Prevention of T2DM: Supporting lifestyle behaviour change
This page describes evidence-based methods for promoting change in lifestyle behaviour. The focus is on promoting changes in diet and physical activity, which are the key behavioural targets for preventing progression to type 2 diabetes.
Fig.1: A meta-analysis of 23 ‘real world’ diabetes prevention programmes demonstrates the wide variation in success in promoting weight loss through behaviour change. Changes in diet and physical activity are central to non-pharmacological efforts to prevent type 2 diabetes. The primary driver of the diabetes prevention effect seems to be via weight loss. However, programmes that aim to achieve weight loss through lifestyle behaviour change get very mixed results (Fig.1), so how can we invest our (usually scarce) resources wisely to maximise the likelihood of success?
A strategy for supporting behaviour change
Evidence from systematic reviews of interventions to change diet and/or physical activity and widespread consultation with experts in the field has informed recommendations for the optimal content of diabetes prevention programmes. These can be summarised as follows:
- Provide specially designed and quality-assured intensive lifestyle-change programmes for groups of 10–15 people at high risk of developing type 2 diabetes.
- Aim to promote changes in both diet and physical activity.
- Use established, well defined behaviour change techniques.
- Engage social support (involve a family member, friend or carer who can offer informational, emotional, or practical support to help them make the necessary changes).
- Build on a coherent set of ‘self-regulatory’ intervention techniques (specific goal setting; prompting self-monitoring; providing feedback on performance; problem-solving; review of behavioural goals).
- Ensure programmes adopt a person-centred, empathy-building approach.
- Maximize frequency or number of contacts.
- Provide information to raise awareness of the benefits of and types of lifestyle changes needed to achieve and maintain a healthy weight, building on what participants already know.
- Explore and reinforce importance and confidence, using techniques like graded goal-setting and problem-solving to build confidence over time.
- Provide at least 16 hours of contact time in total.
- Allow time between sessions, spreading them over a period of 9-18 months (support people to learn from their experiences).
- Ensure programme components are delivered in a logical progression. For example: first explore and establish individual motivations to change; then action planning; then self-monitoring and self-regulation.
Fig.2: The Process Model for Lifestyle Behaviour Change  These recommendations on intervention content can be further synthesised into a set of processes for supporting lifestyle behaviour change (Fig.2).
The first step on the journey of behaviour change is to establish a clear and strong motivation for change. As reasons for change vary from person to person, this process needs to be individually tailored. Even when people seem to be motivated at the outset, it can be useful to spend time exploring and consolidating their motivation to make the reasons for change explicit. This is what will keep them going when they face challenges, so the more salient and accessible you can make these motives, the better. Motivation requires the patient to be able to see a) what the benefits of making a change might be (how would you feel if you were able to lose 10 kg over the next few years? What would your life be like if you were to gain 10 kg?) and b) to feel confident that change is possible - if the journey seems futile, people will be reluctant to set off and trying to ‘persuade them’ or talk about what actions they ‘need to’ do will only generate resistance. To build confidence, you can try to identify barriers and break down the problem into more manageable steps.
The second step is to decide what to change. This requires good, reliable knowledge, such as what is a healthy diet, or what counts as ‘moderate intensity’ physical activity. We should also encourage people to plan and make changes that are enjoyable, rewarding and easily managed as part of the person’s daily or weekly routines. This type of change is much more likely to be sustained than changes which cause discomfort or embarrassment or that are difficult to integrate with the individual’s existing lifestyle. It can also be helpful at the planning stage to try to pre-empt any problems that might occur and think about how to stop this happening (making a ‘coping plan’).
The third phase (Maintenance) is essentially a process of ‘learning from experience’ – this often requires several rounds of trial and error and patients may need to be supported through this process over time – for instance it usually takes 6 or 7 attempts before succeeding in stopping smoking. Once again, problem-solving /addressing barriers to change is a key process here.
Putting it into practice: Designing programmes to support behaviour change
The process model above can be translated into practical interventions by identifying specific behaviour change techniques and strategies to support each process (Fig.3). Information about such techniques and strategies is available in published taxonomies of behaviour change and literature on behaviour change interventions. For instance, there is clear evidence that people who monitor their weight or their physical activity are more successful at making and sustaining changes in diet and physical activity. Daily self-weighing may be more powerful than weekly self-weighing . However, it should be noted that the way that interventions are delivered is just as important as their content – the use of a “person-centred, empathy-building approach”  is particularly important at the motivation stage. Patients will only make changes if they decide that it is something that they want to do – we cannot tell them how to live their lives, or control their behaviour once they have left the consultation room!
- A current hot topic in health psychology is that impulsive and affective (enjoyment related or ‘hedonic’) processes that are not consciously mediated may be as important as rationale (conscious reasoning) processes in mediating behaviour change and maintenance. People will not maintain a lifestyle change unless they are happy with their new lifestyle - if they do not enjoy the physical activity they have started or the new diet they have embarked on, they will not keep it up for long. In relation to eating behaviour, 'food-cravings' can also be powerful mediators of eating behaviour. Many food choices are made automatically, with little conscious involvement and it is easy to opt for a short term pleasure instead of taking the healthy option which will benefit you some time in the distant future – the “instant gratification syndrome”.
Health psychologists are developing and evaluating behaviour change techniques to help overcome unhealthy impulses, but in the meantime, it may be helpful to a) encourage people to "make changes you can live with" (lots of small changes, rather than dramatic changes to diet or activity and b) use existing techniques such as mindfulness techniques or cognitive behavioural therapy to identify ‘danger zones’ (situations that lead to unhealthy eating) and find strategies to counteract them (such as distraction, bringing the decision into conscious awareness, using positive self-talk or relaxation or ‘urge-surfing’ techniques).
Research into maintenance of weight loss (and of change in diet and physical activity) is increasing. Although it has been suggested that there is some “legacy effect” in terms of diabetes prevention for people who lose weight sufficiently to change their glycaemic status , the long term risk reduction (and subsequent economic benefits) will depend on the degree to which weight loss can be sustained. On average, people who lose weight regain the weight lost within 3-5 years. Maintenance of weight loss is associated with higher levels of physical activity, eating a lower-calorie and lower-fat diet, having a regular pattern of eating, self-monitoring of weight and having a medical trigger for weight loss (such as a diagnosis of pre-diabetes). However, the optimal mix of intervention techniques and contact frequency to support maintenance of lifestyle behaviours has yet to be determined.
The use of digital media (smart phones, computers, wearable technology) for supporting behaviour change is another hot topic. Wearable technology, such as wristbands, pedometers and GPS trackers, may have great potential to support processes like self-monitoring of weight and physical activity. Emails and text messaging can help to provide prompts and reminders and social media /online social interactions may help to support education and motivation. However, the evidence base is still mixed and some processes, such as individually tailored engagement and motivation may be more difficult to implement in pre-programmed formats. The best way to use digital media is yet to be determined, but in my view there is great potential for such technology to supplement and reinforce human interactions to optimise the support of behaviour change.
^ National Institute for Health and Clinical Excellence. Preventing type 2 diabetes: Risk identification and interventions for individuals at high risk. National Institute for Health and Clinical Excellence, London, 2012
^ Paulweber B, Valensi P, Lindström J, et al. A European Evidence-Based Guideline for the Prevention of Type 2 Diabetes. Hormone and Metabolic Research 2010; 42:S3-S36 doi: 10.1055/s-0029-1240928.
^ Dunkley A, Bodicoat D, Greaves CJ, et al. Effectiveness of real-world diabetes prevention studies: A meta-analytic systematic review and meta-regression. Diabetes Care 2014; in Press.
^ Greaves CJ, Sheppard KE, Abraham C, et al. Systematic review of reviews of intervention components associated with increased effectiveness in dietary and physical activity interventions. BMC Public Health 2011;11(119):1-12 doi: 10.1186/1471-2458-11-119.
^ Michie S, Ashford S, Sniehotta FF, Dombrowski SU, Bishop A, French DP. A refined taxonomy of behaviour change techniques to help people change their physical activity and healthy eating behaviours: The CALO-RE taxonomy. Psychology & Health 2011; 26(11):1479-98.
^ Greaves CJ. Supporting behaviour change in general practice. In: Barnard K, Lloyd CE, eds. Practical Psychology in Diabetes Care. London: Springer-Verlag, 2012.
^ Stathi A, Fox KR, Withall J, Bentley G, Thompson JL. Promoting physical activity in older adults: A guide for local decision makers. Bath: University of Bath, 2013.
^ Gillison FB, Greaves CJ, Stathi A, et al. "Waste the Waist": The development of an intervention to promote changes in diet and physical activity for people with high cardiovascular risk. Brit J Health Psychol 2012;17(2):327-45 doi: 10.1111/j.2044-8287.2011.02040.x.
^ The Diabetes Prevention Programme Research Group. Diabetes Prevention Programme DPP Lifestyle Materials. Secondary Diabetes Prevention Programme DPP Lifestyle Materials 1996. http://www.bsc.gwu.edu/dpp/lifestyle/dpp_part.html .
^ Miller WR, Rollnick S. Motivational interviewing: Preparing people for change (2nd ed). New York: Guildford Press, 2002.
^ Linde JA, Jeffery RW, French SA, Pronk NP, Boyle RG. Self-weighing in weight gain prevention and weight loss trials. Ann f Behavioral Med 2005;30(3):210-16
^ Perreault L, Pan Q, Mather KJ, Watson KE, Hamman RF, Kahn SE. Effect of regression from prediabetes to normal glucose regulation on long-term reduction in diabetes risk: results from the Diabetes Prevention Program Outcomes Study. The Lancet 2012; 379(9833):2243-51 doi: 10.1016/S0140-6736(12)60525-X.
^ Wing RR, Phelan S. Long-term weight loss maintenance. The Am J Clin Nutr 2005;82(1):222S-25S.