“Everyone thinks that type 2 diabetes is the responsibility of someone else.
“In primary care it’s treated as a progressive incurable condition. We give meds because we work on guidelines and we can see results quickly but this is coming at a cost to the NHS."
These were the words of Dr Peter Foley, NHS General Practitioner and Medical Officer for Diabetes Digital Media, when he spoke at an Educational Conference on Food, Nutrition and Health, hosted by medical student society Nutritank, at the Royal Society of Medicine in London, on Saturday (March 7th).
He explained the mammoth issue caused by this preventable disease.
“Every area is gradually spending more and more and the annual cost to the NHS for medication for diabetes alone costs around £1bn a year - with type 1 making up about 10% of that.
“As a GP it is well worth my while having a discussion with my patients about diet because of the huge difference it can make to their outcome.”
While the government advice tends to circle around low carb and keto diets, Dr Foley points out that following a ‘lower’ carb diet could be just as effective as the more extreme diets simply because the patient will be more likely to stick to it.
He added that it’s important to take into account that there is much more to diet than simply the food a person puts in their mouth – it’s the outcome of their psychological programming which has been influenced by family, friends, society, the food industry, and much more.
So as not to become patronising, Dr Foley says it's important to avoid phrases such as ‘I’m a professional’, ‘I know what I’m talking about’, ‘listen to me’, ‘I know what you need to do’.
“I used to use terms like that and my patients would stop listening. Patient choice is the key to sustained change and continuous lifestyle change so they have to be open and willing to make the changes you advise.”
He doesn’t use phrases such as ‘good food’ or ‘bad food’, nor does he use the words ‘diet’ or ‘restriction’ as these all make the new eating patterns sound difficult and prohibitive. What's more, he never implies the disease if the patient's fault as this will cause them to switch off from any following advice.
“I will explain that these are the cards they’ve been dealt but we can improve this and we can do it together.”
Dr Foley asks his patients to check blood sugar levels before and after every meal. He asks them to continue their usual diet for one week while doing this, then try new foods the second week, then see how the results change.
He'll then discuss with them which foods gave the best and worst readings.
“This means there’s no need to count calories or feel deprived. You make the diet simple and you give the person hope.”
He also follows the GRIN model for positive lifestyle change – goals, resources, increments, noticing – which revolves around making big change through small steps.
“If we eat three meals a day, that’s 84 meals a month. We don’t try to change all 84 in one go.”
Giving the patient hope
Professor Trevor Thompson, professor of primary care education at the University of Bristol, also spoke at the conference to give his advice on the subject.
During his talk he called a patient of his who was diagnosed with type 2 diabetes in 2016 and is now off medication.
The patient explained to the room how he was given hope by the idea that diet could help him fight the disease.
“When a patient comes to see to see a doctor they put their trust in the doctor straight away. When the doctor says to the patient ‘this is something you will have for the rest of your life’, that’s what you accept. But if the doctor says ‘try this diet and see how that affects your body’ that will give them hope and a driver to try to get rid of it’.”
Prof Thompson says he doesn’t like to use the word ‘lifestyle’ as this sounds like a choice when he knows many people are the victims of the food industry and the beliefs they’ve developed through their life.
The 'lifestyle' discussion
He explains that he likes to inform the patient what the ordinary path would be – to prescribe insulin - but asks if they’d like to discuss how they can try and avoid this.
His lifestyle discussion will then follow a structure: Opening, scanning, focusing, motivating, planning, closing.
Opening: Start the discussion with a very open question such as ‘Tell me how you look after your health’. This allows the patient to discuss anything, from diet, to exercise, to meditation.
Scanning: Encourage them to discuss other aspects they haven’t touch upon, whether that be their alcohol consumption of otherwise.
Focusing: Ask the patient if there’s one area they think they would like to focus on improving.
Motivating: Ask why this is particularly important to them. This might lead them to mention something such as being able to play football with their grandchild or feeling confident in the dress they plan to wear to a wedding. This is an important one to come back to, to point out that they might be able to achieve these goals if they make small changes.
Planning: Encourage the patient to pinpoint one thing they could do to achieve this goal.
Closing: A summary of the aims and the motivations and a rehearsal of how they’ll do this.
He adds that its important to remember the ‘OARS’ listening skills: open questions, affirmations, reflections and summary.
Affirmations are simple repetitions of what the patient has said and reflections are repetitions but with a change in wording.
Prof Thompson explains that the patient will use ‘change talk’ when they want to change this behaviour or ‘sustain talk’ when they do not want to change.
“It’s important to strongly affirm the ‘change talk’ and reflect back to them in a positive way.
“When they are in ‘sustained talk’ you can reflect back what they’ve said but suggest they might be interested in taking action.
“You might say ‘I hear that you’re saying this makes you happy but I sense that this is something you would like to be able to live without’.”
He said that the OARS technique is all about encouraging the patient to make realisations for themselves.
“Avoid the reflex reaction to tell them to stop doing something or to tell them that’s clearly the route of their problem. Use your OARS to reveal to them the route of the problem.”
Giving advice
When giving advice, Prof Thompson uses the ‘check, chunk, check’, method.
“Check, is it OK if I share some of my previously experience that might help you?’
“Chunk the information into small and appropriately sized bits of information and check they understand after each chunk of information.
“As a final check, rather than asking ‘do you understand’, ask them ‘how did I do at explaining that?’ This puts the emphasis on me as to whether I’ve done my job, rather than the emphasis on them needing to understand the information.”
Ultimately, Prof Thompson says it's all about guiding the patient to realise their motivations for themselves or any advice will fall on deaf ears.
“Often, as doctors, we can have a lifestyle conversation with a patient and not much happens. That’s OK. The important thing is to try.”