GOALS OF MEDICAL NUTRITIONAL THERAPY IN TYPE 2 DIABETES MELLITUS

An optimal diet for a diabetic should ensure that the individual is both able and encouraged to make appropriate choices:

ASSESSMENT OF DIET

Information gathering about diet should not be restricted to current behaviour, but should also enquire about willingness and barriers to change. An assessment may involve questioning both the patient and other members of the household, and from reviewing a food diary which the patient may be asked to keep.

A nutritional assessment might include information about the following:

At the end of a dietetic assessment, sufficient information should be available to help the patient set achievable dietary goals and know the optimal choices to achieve them.

BASIC DIETARY RECOMMENDATIONS

In 2003 Diabetes UK issued a comprehensive list of consensus-based recommendations for diabetics that drew upon many sources to provide detailed practical advice for professionals to implement (Connor et al 2003). These are summarised in Table 2.1. The American Diabetes Association has also published its recommendations in its annually updated guidance.

TABLE 2.1 Summary of recommendations for a diabetes diet–based upon Diabetes UK 2003 (Connor et al 2003) and ADA position statement (ADA 2007)

* combined should total 60–70% of energy intake

Central to MNT must be changes in the patient’s behaviour. Crucial to helping to bring about change is an understanding of various aspects of health education, discussed in detail later in this section.

MODELS OF DIETARY ADVICE

Appropriate dietary advice should follow practical models that reflect current dietetic thinking. The two following models may provide a useful basis for dietary advice:

Diabetes dietetic advice should emphasise the need to space regular meals and snacks appropriately throughout the day. This will spread nutrient intake and avoid hypoglycaemia. If the daily energy intake is appropriate, the frequency of meals is not critical; however, dieticians advise eating at regular intervals and not undergoing prolonged spells without food: avoiding a “feast or famine” eating pattern. By making the mealtime an occasion to enjoy and savour food, patients may avoid abstractly consuming (possibly excess quantities of) food while focused upon another activity. Patients should be warned to avoid special diabetic products, which are often expensive and with a high fat content.

Due to recent concerns about the accuracy of food labelling in the UK, shoppers do need to pay close attention to the information provided on labels and to not accept blindly adjectives such as “healthy”, “low”, “high” or “restricted”.

WEIGHT MANAGEMENT

(See also discussion of obesity in Chapter 4.)

To achieve a slow and progressive weight loss (1 to 2 kg per month), structured dietary advice (based upon the assessment) should be guiding and supporting the patient to make eating choices that produce a sustained energy deficit of 500 to 1000 kcal per day. These need to be tailored to the patient’s own needs and preferences and combined with increased levels of physical activity.

Most people eat a fairly consistent volume of food from day to day, irrespective of its energy content. Reducing significantly total quantities may be difficult. It is better to focus upon reducing the energy content of this bulk (dietary energy density, expressed as kcal per 100 g or 100 ml of food), allowing a sufficient amount of food to be consumed for satiety, but with a lower energy yield.

Probably the most important change is to replace fat-rich foods and other dietary fat sources with starchy carbohydrate foods, maintaining nutrition. Alcohol contains 7 kcal/g, and should be restricted in a weight management programme.

DIETARY CARBOHYDRATE

The glycaemic response to foods can be affected by several factors:

Dietary carbohydrate is a source not only of energy, but also of water-soluble vitamins and minerals.

DIETARY PROTEIN

Protein is an essential nutrient that provides amino acids for new tissue formation. Protein intake should constitute 15 to 20% of the total energy intake (optimally 0.8 g/kg body weight/day). Moderate hyperglycaemia can cause increased protein turnover, but, since most adults eat at least 50% more protein than required, intake should not be increased to compensate.

DIETARY FAT

Both Diabetes UK (Connor et al 2003) and the National Cholesterol Education Program (Expert Panel 2001) recommend that the total fat should not exceed 35% of the total energy intake. The most important dietary modification is to reduce the intake of saturated fat, the principal dietary determinant of serum LDL-cholesterol levels; saturated and transunsaturated fat should provide less than 7% (ADA 2007) or 10% (Connor et al 2003) of energy. Unfortunately, in most European countries, current intake of saturated fat is above the recommended maximum 10% of total energy intake.

The main advice should be:

Sterols and stanols of plant origin have been shown to reduce serum LDL-C levels, and are now incorporated into spreads and other fat-derived products, such as yoghurts, semi-skimmed milk, cereal bars and soft cheeses. These are marketed as adjuncts to other methods of lowering LDL-cholesterol. However, the spreads are markedly more expensive than conventional margarines, their effect on long-term cardiovascular morbidity and mortality is unknown, and their benefits may be offset by reductions in fat-soluble vitamin absorption and in plasma concentrations of the antioxidants β- and α-carotene and vitamin E. Furthermore, they may not reduce total energy intake or weight.

FIBRE

As with the general population, diabetics should benefit from consuming a range of foods containing fibre, such as fibre-rich cereals (more than 5 g of fibre/serving), fruits, vegetables and whole-grain products. These are sources of vitamins and minerals.

MICRONUTRIENTS AND ANTIOXIDANTS

Diabetics should be aware of both the importance of consuming adequate quantities of vitamins and minerals from natural sources and the potential toxicity of very large doses of these in supplements. Supplementation is indicated only in selected patient groups (e.g. elderly, those on restricted calorie diets and those with proved deficiency). Although diabetics may be in a “state of increased oxidative stress”, there is no placebo-controlled trial evidence of benefit of antioxidant vitamin supplementation.

REDUCED CALORIE SWEETENERS

Reduced calorie sweeteners available include sugar alcohols (erythritol, hydrogenated starch hydrolysates, isomalt, lactitol, maltitol, mannitol, sorbitol and xylitol) and tagatose. If undertaking calorie counting, then one can subtract one-half of sugar alcohol grams from total carbohydrate grams. There is no evidence that consuming sugar alcohol will reduce energy intake significantly or improve glycaemic control over the long term.

CHROMIUM

There is still “insufficient evidence to support any of the proposed health claims for chromium supplementation” (ADA 2007).

ALCOHOLIC DRINKS

The standard advice is: to stay within the recommended limits and to avoid drinking on an empty stomach (risk of significant hypoglycaemia) or as a substitute for a meal. In type 2 diabetics, drinking two to three glasses of wine (or the equivalent quantity of beer) may produce an insignificant drop in blood glucose, but does not increase the risk of hypoglycaemia (Christiansen et al 1996). Alcohol is potentially a major energy source, but it can contribute to elevated blood pressure and serum triglycerides.

OTHER CIRCUMSTANCES

REFERRAL TO DIETICIAN

Practice nurses and GPs are ideally placed to provide the basics of sound nutritional advice and should reinforce this as appropriate when reviews are undertaken. However, a referral to a qualified dietician for an individual dietary assessment is appropriate:

DEFINITIONS

Physical activity can be defined as any skeletal muscle movement that expends energy above resting level.

Exercise is a type of physical activity that is carried out to enhance or maintain an aspect of fitness.

RATIONALE

A sedentary lifestyle is associated with an increased risk of coronary heart disease (CHD). Sedentary individuals are more likely to be obese and have adverse lipid profiles. In one study that recruited diabetic women, those undertaking less than 1 hour per week or no physical activity doubled their risk of having a cardiovascular event, compared to those undertaking at least 7 hours per week of physical activity (Hu et al 2001). Another study that recruited diabetic men found that “low” baseline cardio-respiratory fitness nearly trebled overall mortality compared with “moderate” or “high” fitness, and overall mortality nearly doubled in those reporting no recreational exercise in the previous 3 months, compared to those reporting any recreational physical activity in the same period (Wei et al 2000).

There is no current evidence to demonstrate a direct relationship between levels of physical activity and the development of the macrovascular and microvascular complications of diabetes. The arguments in favour of increased physical activity are based upon extrapolation from the effect of exercise on glycaemia. A recent report by the Chief Medical Officer distinguishes between the preventive effects (which appear to be strong) and the therapeutic effects of physical activity in type 2 diabetics (Department of Health 2004). The key message is that “the correct type of exercise is good”.

Exercise has both short- and long-term benefits in type 2 patients (see Table 2.2). Exercise can be an effective way to reduce the risk of cardiovascular disease (CVD) (Pierce 1999): an appropriate level of physical activity, particularly in conjunction with diet, can improve cardiovascular risk factors, such as blood pressure, weight and lipids. A Cochrane meta-analysis of 14 RCTs “showed that exercise … improves glycaemic control and reduces visceral adipose tissue and plasma triglycerides, but not plasma cholesterol, … even without weight loss” (Thomas et al 2006).

TABLE 2.2 The benefits of exercise for type 2 patients (ADA 1995, Buckley et al 1999)

Prevention: physical activity undertaken in early adult life protects against the subsequent development of type 2 diabetes in middle-aged men and women (Ha & Lean 1997) and in patients with impaired glucose tolerance (Tuomilehto et al 2001)

TARGETS

Most diabetics should seek to be more physically active. The type and level of physical activity undertaken on a regular basis should be appropriate and enjoyable to the individual, and should promote endurance, muscle strength and flexibility – reducing cardiovascular risk.

Published guidelines give criteria for the intensity, type, frequency and duration of physical activity that should be fulfilled in an exercise programme for diabetics. Some of the more important guidelines are summarised in Table 2.3.

EVALUATION PRIOR TO UNDERTAKING AN EXERCISE PROGRAMME

Evaluation may be difficult. As well as eliciting details about the frequency, duration, type and intensity of physical activity, the professional should consider the attitude of the patient towards exercise, and social and cultural factors.

Prior to beginning an exercise programme, a diabetic needs to be assessed for the following:

INTERVENTIONS

The recommendations of different authoritative bodies list several criteria that a suitable exercise programme for patients with diabetes should fulfil, summarised in Table 2.3. Most recommend that exercise should be:

NICE has published guidance on brief interventions that professionals can use to advise inactive individuals to increase levels of physical activity. NICE’s recommendations include that health-care professionals should:

NICE’s options for increased physical activity include approved exercise referral schemes, use of pedometers, and walking and cycling schemes. However, it does admit that there is “insufficient evidence to recommend the use of pedometers and walking and cycling schemes to promote physical activity, other than as part of research studies where effectiveness can be evaluated” (NICE 2006b).

The “ideal” may not be desirable or realistic for all diabetics. In any exercise programme, essential precautions are the inclusion of proper warm up and cooling down, suitable foot care, and adequate hydration and metabolic control (Ruderman et al 2002).

Both attitude to change and social and/or cultural factors need to be considered before undertaking any exercise programme. The goals set determine the balance, duration, intensity and methods of exercise to undertake after the evaluation. The ideal exercise programme combines aerobic (e.g. walking, running, cycling, dancing, swimming, skipping) and anaerobic (e.g. resistive strength training of major muscle groups) activities. The latter have been shown to reduce vascular risk by decreasing resting blood pressure, increasing HDL cholesterol and decreasing insulin resistance.

There are a number of exercise schemes that may be accessible and suitable for diabetics:

Health-care professionals should take great care to ensure that any exercise programme is safe, appropriate to patients’ general physical condition, suitable to their lifestyle and goals, and enjoyable. It is important that exercise includes proper warm-up and cool-down periods; this should also reduce the risk of injury.

Further information about Quality Assurance for exercise programmes is on the Department of Health’s website (http://www.dh.gov.uk). An American perspective is given in the Surgeon General’s report on Physical Activity and Health (US Department of Health 1996).

Table 2.4 gives guidance about maintaining glycaemic control during exercise.

TABLE 2.4 Guidelines for a diabetic’s optimal glycaemic response to exercise

RATIONALE

Half of all smokers die as a result of a smoking-related ailment. Smoking is a major aetiological factor not only for cardiovascular disease and peripheral vascular disease, but also for lung cancer and respiratory conditions. There is a dose correlation between CHD risk and the number of cigarettes smoked daily.

The UKPDS identified smoking as a risk factor for coronary artery disease in type 2 diabetics (Turner 1998). Smoking also promotes the development of microvascular complications of diabetes (retinopathy, nephropathy and foot disease).

Cigarette smoking increases cardiovascular risk by:

Although the main benefits of smoking cessation are the reduction of all-cause mortality and the development of CVD (CHD, stroke and especially PVD; Macleod 1994), there is evidence now emerging that patients with diabetes may be able to reduce their risk of developing some diabetes complications, such as nephropathy and neuropathy by giving up smoking.

It is a source of optimism that the proportion of the English population that smokes has declined. The latest Health Survey for England (NHS Health and Social Care Information Centre 2004) found that:

AIMS

The main aim is to enable and maintain the cessation of smoking.

However, since smoking is a behaviour that is ultimately under the patient’s control, any “target” set must be negotiated and agreed with the patient. Smoking cessation may not be desired by or achievable in some patients: the patient and clinician may have to settle for minimising the extent of the patient’s smoking. Ex-smokers should be discouraged from re-starting smoking.

ASSESSMENT

The patient should be asked:

If the patient is an ex-smoker, it may be helpful to enquire about any problems encountered and the patient’s attitude to his future as a nonsmoker.

If the patient is a current smoker, it is also useful to ascertain:

In patients who are currently or are suspected of smoking, devices can be acquired to check blood levels of carbon monoxide.

The above information may inform the professional’s choice of strategies to use that are mostly likely to promote smoking cessation. Any information elicited should be documented in the clinical records, including if a patient is reluctant to consider change or if any positive encouragement was given to an ex-smoker (NICE 2006a).

It is important for the professional to identify any patient who smokes and may be on the verge of changing behaviour: taking such an opportunity to provide immediate and effective support, using one or more of the interventions discussed below, may achieve a higher rate of success in smoking cessation.

INTERVENTIONS

If the patient is a nonsmoker, the clinician may wish to offer positive encouragement for the patient to continue this behaviour, possibly re-iterating the benefits of smoking and the disadvantages of resuming.

Following its White Paper Smoking Kills in 1998, the Government’s tobacco programme has included the following:

A variety of the available strategies to promote smoking cessation are effective (Lancaster et al 2000). In 2002 NICE recommended that both bupropion and nicotine replacement therapy should be funded by the NHS (NICE Appraisal Committee 2002).

A patient unwilling to consider the benefits of or how to initiate any action to make change is extremely unlikely to respond to any intervention. In such circumstances, all the professional can do is to briefly emphasise the positive health and social benefits of becoming a nonsmoker while underlining the considerable risks of remaining a smoker. Handled sensitively, “the door is left open” and, possibly, a useful idea is planted. In a cross-sectional household survey, nearly half of those who had quit smoking did so as an unplanned attempt: once the decision was made to quit, immediate action was taken without planning (West & Sohal 2006). Professionals need to recognise a patient’s level of motivation in order to target their interventions at those most likely to respond.

Since smoking is a behaviour owned by the individual who does it, any change to this behaviour is also owned by the same individual. Any intervention by a health-care professional needs to respect this concept and be directed at “empowering” the patient to make and implement positive and beneficial choices.

RATIONALE

There is an inverse relationship between alcohol consumption and the risk of CHD mortality (Valmadrid et al 1999, Ajani et al 2000); however, moderate alcohol consumption may offer some protection against stroke (Sacco et al 1999). There are no data available on alcohol consumption and the risk of developing peripheral vascular disease (PVD). There is no evidence that alcohol is a risk factor for the development of diabetic neuropathy.

Alcoholic cardiomyopathy may develop after 10 years of heavy alcohol abuse, due to a direct toxic effect of alcohol upon cardiac muscle. Alcohol abuse is also associated with thiamine deficiency, which can contribute to the development of cardiomyopathy. Alcohol consumption can affect levels of blood pressure, blood glucose and serum triglycerides.

Regular excessive alcohol consumption can also have serious adverse effects upon the psychological well-being of the patient and others, often leading to depression and, in extreme cases, to social chaos.

ASSESSMENT

Alcohol consumption is measured in units, with 1 unit equating to:

A bottle of spirits usually contains 26 to 28 units.

TARGETS

Unlike smoking, moderate alcohol consumption on a regular basis, but not in binges, is not harmful. Risk is a continuum and higher limits are controversial. “Low-risk” drinking is less than 21 units per week in men and 14 units per week in women. Diabetics are advised to avoid drinking more than 3 units of alcohol in one session.

REDUCING ALCOHOL CONSUMPTION

Reducing alcohol consumption, particularly when it is far above the recognised safe upper limit, is often very challenging and its success depends upon a patient’s willingness and commitment to change. The principles are the same for all patients, both non-diabetic and diabetic.

In non-dependent drinkers, particularly those receptive to change, about one-quarter may reduce their drinking following brief GP interventions: these include providing information about safe limits and the harm of excess, and agreeing target consumption and review. Since alcohol-dependent drinkers are likely to suffer withdrawal symptoms (e.g. anxiety, fits, delirium tremens) if they reduce their alcohol consumption, detoxification is required. Although possible in the community, the presence of severe physical, psychological and/or social problems or previous complicated withdrawals, requires detoxification to be undertaken as an inpatient. Such patients should be referred early to the community alcohol team.

In these complex situations, primary care can still play a useful role by:

Sources of support and advice for patients include:

GENERAL PRINCIPLES OF THE PROCESS OF HEALTH EDUCATION

STRUCTURES AND PROCESSES FOR THE DELIVERY OF DIABETES EDUCATION

A PSYCHOLOGICAL APPROACH TO HEALTH EDUCATION CONSULTATIONS

Effective consultation technique

Effective consultation behaviours in all patient contacts, without ignoring clinical issues, are more likely to facilitate changes in a patient’s behaviour. A review published in the BMJ provides a helpful list of concepts and techniques (Gask & Usherwood 2002), but there is a wealth of excellent literature (Launer 2002, Pendleton et al 2003).

“Successful” consultations are more likely to result if:

• A constructive relationship is built

• The professional’s skills are deployed effectively to define problems and to generate potential solutions

• Emotional and social factors also are considered in both diagnosis and management

• The patient’s agenda is elicited and addressed

• The patient is involved appropriately in any decision-making process and management plan. This has been shown to achieve better blood glucose and blood pressure control (Kaplan et al 1989).

One of the authors (SL) has developed his own consultation model that aims to clarify behaviours within consultations more likely to produce beneficial outcomes (see Figure 2.1).

Fig. 2.1 Schematic representation of consultation model

Models of change

Trans-theoretical model of change

In the 1980s the “trans-theoretical model of change” for addiction behaviours was published (Prochaska & DiClemente 1992). Many professionals began to recognise that the model (summarised in Figure 2.2) could be applied to various health-related behaviours, such as smoking, alcohol consumption, diet and exercise. This model is particularly attractive because it recognises that different strategies are required to further change at each stage, and because it reflects the progress and relapse that occurs in real life.

Fig. 2.2 The trans-theoretical model of change

A patient who is uninterested in change is at the pre-contemplative stage. A patient thinking about change (at the contemplative stage) can be helped through the sequential stages of preparation, action and maintenance, leading to safer or healthier behaviour. Relapse can occur but, if recognised, patients can be guided back to the preparation and action stages.

Various triggers may cause a patient to move from being unwilling to being prepared to think about change. This transformation may result from realising that an adverse event may be imminent or more likely, that the problem is connected to current behaviour, and that the benefits of change outweigh the risks and/or disadvantages. If a patient appears unwilling to change, then the professional may wish to use one or more of the following strategies to help the patient move from the pre-contemplation to contemplation:

• Emphasise the positive health and social benefits of change

• Focus upon the risks of maintaining a particular unhealthy aspect of lifestyle

• Help the patient to demolish or find a route around any barriers to change.

Whatever strategy is used, the professional is likely to be seeking to alter the patient’s motivation at this point.

Model of change based upon the “catastrophe theory”

An alternative to the trans-theoretical model has been proposed recently. This is based on a branch of mathematics, where tensions develop in a system so that even small “triggers” can cause “catastrophic” changes. It is proposed “that beliefs, past experiences, and the current situation create varying levels of ‘motivational tension’, in the presence of which even quite small ‘triggers’ can lead to … renunciation.” If a plan for later action is the result, then this “may signify a lower level of commitment” in the individual (West & Sohal 2006).

West has incorporated this concept in a theory of motivation and how it can be applied to addictive behaviours (West 2006). He advises public health campaigns that seek to influence behaviours to focus on the “3 Ts”:

1. Creating motivational tension

2. Triggering action in those who are on the “cusp” of change in their “orientation” to an addictive behaviour, such as smoking

3. Immediate availability of treatment to support attempts to change.

This theory recognises both the often sudden variability in an individual’s motivations and the importance of a timely effective response by the professional to opportunities within a consultation that may be indicated by various cues given by the patient. The trans-theoretical and catastrophe theory models are not incompatible: the trans-theoretical model does not specify duration of time spent at any of its stages. An individual whose motivational tension is a high level, leading to renunciation and “unplanned” change, could be considered to have moved from pre-contemplation to action very rapidly through the contemplation and preparation stages in-between.

Cognitive behaviour therapy (CBT) and motivational approaches

Definitions

Cognitive behaviour therapy (CBT) refers to a group of psychological treatments that include behaviour therapy, behaviour modification and cognitive therapy in various combinations.

Behaviour approaches aim to change behaviour, both as a therapeutic aim in its own right, and to produce other symptomatic improvements.

Cognitive approaches explore how cognition mediates feelings and behaviour. Therapy aims to identify maladaptive thought patterns and to teach the patient to recognise and challenge these.

In practice, therapists combine both approaches (Richardson 1998).

Problem-solving

CBT has a wide range of established clinical applications, especially for mental health problems, such as depression, panic disorder and post-traumatic stress disorder (Enright 1997). There is now increasing interest in using CBT to modify other behaviours. The CBT process can be divided into three sequential steps (that can be undertaken over several encounters):

1. Baseline: “Where are you now?”

Identify the patient’s current state (behaviours, thoughts and feelings) with regard to his condition and well-being, prior to the process of goal setting. This information is important for developing rapport, for assisting change by starting the process of goal setting and for later evaluation.

2. Outcome: “Where do you want to get to?”

Ask the patient to define his goals and to consider his “picture of health”; the patient can be helped to explore the benefits of change, with attention to the expected gains (physical, psychological, cognitive). Goal identification also defines when the intervention is completed.

3. Process: “How are we going to get there?”

An agreed plan of action may include problem solving, graded task setting (small manageable goals that will generative greater self-confidence from success), visualisation, interpersonal “coaching”, and other educational techniques. Both patient and professional will have clearly defined responsibilities in the implementation of the action plan.

Behavioural change can follow the above problem-solving steps. The Outcome stage of the CBT process equates to the “contemplative stage” of the trans-theoretical model.

Motivation

Motivation influences lifestyle and is owned by the individual. Levels of motivation can fluctuate: small triggers can produce sudden and dramatic changes. In order to better understand motivation so as to change it, the professional needs to be aware of the two main components of motivation:

1. Importance, made up of:

• knowledge about gains and losses resulting from any particular behaviour

• concern (balance between too little and too much) about that behaviour

and

2. Confidence, made up of:

• self-esteem

• self-efficacy (belief in the individual’s capability to act).

Structured information gathering by the professional will enable a greater understanding of the patient’s current situation: the constructs of the patient’s motivation (importance of current behaviour and his self-confidence) and an awareness of what outcomes might be feasible from behavioural change.

Simple questions can be asked to explore importance:

• “How do you feel now, on a scale of 1 to 10?”

• “On a scale of 1 to 10, how important is xyz to you?”

• “What would have to happen before you would seriously consider change?” and confidence:

• “How confident, on a scale of 1 to 10, do you feel about being able to change xyz?”

• “How can I help you to make that change?”

• “How successful have you been in previous attempts – what went wrong?”

If the status of a patient’s motivational components are applied to the trans-theoretical model of change:

• at the pre-contemplation stage, the importance score will be low

• at the contemplation stage, the importance score will be high, but the confidence score may be low

• at the preparation stage, both importance and confidence scores need to be high.

To facilitate a patient’s progress through the CBT process, the professional may wish to employ motivational interviewing techniques (summarised in Figure 2.3). Professionals can combine effective consulting techniques with motivational approaches and CBT. Those who seek to integrate these skills into their daily practice require training, practice and regular feedback.

Fig. 2.3 The key tasks of motivational interviewing

Identifying and stimulating the patient’s awareness of the need for change can use motivational “linguistic patterns” to emphasise the benefits of change; e.g. “As you begin eating more healthily and regularly, you will notice that your general well-being will improve. This will be because your blood sugar is becoming stable, and this, in turn, means that you will have more energy.”

When the patient is ambivalent about the importance of change, it is useful to ask him to complete a grid, comparing the benefits and losses of change against those of no change (see Figure 2.4). Another strategy is to explore what would need to happen or alter to increase the importance of change for the patient. The patient should be able to express concerns about his current behaviour and the arguments for change, in order that his “decisional balance” is tipped towards action. This could also be seen as attempting to increase “motivational tension”.

Fig. 2.4 Grid to help explore the benefits of change

Where confidence is low, the professional needs to consider what “blocks” confidence; these may include:

• lack of knowledge and skills

• lack of support (from family, friends or professionals)

• past failures to change

• poor function (lack of alternative behaviours)

• psychological distress, such as anxiety, depression, low self-esteem.

The nature of the “block” will influence which strategy is used to try to dismantle it. It is sometimes helpful to ask a patient to recall previous strategies used to achieve success. The professional should have strong “interpersonal” skills and be able to negotiate with patients some specific plans with clear goals that require concrete actions in small steps, providing constructive feedback that develops a patient’s ability to learn from “lapses”.

The professional needs to be aware also of the effects of secondary gain, control and emotional expression within the patient’s illness behaviour. Most people know what is good for them and how to achieve it. Just as smoking-cessation interventions are ineffective when the “benefits” to the patient of remaining a smoker are ignored, so too can some features be overlooked within the psychological management of physical conditions. An example is the patient who, after a row with his or her partner, sabotages some aspect of the diabetic programme (ignores diet, omits medication) to force the partner to take the roles of rescuer and consoler. This sabotage may be how a patient expresses anger, but it has negative health consequences. In contrast, healthy people under stress, who push themselves too far and risk adverse health, are not “saboteurs”. The professional can uncover subconscious motives and challenge the patient, then help the patient take ‘ownership’ of his behaviour.

KEY POINTS

• The important health educational messages are to eat sensibly, be more physically active, stop smoking, and to moderate alcohol intake.

• A healthy diet should provide essential nutrition, reduce cardiovascular risk and allow adaptation to metabolic problems.

• The main components of an exercise programme should include aerobic acitivity undertaken at least 3 times per week, of at least 150 minutes duration per week, and of moderate intensity (50 to 70% of maximum heart rate).

• Beyond simple advice, smokers should be offered help to quit using a variety of measures.

• Health education is more than imparting information; it should enable patients to make healthier choices.

• Busy professionals can employ effective techniques that may alter a patient’s motivation. Behavioural rather than didactic approaches are more likely to succeed.

• Evidence for the benefits of various educational approaches remains limited.