prev. Med. 36 (2003) 464–470. [41] A.R. Feinstein, D.V. Cicchetti, High agreement but low kappa: I. The problems of two paradoxes, J. Clin. Epidemiol. 43 (1990) 543–549.
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Contents lists available at ScienceDirect
Primary Care Diabetes journal homepage: http://www.elsevier.com/locate/pcd
Original research
How motivated are patients with type 2 diabetes to change their lifestyle? A survey among patients and healthcare professionals Joris J. Linmans ∗ , J. André Knottnerus, Mark Spigt CAPHRI School for Public Health and Primary Care, Department of General Practice, Maastricht University, PO Box 616, 6200 MD Maastricht, The Netherlands
a r t i c l e
i n f o
a b s t r a c t
Article history:
Aim: It is unknown to what extend patients with type 2 diabetes mellitus (T2DM) in primary
Received 25 October 2014
care are motivated to change their lifestyle. We assessed the level of motivation to change
Received in revised form
lifestyle and the agreement for that level between patients and healthcare professionals.
5 February 2015
Methods: Patients with T2DM (150) filled in a questionnaire to assess the level of motivation
Accepted 8 February 2015
to change their lifestyle, using a single question with three answer options. We investigated
Available online xxx
the agreement for this level between these patients and their healthcare professionals (12 professionals). In addition, we investigated and compared the level of physical activity as
Keywords:
indicated by the patients and the healthcare professionals.
Diabetes mellitus, type 2
Results: A large part of the patients reported to have a deficient physical activity level (35%
Life style
according to patients, 47% according to healthcare professionals, kappa 0.32) and were not
Motivation
motivated to change their lifestyle level (29% according to patients, 43% according to health-
Primary health care
care professionals, kappa 0.13). Patients tended to overestimate their physical activity and their motivation to change in comparison with their healthcare professionals. Conclusions: Patients with T2DM in primary care should increase their physical activity level. Healthcare professionals often do not know whether patients are motivated to change their lifestyle, and should therefore assess motivation regularly to optimize lifestyle management. © 2015 Primary Care Diabetes Europe. Published by Elsevier Ltd. All rights reserved.
1.
Introduction
An unhealthy lifestyle is one of the most important etiologic factors of type 2 diabetes (T2DM) and for that reason one of the most important targets in therapy [1–3]. Lifestyle programs in controlled settings have been proven effective in reducing the
∗
incidence of T2DM in individuals with impaired glucose tolerance [4], but in routine practice achieving similar results seems difficult [5,6]. Meanwhile, the threat of a diabetes pandemic has not decreased [7,8]. Given this pandemic, lifestyle behavior change is crucial in the management of T2DM in primary care. Success in achieving sustainable behavior change depends on the motivation of the patient [9,10]. It has also been
Corresponding author. Tel.: +31 0 43 388 4186; fax: +31 0 43 3619344. E-mail address: [email protected] (J.J. Linmans).
http://dx.doi.org/10.1016/j.pcd.2015.02.001 1751-9918/© 2015 Primary Care Diabetes Europe. Published by Elsevier Ltd. All rights reserved.
Please cite this article in press as: J.J. Linmans, et al., How motivated are patients with type 2 diabetes to change their lifestyle? A survey among patients and healthcare professionals, Prim. Care Diab. (2015), http://dx.doi.org/10.1016/j.pcd.2015.02.001
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shown that patient motivation is a key element for successful self-management [11]. Because of the importance of patient motivation, the level of the motivation should be assessed, for example to be able to target counseling. However, is has been shown that GP’s assess the patients’ readiness to change their lifestyle with low accuracy [12]. Previous research found that patients were generally not motivated to self-manage their diabetes [13]. In addition, a study showed that patients with T2DM follow exercise recommendations only in 34% of the time and follow diet recommendations in 59% [14]. Another study [15] found that obese patients were only slightly motivated to lose weight (6.6 on 10-point scale), but their physicians were even less optimistic (an average 4.7). Research also suggests that the majority of patients with T2DM were not physically active [16] and were not motivated to become active in the next six months [16,17]. The extent to which patients with T2DM in primary care are motivated to change their lifestyle is a crucial factor in diabetes management. However, we could not find any study on the motivation for lifestyle changes in patients with T2DM in primary care and the agreement between patients and health professionals. Therefore, the aim of this study was to investigate the motivation to change lifestyle in patients with T2DM in primary care and to assess whether patients and health professionals had similar motivation estimates. In addition, we investigated the agreement between patients and health professionals for physical activity and for lifestyle topics discussed during the consultations.
2.
Method
2.1.
Procedure
We contacted 10 primary healthcare centers in the southern part of the Netherlands based on our existing research network. Diabetes care in the Netherlands is organized according to a diabetes management program (DMP). Within this DMP, the patient has four consultations every year with a diabetes practice nurse (DPN) supervised by the general practitioner. When necessary, extra consultations can be scheduled. All DPNs were asked to randomly include patients who visited the general practice for a regular diabetes check-up during two successive weeks. To be able to answer our research questions using this observational study, we aimed to included 150 patients. DPNs were provided with coded patients and DPN questionnaire sets. Patients who were willing to participate were asked the fill in a questionnaire after the consultation with the DPN. The DPN was also asked to fill in a questionnaire for each patient after the consultation. Data were collected from December 2013 until June 2014. The Medical Ethical Committee of Maastricht University Medical Centre has approved this study (number: METC 134-093). All patients signed an informed consent form.
Dutch language and were not physically disabled for any reason, could participate.
2.3.
The questionnaire contained several items. The patient was asked to provide information on a number of individual characteristics (e.g. age, gender, how many years of diabetes, weight, length, type of medication, Dutch Standard for Healthy Physical activity (exercising at moderate intensity at least half an hour for five or more days a week: deficient, sufficient, sportive), following a physical activity programs and/or diet program). Regarding lifestyle assessment, we are aware that there are several important aspects of lifestyle. However, for pragmatic purposes, in this study we focused on physical activity and diet. The question about the patients’ motivation for lifestyle change was derived from the motivation to stop scale: one question with seven answer options of motivation to stop smoking with accurate predictive value [18]. We adapted this question for two reasons. First, to be able to implement the question in usual care, it should be as short, practical and as little time consuming as possible. Second, in future practice we would want to be able to tailor care to the level of motivation of the patient. However, to tailor lifestyle management to seven different levels is unfeasible. Therefore, we developed a three level motivation scale. Participants were asked: ‘which of the following describes you best’. The three answer options were: 1—I don’t want to improve my lifestyle (healthier diet and/or improve physical activity), 2—I want to improve my lifestyle (healthier diet and/or improve physical activity), but don’t know when I will, 3—I really want to improve my lifestyle (healthier diet and/or improve physical activity) and I want to start now. For now, we chose to ask whether patients wanted to change their lifestyle in general and decided not to split lifestyle motivation into more questions. We did this because we believe this is, also in real-world care, the most efficient first step. Later, healthcare professionals could explore in more detail what part of lifestyle patients want to change. In addition, we asked the patients whether lifestyle was discussed during the consultation and whether the patient received advice on how to improve their physical activity and/or diet. Biomedical data (blood pressure, BMI, medication usage, cholesterol, kidney function, retinopathy, Dutch Standard for Healthy Physical activity, smoking status, risk of diabetic foot ulcers, abdominal circumference, glucose and HbA1c levels), were derived from the electronic medical records. To be able to investigate the agreement between the patient and the DPN for the level of motivation of the patient, the DPN was asked to answer the single-item motivation question about the patient directly after the consultation. In addition, DPNs were asked whether they discussed lifestyle during the consultation and whether they gave advice on how to improve physical activity and/or diet.
2.4. 2.2.
Measurements
Data analyses
Study population
All patients in primary care with type 2 diabetes who had a regular quarterly consultation with the DPN, who could read
We used descriptive statistics to describe the study population of participants. Agreement was quantified using Cohen’s kappa coefficient. The nesting of patients within practices
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was taken into account in the computation of the agreement standard error by using the method of Yang and Zhou [19]. Because in the Netherlands patients with T2DM with a BMI ≥ 25 are advised to lose weight [20], the agreement between patients and DPN for this subpopulation was analyzed separately. According to Fleiss [21] there is excellent agreement beyond chance when kappa is higher than 0.75, there is reasonable to good agreement when kappa is between 0.40 and 0.75 and poor agreement when kappa is lower than 0.40. The descriptive analyses were conducted using SPSS 21 and the agreement analyses were conducted using the statistical software R.
3.
Results
Twelve DPNs from 10 practices participated in this study and they asked 150 patients to participate. Nine patients were invited to participate, but did not return the questionnaire. Patient characteristics are shown in Table 1. The mean age was 64 years and 64% was male and 36% female. The mean BMI was 29.2 kg/m2 . According to the patients’ perception, the level of their physical activity was deficient in 35% (49 patients) (see Table 2), and deficient in 47% (66 patients) according to the DPNs. Patients were more positive in 28% (18 + 8 + 13 = 39) of the cases compared with 16% (5 + 4 + 14 = 23) of the cases where DPNs were more positive. Agreement for physical activity rating between patient and DPN was seen in 56% (79 cases) and kappa was low (0.32, p < 0.0001). Patients also tended to be more positive about their motivation to change in comparison with DPNs (Table 2). A large group of patients, 43% (61 patients), were not motivated to change according to the DPN, while 29% (41 patients) of the patients reported to be not motivated to change their lifestyle. Patients were in 35% (22 + 16 + 11 = 49) more positive about their motivation to change than DPNs (24%, 8 + 10 + 16 = 34). Only in 41% (58) of the cases, patient and DPN agreed upon the level of motivation. Cohen’s kappa for motivation was very poor (kappa 0.13, p = 0.11). Interestingly, 16 patients said they were really motivated to change their lifestyle immediately, while the DPN stated that these patients were not motivated at all. Similar results were found in the subgroup of patients with a BMI ≥ 25 (Table 3). A large number of patients did not have sufficient exercise (48% according to DPNs and 37% according to patients). For both physical activity and motivation, patients were more positive than DPNs (34% vs. 15% and 39% vs. 23%, respectively). For physical activity, patients and DPNs agreed in 59% (73 cases), with a low kappa of 0.36 (p < 0.0001). Agreement for motivation to change was very poor with a kappa of 0.084 (p = 0.32) and agreement was only observed in 38% (47 cases). Again for this subgroup, 15 patients said to be really motivated for lifestyle change immediately, while the DPN said they were not motivated at all. According to DPNs, 44% was not motivated to change, while patients said in 27% not to be motivated. In a large number of cases (78%, 109 cases) patients and DPNs agreed that physical activity was discussed (Table 4). Also for diet, they agreed in 69% (96 cases) that this was
Table 1 – Patient characteristics. Characteristics
N = 141
Age (years) Years of T2DM Gender Male Female Smoking Weight (kg) Length (cm) BMI (kg/m2 ) Abdominal circumference (cm) Systolic blood pressure (mmHg) Diastolic blood pressure (mmHg) Fasting glucose (capillary) (mmol/l) HbA1c (%) Total cholesterol (mmol/l) LDL cholesterol (mmol/l) HDL cholesterol (mmol/l) Triglycerides (mmol/l) Plasma creatinine (mol/l) Renal function (GFR) under 60 ml/min Microalbuminuria Macroalbuminuria Diabetic retinopathy Risk for foot ulcers (0–3) Oral blood glucose lowering drugs Insulin Antihypertensive drugs Lipid lowering drugs
64.2 (10.5) 7.6 (5.8) 91 (64.5%) 50 (35.5%) 16 (11.3%) 86.7 (17.3) 170.5 (17.3) 29.2 (4.2) 102.6 (14.7) 135.8 (15.2) 78.5 (8.7) 7.9 (6.1) 6.7 (1.0) 4.4 (1.1) 2.3 (0.9) 1.3 (0.4) 1.8 (1.1) 83.5 (19.3) 19 (13.5%) 14 (9.9%) 0 10 (7.1%) 0.4 (0.6) 114 (80.9%) 20 (14.2%) 100 (70.9%) 113 (80.1%)
T2DM, type 2 diabetes mellitus; BMI, body mass index; HbA1c, glycated haemoglobin; LDL, low-density lipoprotein; HDL, highdensity lipoprotein; GFR, glomerular filtration rate. A GFR below 60 ml/min is considered as a diminished renal function. However, can be acceptable depending on age. Microalbuminuria: males 2.5–25 mg albumin/mmol creatinine, females 3.5–35 mg albumin/mmol creatinine. Macroalbuminuria: males >25 mg albumin/mmol creatinine, females >35 mg albumin/mmol creatinine. Risk for foot ulcers according to the SIMM’s classification [20]: diabetic foot risk classification system: 0 = no higher risk; 1 = slightly higher risk, loss of sensibility or signs of peripheral arterial disease; 2 = high risk, a combination of loss of sensibility and/or signs of peripheral arterial disease and/or signs of elevated pressure; 3 = ulcer or amputation in history. Data are presented as means (SD), unless otherwise stated.
discussed. Because kappa is a measure to indicate differences (compared with the agreement based on chance), the relatively low kappa (0.32 and 0.076) can be explained by this homogenous group where both parties answered with ‘yes’ (unbalance in the marginal totals). While patients and DPN agreed on the fact that lifestyle had been discussed during the consultation, Table 5 shows that they did not agree on whether advice had been given. In total, 34% disagreed for advice given about physical activity (kappa 0.32, p < 0.0001) and 44% disagreed for advice given about diet (kappa 0.14, p = 0.0002).
4.
Discussion
4.1.
Summary of main findings
In our study, many patients with T2DM reported that they were physically inactive and were not motivated to change
Please cite this article in press as: J.J. Linmans, et al., How motivated are patients with type 2 diabetes to change their lifestyle? A survey among patients and healthcare professionals, Prim. Care Diab. (2015), http://dx.doi.org/10.1016/j.pcd.2015.02.001
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Table 2 – Agreement between patient and DPN for motivation and physical activity. All patients. Patient (N = 141) Deficient
Sufficient
Sportive
Total (%)
Ä (CI)
p-Value
40 5 4 49 (34.8) No 23 8 10 41 (28.1)
18 31 14 63 (44.7) Maybe 22 17 16 55 (39.0)
8 13 8 29 (20.6) Yes 16 11 18 45 (31.9)
66 (46.8) 49 (34.8) 26 (18.4) 141
0.32 (0.16–0.47)
<0.0001
61 (43.3) 36 (25.5) 44 (31.2) 141
0.13 (−0.027–0.28)
0.11
Physical activity DPN Deficient Sufficient Sportive Total (%) Motivation to change No Maybe Yes Total (%)
Physical activity level: Sufficient: exercising according to the Dutch Standard for Healthy Physical activity (exercising at moderate intensity at least half an hour for five or more days a week). Deficient: exercising less than those with a sufficient level. Sportive: exercising more than those with a sufficient level. The level of motivation for lifestyle change according to three options: No (1), I don’t want to improve my lifestyle (healthier diet and/or improve physical activity), Maybe (2), I want to improve my lifestyle, but don’t know when I will, Yes (3), I really want to improve my lifestyle and I want to start from now on. DPN = diabetes practice nurse.
Table 3 – Agreement between patient and DPN for motivation and physical activity. Patients with a BMI ≥ 25. Patient (N = 124) Deficient Physical activity DPN Deficient Sufficient Sportive Total (%) Motivation to change No Maybe Yes Total (%)
38 4 4 46 (37.1) No 17 8 8 33 (26.6)
Sufficient
Sportive
Total (%)
Ä (CI)
p-Value
15 28 11 54 (43.5) Maybe 22 15 13 50 (40.3)
7 10 7 24 (19.4) Yes 15 11 15 41 (33.1)
60 (48.4) 42 (33.9) 22 (17.7) 124
0.36 (0.20–0.41)
<0.0001
54 (43.5) 34 (27.4) 36 (29.0) 124
0.084 (−0.080–0.25)
0.32
Physical activity level: Sufficient: exercising according to the Dutch Standard for Healthy Physical activity (exercising at moderate intensity at least half an hour for five or more days a week). Deficient: exercising less than those with a sufficient level. Sportive: exercising more than those with a sufficient level. The level of motivation for lifestyle change according to three options: No (1), I don’t want to improve my lifestyle (healthier diet and/or improve physical activity), Maybe (2), I want to improve my lifestyle, but don’t know when I will, Yes (3), I really want to improve my lifestyle and I want to start from now on. DPN = diabetes practice nurse.
Table 4 – Agreement between patient and DPN for discussing physical activity and diet during consultation. Patient (N = 140)
Physical activity DPN No Yes Total (%) Diet No Yes Total (%)
No
Yes
Total (%)
Ä (CI)
p-Value
8 14 22 (15.7)
9 109 118 (84.3)
17 (12.1) 123 (87.9) 140
0.32 (0.16–0.47)
<0.0001
6 17 23 (16.4)
21 96 117 (83.6)
27 (19.3) 113 (80.7) 140
0.076 (−0.080–0.23)
0.34
DPN = diabetes practice nurse.
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Table 5 – Agreement between patient and DPN for giving advice about physical activity and diet during consultation. Patient (N = 140)
Physical activity DPN No Yes Total (%) Diet No Yes Total (%)
Total (%)
Ä (CI)
No
Yes
p-Value
41 15 56 (40.0)
33 51 84 (60.0)
74 (52.9) 66 (47.1) 140
0.32 (0.21–0.44)
<0.0001
34 20 54 (38.6)
41 45 86 (61.4)
75 (53.6) 65 (46.4) 140
0.14 (0.067–0.22)
0.0002
DPN = diabetes practice nurse.
their lifestyle. There was poor agreement between patients and DPNs for the level of physical activity of the patients, and for the motivation of the patients to change their lifestyle. Patients were generally more positive about their level of physical activity compared to DPNs, and they also were more positive about their motivation to change their lifestyle. Patients and DPNs generally agreed that physical activity and diet was discussed during the consultation. However, in general, they did not agree that DPNs gave advice to patients about physical activity and diet.
4.2.
Comparison with existing literature
Sufficient physical activity is an essential part of the management of T2DM. We found however, that 47% of patients with T2DM reported insufficient physical activity. This is in line with previous studies [6,22–24] that found that the level of activity was deficient in 51–82%. Oftedal et al. [23] showed that patients with T2DM believed they had the ability to start exercise and diet management, but less than 10% exercised daily and 25% adhered to their diet daily. In addition, our results showed that patients tended to overestimate their physical activity level compared with DPNs. These results are consistent with previous research [25,26]. Therefore, increasing physical activity in patients with T2DM will still be a challenging task [27,28], especially in overestimators [29]. Motivation is a key element for behavior change. Our results show that 28% of the patients were not motivated to change their lifestyle, but this concerned 43% of the patients according to the DPNs. These results are in agreement with studies that used the stages of change by Prochaska and DiClemente [30] to indicate patients’ readiness to change their behavior. These studies found that among different groups of patients in primary care a large proportion (29–41%) was not motivated (precontemplators) to change their lifestyle [12,22]. In addition, we also found that a large group of patients with a BMI ≥ 25 (27%) were not motivated to change their lifestyle. These people might even benefit most from improving their lifestyle. Several barriers have been identified for lifestyle behavior change. Some of these are: patients do not regard diabetes as a serious disease [31], misperception of the patients’ actual lifestyle behavior [32], decrease in wellbeing [33], asymptomatic disease, increased costs, cultural background [11], patients are satisfied with their behavior [34], frustration from lack of success [35], physical limitations, lack
of time [36] and interference with work [37]. In the end however, without being motivated, acquiring and maintaining a healthy lifestyle will probably be impossible. When healthcare professionals do not know the patients’ motivation or do not agree with patients, they are unable to level to the needs of the patients and provide patient-centered care. Patient-centeredness is associated with increased patient satisfaction and improved health outcomes [13,38]. The results of this study showed that there is little agreement between patients and DPNs. Agreement for motivation for lifestyle change was only seen in 41% of all cases (kappa 0.13). The DAWN-study [39] showed that healthcare professional estimates of success in treatment adherence were much lower than patient estimates of success, especially for lifestyle behaviors (diet and exercise). A study by Befort et al. [15] found that GPs were less optimistic about weight loss than obese patients themselves. Patients reported in 26% to be completely motivated, whereas GPs rated these patients in 3% being completely motivated. Little agreement about the level of motivation may impede good communication and therefore good lifestyle management for patients with T2DM. Besides, management can be targeted at the wrong patients.
4.3.
Limitations
Patients were selected by their own DPNs, which could have resulted in selection bias. However, it is more likely that DPNs selected patients of whom they knew the lifestyle habits and motivation to change. Therefore, if this resulted in selection bias, our results, showing poor agreement, probably tends towards an overestimation of the true agreement. Because questionnaires were filled-in directly after the consultation, we could minimize recall bias as much as possible. Knowing the content of the questionnaire however, may have caused the DPNs to give extra attention to motivation and lifestyle during subsequent consultations. On the other hand, evidence showed that research within real-world medical practice influenced the behavior of healthcare professionals very little during a study [15,40]. Our question to assess motivation was not validated in previous research. We adapted the question from the validated motivation to stop smoking scale [18]. Our question however, is a very pragmatic approach to asses not so much only the motivation to change lifestyle, but rather to assess the agreement between DPNs and patients. Whether the
Please cite this article in press as: J.J. Linmans, et al., How motivated are patients with type 2 diabetes to change their lifestyle? A survey among patients and healthcare professionals, Prim. Care Diab. (2015), http://dx.doi.org/10.1016/j.pcd.2015.02.001
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question we used accurately measures the motivation to change lifestyle could be investigated in future research. Nevertheless, assessing the motivation for lifestyle change in a structural manner is for now not a topic within the DMP and implementing such a question might already be a substantial improvement. We did not measure the actual level of physical activity. Therefore, we cannot clearly proof whether the level of physical activity reported by the patient or by the DPN is correct. Our results show that patients report a higher level than DPNs. Because patients tend to report a higher level of physical activity than the actual measured level [25,26], we believe we can describe that patients tended to overestimate their physical activity level compared with DPN’s. Kappa is a widely used statistical measure to assess the agreement between two raters. However, kappa is sometimes a less practical method; for example, when the distribution of the marginal totals is unbalanced. Therefore, an observed high agreement with a low kappa can be found [41]. We also encountered this problem when calculating the agreement for discussing physical activity and diet during consultation, as we described in Section 3. The marginal totals for the other calculations were more in balance. In this analysis, we chose not to account for the differences of the degree of disagreement (weighted kappa) between different subgroups. For now, we were interested in the level of disagreement between patients and DPNs in general. However, we did account for the nesting of data using the method of Yang and Zhou [19].
4.4.
Implications for clinical practice
To be able to assist the patient with T2DM with the struggle of lifestyle management, healthcare professionals and patients should cooperate at the same level. Not only for the actual behavior of the patient (e.g. physical activity), but also for the motivation to change that behavior. Assessing the motivation of the patients to change their lifestyle in a structural way can assist health professionals to adapt to the needs of the patient. We suggest investigating the possibilities to adopt the motivation question within the everyday lifestyle management for patients with T2DM in usual care.
5.
Conclusion
Patients with T2DM in general practice should increase physical activity toward a sufficient level. Since motivation plays a key role in behavior change, we need pragmatic tools to gain insight into the patients’ motivation to change lifestyle. The question about the motivation for lifestyle change as we proposed in the manuscript is a practically useful tool and may help patients and primary healthcare professionals in such a way that lifestyle management can be targeted and optimized in general practice.
Conflict of interest The authors declare that they have no conflicts of interest.
Acknowledgements The authors would like to thank Dr. S. Vanbelle for her help with the data analyses.
references
[1] N. Boulé, E. Haddad, G. Kenny, G. Wells, R. Sigal, Effects of exercise on glycemic control and body mass in type 2 diabetes mellitus: a meta-analysis of controlled clinical trials, JAMA 286 (10) (2001) 1218–1227. [2] L.M. Delahanty, D.M. Nathan, Implications of the diabetes prevention program and Look AHEAD clinical trials for lifestyle interventions, J. Am. Diet. Assoc. 108 (4 Suppl 1) (2008) S66–S72. [3] D.E. Thomas, E.J. Elliott, G.A. Naughton, Exercise for type 2 diabetes mellitus, Cochrane Database Syst. Rev. 3 (2006) CD002968. [4] C.L. Gillies, K.R. Abrams, P.C. Lambert, N.J. Cooper, A.J. Sutton, R.T. Hsu, et al., Pharmacological and lifestyle interventions to prevent or delay type 2 diabetes in people with impaired glucose tolerance: systematic review and meta-analysis, BMJ 334 (2007) 299. [5] M. Cardona-Morrell, L. Rychetnik, S.L. Morrell, P.T. Espinel, A. Bauman, Reduction of diabetes risk in routine clinical practice: are physical activity and nutrition interventions feasible and are the outcomes from reference trials replicable? A systematic review and meta-analysis, BMC Public Health 10 (2010) 653. [6] J.J. Linmans, W. Viechtbauer, T. Koppenaal, M. Spigt, J.A. Knottnerus, Using electronic medical records analysis to investigate the effectiveness of lifestyle programs in real-world primary care is challenging: a case study in diabetes mellitus, J. Clin. Epidemiol. 65 (7) (2012) 785–792. [7] G. Danaei, M.M. Finucane, Y. Lu, G.M. Singh, M.J. Cowan, C.J. Paciorek, et al., National, regional, and global trends in fasting plasma glucose and diabetes prevalence since 1980: systematic analysis of health examination surveys and epidemiological studies with 370 country-years and 2·7 million participants, Lancet 378 (9785) (2011) 31–40. [8] S. Wild, G. Roglic, A. Green, R. Sicree, H. King, Global prevalence of diabetes. Estimates for the year 2000 and projections for 2030, Diabetes Care 27 (5) (2004) 1047–1053. [9] M.K. Baker, K. Simpson, B. Lloyd, A.E. Bauman, M.A.F. Singh, Behavioral strategies in diabetes prevention programs: a systematic review of randomized controlled trials, Diabetes Res. Clin. Pract. 91 (1) (2010) 1–12. [10] E. Deci, R. Ryan (Eds.), Intrinsic Motivation and Self-Determination in Human Behavior, Plenum, New York, NY, 1985. [11] J.B. Brown, S.B. Harris, S. Webster-Bogaert, S. Wetmore, C. Faulds, M. Stewart, The role of patient, physician and systemic factors in the management of type 2 diabetes mellitus, Fam. Pract. 19 (4) (2002) 344–349. [12] M.W. Verheijden, J.C. Bakx, I.C.G. Delemarre, A.J. Wanders, N.M. van Woudenbergh, B.J. Bottema, et al., GPs’ assessment of patients’ readiness to change diet, activity and smoking, Br. J. Gen. Pract. 55 (2005) 452–457. [13] J. Moran, H. Bekker, G. Latchford, Everyday use of patient-centred, motivational techniques in routine consultations between doctors and patients with diabetes, Patient Educ. Couns. 73 (2008) 224–231. [14] D.J. Toobert, S.E. Hampson, R.E. Glasgow, The summary of diabetes self-care activities measure: results from 7 studies and a revised scale, Diabetes Care 23 (2000) 943–950.
Please cite this article in press as: J.J. Linmans, et al., How motivated are patients with type 2 diabetes to change their lifestyle? A survey among patients and healthcare professionals, Prim. Care Diab. (2015), http://dx.doi.org/10.1016/j.pcd.2015.02.001
PCD-452; No. of Pages 7
ARTICLE IN PRESS p r i m a r y c a r e d i a b e t e s x x x ( 2 0 1 5 ) xxx–xxx
[15] C.A. Befort, K.A. Greiner, S. Hall, K.M. Pulvers, N.L. Nollen, A. Charbonneau, et al., Weight-related perceptions among patients and physicians: how well do physicians judge patients’ motivation to lose weight, J. Gen. Intern. Med. 21 (2006) 1086–1090. [16] A.F. Kirk, N. Mutrie, P.D. Macintyre, M.B. Fisher, Promoting and maintaining physical activity in people with type 2 diabetes, Am. J. Prev. Med. 27 (2004) 289–296. [17] E. Centis, M. Trento, A. Dei Cas, A.E. Pontiroli, P. De Feo, A. Bruno, et al., Stage of change and motivation to healthy diet and habitual physical activity in type 2 diabetes, Acta Diabetol. 51 (2014) 559–566. [18] D. Kotz, J. Brown, R. West, Predictive validity of the motivation to stop scale (MTSS): a single-item measure of motivation to stop smoking, Drug Alcohol Depend 128 (2013) 15–19. [19] Z. Yang, M. Zhou, Kappa statistic for clustered matched-pair data, Stat Med 33 (2014) 2612–2633. [20] G. Rutten, W. De Grauw, G. Nijpels, S. Houweling, F. Van de Laar, H. Bilo, et al., NHG-Standaard diabetes mellitus type 2 (derde herziening), Huisarts Wet 56 (10) (2013) 512–525. [21] J. Fleiss, Statistical Methods for Rates and Proportions, Wiley, New York, NY, 1981. [22] G. Grandes, A. Sánchez, J. Torcal, R.O. Sánchez-Pinilla, K. Lizarraga, J. Serra, Targeting physical activity promotion in general practice: characteristics of inactive patients and willingness to change, BMC Public Health 8 (2008) 172. [23] B. Oftedal, E. Bru, B. Karlsen, Motivation for diet and exercise management among adults with type 2 diabetes, Scand. J. Caring Sci. 25 (2011) 735–744. [24] K. Vähäsarja, S. Salmela, J. Villberg, P. Rintala, M. Vanhala, T. Saaristo, et al., Perceived need to increase physical activity levels among adults at high risk of type 2 diabetes: a cross-sectional analysis within a community-based diabetes prevention project FIN-D2D, BMC Public Health 12 (2012) 514. [25] L. Lechner, C. Bolman, M. Van Dijke, Factors related to misperception of physical activity in The Netherlands and implications for health promotion programmes, Health Promot. Int. 21 (2006) 104–112. [26] G. Ronda, P. Van Assema, J. Brug, Stages of change, psychological factors and awareness of physical activity levels in The Netherlands, Health Promot. Int. 16 (2001) 305–314. [27] D. Simons-Morton, S. Blair, A. King, T. Morgan, W. Applegate, M. O’Toole, Effects of physical activity counseling in primary care: the Activity Counseling Trial: a randomized controlled trial, JAMA 286 (6) (2001) 677–687. [28] N.H. Williams, M. Hendry, B. France, R. Lewis, C. Wilkinson, Effectiveness of exercise-referral schemes to promote physical activity in adults: systematic review, Br. J. Gen. Pract. 57 (545) (2007) 979–986.
7
[29] E.M. van Sluijs, S.J. Griffin, M.N. van Poppel, A cross-sectional study of awareness of physical activity: associations with personal, behavioral and psychosocial factors, Int. J. Behav. Nutr. Phys. Act. 4 (2007) 53. [30] J.O. Prochaska, C.C. DiClemente, Stages and processes of self-change of smoking: toward an integrative model of change, J. Consult. Clin. Psychol. 51 (3) (1983) 390–395. [31] M. Clark, S.E. Hampson, Comparison of patients’ and healthcare professionals’ beliefs about and attitudes towards type 2 diabetes, Diabet. Med. 20 (2003) 152–154. [32] R. Jansink, J. Braspenning, E. Keizer, T. van der Weijden, G. Elwyn, R. Grol, Misperception of patients with type 2 diabetes about diet and physical activity, and its effects on readiness to change, J. Diabetes 4 (2012) 417–423. [33] M. Wermeling, U. Thiele-Manjali, J. Koschack, G. Lucius-Hoene, W. Himmel, Type 2 diabetes patients’ perspectives on lifestyle counselling and weight management in general practice: a qualitative study, BMC Fam. Pract. 15 (2014) 97. [34] P.W. Vermunt, I.E. Milder, F. Wielaard, C.A. Baan, J.D. Schelfhout, G.P. Westert, et al., Behavior change in a lifestyle intervention for type 2 diabetes prevention in Dutch primary care: opportunities for intervention content, BMC Fam. Pract. 14 (2013) 78. [35] J. Nagelkerk, K. Reick, L. Meengs, Perceived barriers and effective strategies to diabetes self-management, J. Adv. Nurs. 54 (2006) 151–158. [36] G.R. Dutton, J. Johnson, D. Whitehead, J.S. Bodenlos, P.J. Brantley, Barriers to physical activity among predominantly low-income African-American patients with type 2 diabetes, Diabetes Care 28 (2005) 1209–1210. [37] E. Hansen, B.J. Landstad, O. Hellzén, S. Svebak, Motivation for lifestyle changes to improve health in people with impaired glucose tolerance, Scand. J. Caring Sci. 25 (2011) 484–490. [38] M. Stewart, J.B. Brown, A. Donner, I.R. McWhinney, J. Oates, W.W. Weston, et al., The impact of patient-centered care on outcomes, J. Fam. Pract. 49 (2000) 796–804. [39] M. Peyrot, R.R. Rubin, T. Lauritzen, F.J. Snoek, D.R. Matthews, S.E. Skovlund, Psychosocial problems and barriers to improved diabetes management: results of the Cross-National Diabetes Attitudes, Wishes and Needs (DAWN) Study, Diabet. Med. 22 (2005) 1379–1385. [40] E.F. Ellerbeck, W.S. Choi, K. McCarter, D.G. Jolicoeur, A. Greiner, J.S. Ahluwalia, Impact of patient characteristics on physician’s smoking cessation strategies, Prev. Med. 36 (2003) 464–470. [41] A.R. Feinstein, D.V. Cicchetti, High agreement but low kappa: I. The problems of two paradoxes, J. Clin. Epidemiol. 43 (1990) 543–549.
Please cite this article in press as: J.J. Linmans, et al., How motivated are patients with type 2 diabetes to change their lifestyle? A survey among patients and healthcare professionals, Prim. Care Diab. (2015), http://dx.doi.org/10.1016/j.pcd.2015.02.001