“You’ve got pre-diabetes.” What does the patient do next?

Diabetes prevention is a national priority, and those on the pathway to diabetes are now given the diagnosis "pre-diabetes" to encourage lifestyle changes that improve their outlook. But what's the reality for those given a diagnosis? NIHR Doctoral Research Fellow and DPhil Student Eleanor Barry writes about her latest research (published in BMC Medicine) looking at how behaviours change following a pre-diabetes diagnosis, spotlighting a range of social and cultural factors for policymakers to consider. 

The National Diabetes Prevention Programme has been rolled out across England. GPs are diagnosing people with ‘pre-diabetes’ (non-diabetic levels of hyperglycaemia) and then referring them onto the National Diabetes Prevention Programme. How do people respond to this diagnosis? Will they show up to lifestyle education? What’s the chance that they will achieve lifelong behaviour change? These research questions came from working with clinicians and commissioners tasked with preventing diabetes in a deprived area of East London.

What we did

To tackle these questions, we undertook a review of the literature (the third in a series of systematic reviews examining the evidence behind diabetes prevention policies, here and here.  Our research question was “how does the diagnosis of pre-diabetes affect people’s risk perception and health-related behaviours – and what are the wider influences on this?” 

A traditional systematic review with meta-analysis was not possible due to the heterogeneity of the literature (which included quantitative surveys as well as in-depth qualitative studies) and the differing ways in which authors had framed their questions and analysed their data. 

We used a relatively new technique called meta-narrative review, which begins by grouping studies by their common assumptions and theoretical perspectives. We also used William Cockerham’s Health Lifestyle Theory, which considers the interplay of an individual’s life choices with what might be called their life chances (determined by wider structural and social influences such as living conditions, health literacy, environmental influences). Even when a person is technically free to choose to behave in a particular way, wider social influences powerfully shape and constrain their actual ability to act (see Figure 1, Barry et al., 2018).

What we found

15 studies were included, which we grouped into three broad meta-narratives (that is, ways of conceptualising and researching the topic).

The first way people had conceptualised pre-diabetes was as a biochemical abnormality that put the patient on the ‘pathway’ to type 2 diabetes. Such studies, which tended to be led by clinical doctors, recommended solutions in the form of individual behaviour change (eat less, exercise more) with a view to stopping the inexorable progression in glycaemic control. But most such studies did not go on to explore the real-world challenges associated with such change. 

The second way of conceptualising pre-diabetes was in terms of the psychology of behaviour change. Such studies, often led by psychologists, explored different theories of how a person might change their lifestyle (i.e. adjust to a different diet or increase their physical activity level), including some consideration of the tactics that patients might use to negotiate cultural or other contextual factors.

In short, even when people want to change their behaviours, they may be unlikely to be able to do so if they are subject to overwhelming structural influences such as poverty, poor housing, low health literacy, poor affordability and availability of healthy food choices.

Thirdly (and unusually – only two papers in our review did this), some authors placed most emphasis on the context in which people with pre-diabetes live their lives (the ‘chances’ open to a person and how these influenced ‘choices’).  These studies were led by researchers with a sociological background who were interested in the social determinants of health. In short, even when people want to change their behaviours, they may be unlikely to be able to do so if they are subject to overwhelming structural influences such as poverty, poor housing, low health literacy, poor affordability and availability of healthy food choices.

We were struck by the dominance of individual-level approaches in the primary studies in our dataset. Unsurprisingly, researchers who only looked for individual level influences on the outcome of pre-diabetes saw potential solutions only at this level. But type 2 diabetes is as much a social condition as a biological one – and our review suggests that we need to provide individual-level interventions (such as lifestyle education) and address the wider environment in which people will need to live out their healthier lifestyles.

But type 2 diabetes is as much a social condition as a biological one – and our review suggests that we need to provide individual-level interventions (such as lifestyle education) and address the wider environment in which people will need to live out their healthier lifestyles.

Diabetes prevention policies are currently dominated by trial-based biomedical research which through their designs (randomisation, allocation concealment) erase the complex social mechanisms underlying disease development. This evidence base contains little knowledge of how individuals view their world, move within it and negotiate the struggles and stresses of daily lives. This information is crucial when targeting lifestyles socially constructed over a lifetime. Most authors of the studies included in our review mentioned environmental elements that might influence behaviour change but did not formally include these in their research design or make recommendations to address them.

Many leading researchers have called for a paradigm shift in prevention research using societal perspectives, addressing upstream influences on health and taking a complex systems approach to multi-causal problems like diabetes. Our review identifies the need for an interdisciplinary primary prevention research to enhance the current individualist research paradigm by exploring population-level approaches, perhaps by framing behaviours as social practices rather than individual choices. Wider incorporation of social research in policy construction process will provide a greater understanding of the complexity of the conditions policies are trying to prevent as well and broaden prevention strategies to improve the health of populations.

Further reading:

How are health-related behaviours influenced by a diagnosis of pre-diabetes? A meta-narrative review.
Barry E, Greenhalgh T, Fahy N. BMC Medicine 2018;16:121

Preventing type 2 diabetes: systematic review of studies of cost-effectiveness of lifestyle programmes and metformin, with and without screening, for pre-diabetes.
Roberts S, Barry E, Craig D, Airoldi M, Bevan G, Greenhalgh T.  BMJ Open. 2017;7(11):e017184.

Efficacy and effectiveness of screen and treat policies in prevention of type 2 diabetes: systematic review and meta-analysis of screening tests and interventions
Barry E, Roberts S, Oke J, Vijayaraghavan S, Normansell R, Greenhalgh T.
BMJ. 2017;356:i6538.

Theories of practice and public health: understanding (un)healthy practices.
Blue S, Shove E, Carmona C, Kelly MP.
Critical Public Health. 2014;26(1):36-50.

The global obesity pandemic: shaped by global drivers and local environments.
Swinburn BA, Sacks G, Hall KD, McPherson K, Finegood DT, Moodie ML, et al.
The Lancet. 2011;378(9793):804-14.

The need for a complex systems model of evidence for public health.
Rutter H, Savona N, Glonti K, Bibby J, Cummins S, Finegood DT, et al.
The Lancet. 2017;390(10112):2602-4.

Towards a critical complex systems approach to public health.
Salway S, Green J.
Critical Public Health. 2017;27(5):523-4.

Social Practices, Intervention and Sustainability: Beyond behaviour change. 
Strengers YM, Cecily. London: Routledge; 2015.

Eleanor Barry's research was funded by a National Institute for Health Research (NIHR) in-practice fellowship. The views are those of the author and not necessarily those of the NIHR, the NHS or the Department of Health and Social Care.