Behavior Change Technique in Type 2 Diabetes: An Expert Perspective

Type 2 diabetes affects 30.3 million people in the United States, which represents 9.4% of the population.¹ Poor diet has been strongly linked to diabetes, cardiovascular disease, and stroke.^2,3 Reduced risk of diabetes and better glycemic control are associated with diets rich in legumes, whole grains, fruits, vegetables, and nuts; moderate alcohol consumption; and lower intake of refined grains, red or processed meat, and sugar-sweetened beverages.⁴ Given the prevalence of fast food, large portion sizes, and processed food in the American diet, a significant shift in dietary habits can be challenging for patients with diabetes.

Endocrinology Advisor spoke with Daniel Einhorn, MD, medical director of the Scripps Whittier Diabetes Institute and president of Diabetes and Endocrine Associates in La Jolla, California, about behavior change technique (BCT) and the dietary environment.

Behavior Change Technique and the Dietary Environment

BCT, an observable, replicable, and irreducible component of an intervention that targets causal behavior, may help achieve dietary changes in patients with type 2 diabetes.⁵ Various studies have investigated the role of BCT in dietary changes in patients with type 2 diabetes; some established a significant relationship, some did not, and some identified different BCTs than others, highlighting this area of controversy in the management of diabetes.⁶

A recent meta-analysis of 54 studies explored the most effective BCTs and diets to improve glycemic control and reduce body weight.⁵ Diet interventions were effective in lowering glycated hemoglobin (HbA_1c); those changing or controlling the dietary environment resulted in a larger reduction than those seeking to change behavior. The variety of dietary approaches seen in the meta-analysis allowed for further investigation to identify the approach that resulted in the largest HbA_1c decrease. This meta-analysis demonstrated that meal replacements and high-protein diets were more effective than low-carbohydrate, low-fat, or low-glycemic-index diets.⁵ The studies controlling the dietary environment, however, also had the highest dropout rate.⁵

A study of partial meal replacement plans has shown that over 1 year, participants who consumed at least 2 meals or snacks through meal replacement had a higher adherence rate to dietary recommendations compared with those who did not consume any meal replacements.⁷ However, there are currently no data from this trial assessing adherence to dietary recommendations following the cessation of the partial meal replacement plan. It is important to place trial results in the context of clinical practice and ongoing patient behavior. A change in dietary environment, such as having food provided to the patient, may not be sustainable outside clinical trials. Cost may also be a factor for some patients.

Some have expressed concerns over temporary changes in dietary environments. Dr Einhorn states that “temporary restrictive diets do not work in the long run. Metabolism slows with these diets and gains that take months may be reversed in days after ending the diet.” Additionally, studies have demonstrated that patients who overexert self-control in response to a lapse in dietary restrictions are more likely to lapse in the future.⁸

When assessing specific BCTs related to diet, social comparison and feedback on behavior were associated with significant reductions in HbA_1c.⁵ Furthermore, subgroup analysis of studies using only true control groups that sought to change behavior indicated that feedback on behavior and adding objects to the environment were also effective, and problem-solving was effective in studies that sought to change the dietary environment. ⁵ Another study revealed that goal setting, goal review, and preparing for/dealing with setbacks all significantly reduced self-reported fat intake, and self-monitoring showed a statistical trend.⁶ Data from these studies suggest many techniques that may be helpful for patients when adopting new dietary habits.

Implementing Dietary Changes

The American Diabetes Association recommends an individualized eating plan based on the patient’s current eating habits, preferences, and goals.⁹ Numerous dietary examples (such as the Mediterranean and plant-based diets) as well as identified techniques, as discussed above, can aid in lasting dietary changes. It is also important to account for cultural differences, support systems, and socioeconomic status when implementing dietary changes. A study of dietary changes in low-income urban neighborhoods saw a strong influence of social environment. Patients who had support, opportunities for observational learning, and skills and knowledge of strategies to enact dietary changes were able to improve their diet.¹⁰

Dr Einhorn states: “Food is a major source of joy for most people and you must love your diet.” This is a key aspect of dietary change in patients with type 2 diabetes. Practical advice and easy-to-implement techniques to increase plant-based, lean, and nonprocessed foods should be discussed with patients. Dr Einhorn suggests that patients should “…remember that spices are usually calorie free. If patients change their diet, they should make it a delight to live with.” Communication about realistic changes is integral to maintaining dietary changes to improve glycemic control.

Conclusion

Diet is a significant influence in type 2 diabetes, and a balanced diet plays an integral role in maintaining a healthy glycemic level. BCTs can be effective, though these as well as dietary goals should be individualized. Changes in the dietary environment may be more effective than BCTs in the adoption of new eating habits, and it is also important to include long-term sustainability when proposing any dietary changes to patients with type 2 diabetes.

References

1. Centers for Disease Control and Prevention. National diabetes statistics report, 2017: estimates of diabetes and its burden in the United States. 2017. https://www.cdc.gov/diabetes/pdfs/data/statistics/national-diabetes-statistics-report.pdf. Accessed February 21, 2018.
2. Micha R, Peñalvo JL, Cudhea F, Imamura F, Rehm CD, Mozaffarian D. Association between dietary factors and mortality from heart disease, stroke, and type 2 diabetes in the United States. JAMA. 2017;317(9):912-924.
3. Ardisson Korat AV, Willett WC, Hu FB. Diet, lifestyle, and genetic risk factors for type 2 diabetes: a review from the Nurses’ Health Study, Nurses’ Health Study 2, and Health Professionals’ Follow-up Study. Curr Nutr Rep. 2014;3(4):345-354.
4. Ley SH, Hamdy O, Mohan V, Hu FB. Prevention and management of type 2 diabetes: dietary components and nutritional strategies. Lancet. 2014;383(9933):1999-2007.
5. Cradock KA, ÓLaighin G, Finucane FM, et al. Diet behavior change techniques in type 2 diabetes: a systematic review and meta-analysis. Diabetes Care. 2017;40(12):1800-1810.
6. Hankonen N, Sutton S, Prevost AT, et al. Which behavior change techniques are associated with changes in physical activity, diet and body mass index in people with recently diagnosed diabetes?Ann Behav Med. 2015;49(1):7-17.
7. Raynor HA, Anderson AM, Miller GD, et al. Partial meal replacement plan and quality of the diet at one year: Action for Health in Diabetes (Look AHEAD) Trial. J Acad Nutr Diet. 2015;115(5):731-742.
8. Jenkins BN, Rook KS, Borges-Garcia R, Franks MM, Stephens MAP. Too much of a good thing? Overexertion of self-control and dietary adherence in individuals with type 2 diabetes. Br J Health Psychol. 2016;21(3):648-659.
9. American Diabetes Association. 4. Lifestyle management: standards of medical care in diabetes—2018. Diabetes Care. 2018;41(Suppl 1):S38-S50.
10. Pollard SL, Zachary DA, Wingert K, Booker SS, Surkan PJ. Family and community influences on diabetes-related dietary change in a low-income urban neighborhood. Diabetes Educ. 2014;40(4):462-469.