Helping patients achieve type 2 diabetes remission

By Sharon Hills, Practice Nurse, St Kilda Medical Group 

Source: APNA Primary Times Summer 2022-23 (Volume 22, Issue 2)


Primary health care nurses can play an important role in supporting patients with type 2 diabetes (T2D) to achieve remission. Patient-centred care, including active listening, allows nurses to build rapport with patients and to engage in discussions that can lead to significant lifestyle changes.  

Have you ever looked at the list of patients booked to see you, either in general practice or in a community setting, and experienced dread because a ‘difficult’ patient is coming to see you? Someone with T2D who requires lots of your energy and then never does what you’ve asked them to do? I used to feel that way, frustrated and sometimes even helpless.  

A few years ago, I did some training in motivational interviewing, which is a client-centred communication style developed by clinical psychologists Miller and Rollnick.1 The technique aims to bring about behaviour change by helping patients to explore and resolve indecision. I started incorporating this more patient-centred approach into my care-planning sessions with people with T2D; however, putting the technique into practice was challenging. I tended to rush into problem-solving too quickly and often imparted my very good ideas before the patients were ready to hear them.  

On a busy day full of competing demands, switching from a clinical directive communication style to a more patient-centred form of communication required some effort. However, the more familiar I became with the core ‘spirit’ of motivational interviewing, the better I became at keeping quiet during the consultation and letting the patient come to their own reasons and solutions for changing their lifestyle behaviours. If we jump into the ‘how’ and the ‘when’ of change too soon, we are likely to run into resistance and inaction. It’s important to let patients consider whether and why they would want to make a change. 

Until recently, it was thought that once an individual had T2D, it was irreversible and slowly progressive. However, research in the UK over the past few years has demonstrated that the processes that cause T2D can be returned to normal if individuals can achieve a weight loss of around 15 kg.2 Even a small weight loss of 5–10% can result in significant health benefits. Despite this, most primary health care settings have been slow to adopt effective systems for supporting T2D reversal. The focus is still firmly on adding medications for glycaemic control. However, with adequate and sustained support, lifestyle interventions have been shown to reduce HbA1c and cholesterol and improve systolic blood pressure, which can independently reduce the risk of cardiovascular disease, all-cause death or both by 10–20%.3 

Addressing patients’ lifestyle issues, such as diet and physical activity, is complex. Health-care professionals need to have the knowledge and intrinsic motivation to engage in and address behaviour change. It also requires that people with T2D are ready to make long-term changes. 

I am undertaking PhD research on improving general practice nurses’ engagement in lifestyle-change discussions with people with T2D. I am bringing together all the evidence from the literature to determine how we can shift our communication style from directive to guiding. Incorporating specific phrases, flow charts and other tools into our busy workdays could make these conversations easier and more impactful (see Table 1 for examples). Developing strategies for use when it is difficult to find ‘change talk’ cues from our patients could help our conversations move on more smoothly. It is not our job to make people change, but it is our job to help patients with T2D recognise their own good reasons for change. 

Remission may not be possible for everyone with T2D, but it can be life-changing for those who are willing and able to make the necessary changes. The relationships we develop with our patients enable the important lifestyle discussions that can help make the remission of diabetes a reality. 

To participate in the study on general practice nurses' engagement in lifestyle discussions with people living with type 2 diabetes, please scan this QR code. 

 

References 

  1. S Rollnick and WR Miller, ‘What is motivational interviewing?’, Behav Cogn Psychother, 1995, 23(4):325–334. 

  1. R Taylor, A Ramachandran, W Yancy and N Forouhi, ‘Nutritional basis of type 2 diabetes remission’, BMJ, 2021, 373:n1449. 

  1. R Taylor and AC Barnes, ‘Can type 2 diabetes be reversed, and how can this best be achieved? James Lind Alliance research priority number one’, Diabet Med, 2019, 36(3), 308–315. 

 

Table 1. Examples of simple motivational interviewing skills and possible questions for patients with T2D 

Open questions 

Invite the patient to think a bit before responding. Allows you to be curious. Let the patient do most of the talking. 

Tell me a little about how you’re getting exercise and staying active? 

How have you been making decisions about what to eat or not to eat? 

Affirmations 

Recognise and acknowledge strengths and actions and offer positive feedback. Often patients are concerned that they will be scolded or lectured if they admit to unhealthy behaviour.  

 

It takes a lot of strength to keep making healthy choices. 

 

You did a great job in cutting back on the amount of treats you had last week.  

Reflective listening 

Mirror what the patient is saying. This shows the patient you understand what they are saying and they can hear their stated motivations or ambivalence. 

It sounds like although it was hard for you, you did manage to walk 3 times this week. 

It seems like, with all that is going on for you, it is not a good time for you to make changes to your diet right now. 

Summary 

Emphasise personal choice. This pulls together relevant information. 

Let me just make sure I’ve got this right. You are worried about your diabetes and although you want to lose weight, you are mindful of the effort it will take and would like some further information before you take any action. Am I close?  

Note. This table has been adapted from Rollnick and Miller.

 

 

 

 

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