PhD Study : Assessing and addressing behaviour change barriers in the prevention of Type 2 Diabetes, using Low Intensity CBT

Summary

This scholarship is linked to the Northern Ireland Programme for Government.

Background: National and governmental policy suggests that there is a responsibility to address the already recognised Diabetes epidemic. The epidemic  predictions are that by 2030, there may be up to 439 million people globally with Type 2 Diabetes, with the predicted future figure of Pre-Diabetes being 472 million by 2030 (IDF) Atlas, as cited in  Uusitupa et al, (2011). Therefore, it is clear that there is an immediate and pro-active need to try to prevent Type 2 Diabetes, by way of active and effective intervention. Gillies et al., (2007) claims that there is strong evidence to suggest that 80-90% of all cases of Type 2 Diabetes could be prevented through lifestyle behaviour change, where it has been observed that Lifestyle interventions can reduce the risk of Type 2 Diabetes by 40-60% (Gillies et al. BMJ 2007).

With this evidence, the prevention of type 2 diabetes is a globally recognised health care priority, and there has been many diabetes prevention programmes (DPP)  delivered in many countries (The Diabetes Prevention Program Research Group, 2002, 2009; Lindström et al., 2005; Tuomilehto et al., 2001; Ramachandran et al., 2006; Toft et al., 2008) . The most ground-breaking of these DPP’s were able to show a significant effect in reversing the risk of developing Type 2 Diabetes by 58% (Lindström , Louheranta, Mannelin, et al; The Finnish Diabetes Prevention Study (DPS), 2003), with similar results in other DPP’s (take action to prevent type 2 Diabetes) in Europe (Lindström et al., 2005).  Europe and other international countries appear to be well ahead of UK, Ireland and Northern Ireland, but these DPP’s continue to have room for improvement.

The most recent paper published by Tuomilehto, Schwarz, Lindström,  (2011), highlights the need  again to stop the pattern of the Diabetes epidemic and suggest that this can only be done via evidence based recommendations on the prevention of Type 2 Diabetes. They further recommend the need to identify and use people who have been trained in lifestyle management, diet, physical activity, and psychosocial issues within health sector organisations. Their final recommendation suggests that research focusing on the prevention of Type 2 Diabetes ‘must be expanded’. They inform us about the pros and areas of development still needed, and state that the trials documented thus far have provided a good basis, but it seems that there is more do to source the most efficacious methods of prevention Type 2 Diabetes, particularly in various societies and cultural settings. Tuomilehto et al (2011) also refer to the need for a more “personalized medicine” approach to Type 2 Diabetes prevention, in particular implementing these in real life settings. Existing UK Diabetes Prevention Programmes (DPPs) The only two know DPP’`s in the United Kingdom, which are currently being trialled are ‘Walking away from Diabetes’, which has been trialled and transferred into a primary care setting (Yates et al., 2012). Initial findings indicate that this programme is demonstrating good efficacy in being able to reduce BMI and Diabetes risk scores based on the ‘Leicester Risk indicator’ (Goldby et al, 2011).

Whilst initial outcomes appear positive in reducing Diabetes Risk, the full outcome is not fully known, as the programme is still currently running. The second trial underway is called ‘Lets Prevent Diabetes’ by Gray , Khunti, William, Goldby,  Troughton , Yates,  Gray , Davies (2012). This trial aims to reduce diabetes risk further by combining diet and exercise/ healthy lifestyles, into routine primary care in the UK. This team of researchers also adapted the previous DPP ‘Walking away from Diabetes’ by adding in both dietary advice and motivational maintenance via offering telephone support. This trial is ongoing, and the full outcomes have yet to be released. Nevertheless, Desmond has approved the programme and has endorsing health care providers to use this model.

As these two DPPs are awaiting their full outcomes to be reported, some initial reports again (as Tuomilehto et al., 2011 highlighted) that a ‘personalised medicine’ approach may still be required, in addition to ensuring that clients feel a sense of ongoing engagement with maintaining a healthy lifestyle, long after active intervention ceases. Furthermore, the active identification and simultaneous address of psychological barriers (such as depression and binge eating) has not been incorporated into either of the above two trials. Psychological barriers such as depression have been well established to be associated with the maintenance of obesity (Byrne, Cooper & Fairburn, 2003; Klem, Wing, Mc Guire, Seagle & Hill, 1997; Wing & Hill, 2001).

Evidence associated with obesity management research relates strongly to Diabetes prevention, as Uusitupa, Tuomilehto and Puska (2011) clearly state that the prevention of Type 2 Diabetes is closely associated with the prevention of obesity. Potential negative psychosocial and behavioural factors may also interfere with the prevention of Type 2 Diabetes  as  some DPP studies (highlighted above) explain that there were a number of unreported people who dropped out of the trials, where the reason was not fully determined (Greaves, Redd,& Sheppard, 2010). However, the authors suggest that more emotional support may have been needed and not given. Furthermore, Lindström et al., (2006) reported that after 7 years, the incident rate of Diabetes negatively reduced from some 60% to 36%. Therefore, 64% overall continued to go on to develop Type 2 Diabetes after 7years. Lindström et al., (2006) concluded that, although this was not necessarily considered to be a negative finding, further research was needed regarding the intensity and duration of these interventions for people with Pre- Diabetes.

Currently, in Northern Ireland (and to our knowledge Republic of Ireland) there are no DPPs operating in primary or community level care, despite government targets listing the prevention of diabetes risk as a priority. Such government policies relating to tackling obesity are already reported in the literature, such as the Department of Health (2008) paper, ‘Tackling Obesities: Future Choices –Obesogenic Environments’. This government paper suggests that policy needs to focus on interventions targeting behaviour change ‘across the life course’, with attention being given to the psychologically driven behaviours relating to food and physical activity. Hence, those with Pre-Diabetes may need to be screened and treated for the incidence of depression, anxiety, emotional overeating, low self-efficacy, as part of routine screening within a Diabetes Prevention Programme (DPP). Furthermore, in terms of treatment planning and design, theoretical models, such as the Health Action Process Approach HAPA model (Schwarzer, Lippke & Luszczynska, 2011), could be used to assist in the design of Diabetes Prevention Programs (DPP’S) (Tuomilehto et al., 2001), incorporating specific treatments for such adverse psychosocial characteristics, evidenced within those with Pre-Diabetes.

Rationale: The current PhD proposal therefore wishes to not only assess for psychosocial barriers to lifestyle behaviour change in the context of diabetes prevention, but also attempt to pilot an intervention which offers low intensity CBT, delivered by local community based Psychological Wellbeing Practitioners (PWP’s) to people with a diagnosis of Pre-Diabetes or Impaired Glucose Tolerance. PWP are trained to offer a co-produced, collaborative, tailored and personalised medicine approach, using low intensity Cognitive Behaviour Therapy approaches, such as motivational interviewing, behaviour activation for depressive symptoms, cognitive restructuring for low self-efficacy and low motivation, in addition to problem solving, dealing with worry and offering general emotional support.  PWP’s also strongly endorse healthy eating and exercise for not on health but also mental health change. They use a collaborative approach and engage other community supports as necessary, and will utilise social prescribing to enable long lasting change, even when the trail intervention period has ended.

Furthermore, implementing this at the community level, rather than in primary care services may also be required to allow for ongoing support for hard to reach areas / groups. PWP’s also adopt the COM-B model  (which stands for commitment, opportunity, motivation and barriers) in their day to day practice, whereby those who, for whatever reason, cannot commit to healthy lifestyle due to psychological barriers, may need to address such barriers before the above can have a chance to work. Therefore, the intention is to intervene with the negative psychological barriers in order to support positive health behaviour change. This would fit well within a HAPA theoretical framework for intervention design.

Research methods

1-Cross sectional survey: Assessing for psychosocial correlates in people with Pre-Diabetes as potential barriers to lifestyle change

2-A systematic review of psychological interventions used to support behaviour change within a chronic illness prevention contexts or specifically Pre-Diabetes.

3-A pilot diabetes prevention intervention offering a novel implementation of referring all participants with Pre-Diabetes to Psychological Wellbeing Practitioner.

Outcome aims are to reduce diabetes risk scores to normal levels. Measures: Screening for Pre-Diabetes or Impaired Glucose Tolerance Finnish Diabetes type 2 risk assessment (Lindström & Tuomilehto, 2003). The Finnish Type 2 Diabetes Risk Assessment Form developed in 2001 is an example of an effective patient questionnaire and should be used as the basis for developing national questionnaires which take into account local factors. It has eight scored questions, with the total test score providing a measure of the probability of developing type 2 diabetes over the following 10 years. HBa1c: HBA1C refers to glycated haemoglobin, which develops when haemoglobin joins with glucose in the blood. Measuring HBA1C gives an indication of blood sugar levels over a period. (American Diabetes Association, 2014).

According to NHS ‘UK expert group has recommended that an HbA1c level of 6-6.4% (42-47 mmol/mol) would indicate that a person has a high risk of developing diabetes’; http://www.nhs.uk/Conditions/Diabetes-type2/Pages/Diagnosis.aspx Activity Measure: GENEActiv GENEActiv is a wrist-worn accelerometer suitable for both clinical trial and free-living applications. The device provides raw data on acceleration, physical activity intensity, and sleep/wake movements, making it suitable for data collection in a clinical setting (Pavey et al., 2014; Dillon et al., 2015). Body Mass Index PHQ-9 Measure of Depression  (Kroenke , Spitzer, Williams, Monahan, Löwe , 2007) GAD-7 Measure of Anxiety  (Spitzer,  Kroenke, Williams , et al, 2006). Binge Eating Scale (Gormally et al., 1982)

References:

American Diabetes Association (2014). Standards of medical care in diabetes – 2014. Diabetes Care, 37, S14-S80.

Cohen, J. (1988). Statistical power analysis for the behavioral sciences (2nd edition).

Hillsdale, NJ: Erlbaum. Dillon, C., Powell, C, Dowd, K., & Donnelly, A. E. (2015). Criterion validity and calibratiomn fo the GENEActiv accelerometer in adults. International Conference on ambulatory monitoring of Physical Activity and Movement, Limerick, Ireland.

Faul, F., Erdfelder, E., Lang, A. G., & Buchner, A. (2007). G* Power 3: A flexible statistical power analysis program for the social, behavioral, and biomedical sciences. Behavior research methods, 39(2), 175-191.

Gillies et al (2007). Pharmacological and lifestyle intervention to prevent or delay type 2 diabetes in people with Impaired Glucose Tolerance: systematic review and meta-analysis, BMJ, 334: 299; 6)

Goldby, S., Gray L . G, ,Khunti, K., Williams, S., Sheppard, D., Taub, N.,  Yates,T ,  Davies, M.J. (2011). Using the Leicester practice risk score to identify people with diabetes and impaired glucose regulation. Poster Presentation - Diabetes UK

Gormally, J.,  Black, S.,  Daston, S.,  Rardin, D. (1982). The assessment of binge eating severity among obese persons. Addictive Behaviors, Volume 7, Issue 1, 1982, Pages 47–55

Greaves et al (2011). Systematic review of reviews of intervention components associated with increased effectiveness in dietary and physical activity interventions, BMC Public Health 2011, 11: 119;

Gray L.J, Khunti K, William S, Goldby S, Troughton J, Yates T, Gray A, Davies MJ (2012). Let's Prevent Diabetes: study protocol for a cluster randomised controlled trial of an educational intervention in a multi-ethnic UK population with screen detected impaired glucose regulation. Cardiovascular Diabetology, 11:56

Essential criteria

Applicants should hold, or expect to obtain, a First or Upper Second Class Honours Degree in a subject relevant to the proposed area of study.

We may also consider applications from those who hold equivalent qualifications, for example, a Lower Second Class Honours Degree plus a Master’s Degree with Distinction.

In exceptional circumstances, the University may consider a portfolio of evidence from applicants who have appropriate professional experience which is equivalent to the learning outcomes of an Honours degree in lieu of academic qualifications.

Desirable Criteria

If the University receives a large number of applicants for the project, the following desirable criteria may be applied to shortlist applicants for interview.

• First Class Honours (1st) Degree
• Masters at 70%
• Research project completion within taught Masters degree or MRES
• Experience using research methods or other approaches relevant to the subject domain
• Publications record appropriate to career stage

Funding and eligibility

The University offers the following levels of support:

Department for the Economy (DFE)

The scholarship will cover tuition fees at the Home rate and a maintenance allowance of £19,000 (tbc) per annum for three years (subject to satisfactory academic performance).

This scholarship also comes with £900 per annum for three years as a research training support grant (RTSG) allocation to help support the PhD researcher.

• Candidates with pre-settled or settled status under the EU Settlement Scheme, who also satisfy a three year residency requirement in the UK prior to the start of the course for which a Studentship is held MAY receive a Studentship covering fees and maintenance.
• Republic of Ireland (ROI) nationals who satisfy three years’ residency in the UK prior to the start of the course MAY receive a Studentship covering fees and maintenance (ROI nationals don’t need to have pre-settled or settled status under the EU Settlement Scheme to qualify).
• Other non-ROI EU applicants are ‘International’ are not eligible for this source of funding.
• Applicants who already hold a doctoral degree or who have been registered on a programme of research leading to the award of a doctoral degree on a full-time basis for more than one year (or part-time equivalent) are NOT eligible to apply for an award.

Due consideration should be given to financing your studies. Further information on cost of living