Dietary and physical activity counselling on Type 2 diabetes and impaired glucose tolerance by physicians and nurses in primary healthcare in Finland

Abstract

Objective. To investigate the initiation of dietary and physical activity counselling and the arguments used when discussing physical activity and the type and consumption of dietary fats, during nurse–patient and physician–patient diabetic lifestyle counselling. Design and subjects. This study is a part of a larger follow-up research project focusing on diabetes counselling. The data include 129 videotaped counselling sessions between 17 patients and their physicians and nurses. Content analysis was carried out by identifying the verbal comments and reactions of participants concerning both physical activity and the type and consumption of dietary fats. Results. The physicians and nurses spent little time on dietary and physical activity counselling. The counselling sessions consisted mainly of short questions with minimal feedback from either party. The beginning of the sessions concentrated on blood cholesterol levels and the extent of physical activity. The health professionals failed to emphasize the roles of reduced dietary fats and increased physical activity in substituting for or supplementing diabetes care. Although the patients communicated the factors that encouraged or discouraged physical activity the subject was generally not pursued by the health professionals. Conclusion. Within primary care there is a need for methods that would facilitate the discussion of health behaviour changes. In healthcare settings, education and training are required to develop the communication skills of health professionals in all aspects of preventive medicine.

• Content analysis
• dietary and physical activity counselling
• family practice
• type 2 diabetes

Lifestyle changes including increased physical activity, reduced fat and increased fibre were found to be even more effective than medication in type 2 diabetes prevention [1], [2]. People with type 2 diabetes are often obese [3] and have difficulty avoiding the consumption of saturated fats [4]. In the average diet about half of fats are hidden and saturated [5], [6]. Most hard fats come from cheeses, meat foods, yoghurts, ice-creams, and both sweet and savoury pastries [7]. Visible and flowing fats come mainly from dietary fats and sauces used in salads or cooking [8].

Conclusive evidence recommends that adults undertake moderate exercise most days of the week, preferably daily, for at least 30 minutes, either in one session or divided into several sessions. Physical activity could involve a brisk walk, mowing the lawn, dancing, swimming, or bicycling on level terrain. Walking a distance exceeding three kilometres meets the basic daily requirement for health-enhancing physical activity of adults with normal fitness [1], [2], [9].

Dietary changes and increased physical activity were found to be even more effective than medication in type 2 diabetes prevention.

• The health professional used little time for dietary and physical activity counselling. The significance of nutrition and physical exercise for the care and prevention of diabetes was referred to only briefly in discussions.

• The discussions were routine, uninteresting, and superficial. They revealed the limitations of the conversational skills of both the patient and the health professional.

• The great challenge for healthcare is to develop new counselling models on the basis of the current resources, in both education and training of health professionals’ communication skills.

Health professionals have been proven to spend little time on dietary and physical activity counselling with diabetes patients [4], [10–12]. Lifestyle counselling sessions are often superficial [13–15]. Although patients already know about healthy physical activity and diet, they have problems with the practical application of this knowledge [16], [17]. Commonly agreed definitions used in lifestyle counselling, such as collaborative goal-setting, active problem-solving, the patient's stages of change, barriers to change, and decision-making related to lifestyles, are rarely discussed [12], [18]. This kind of counselling might produce better results than could be achieved by merely giving information [19], [20]. This may be one reason why health counselling and the quality of life of a diabetic correlate weakly [21].

The purpose of this study was to quantify the dietary and physical activity counselling given by health professionals (physicians and diabetes nurses or public health nurses) during type 2 diabetes visits. Another aim was to investigate the initiation of dietary and physical activity counselling and the arguments that patients and health professionals used when discussing both physical activity and the type and consumption of dietary fats.

Materials and methods

The data, 129 videotaped counselling sessions of 17 patients (8 women and 9 men, mean age 54.6 years) with seven physicians and five nurses, were collected in 2000–2002 as an integral part of the patients’ diabetes care in Finnish primary healthcare, in urban and built-up areas. Ten patients were retired, three were unemployed, and four were employed. The number of sessions varied between different patients from 0 to 7 visits with physicians and from 2 to 11 visits with nurses.

The inclusion criteria for patients were: (1) recently diagnosed with type 2 diabetes or IGT, (2) age 40–70 years and willing to participate in a follow-up study. At the beginning of the data collection, five of the patients had a formal diagnosis of type 2 diabetes and were on medication for it; one of them was treated with insulin. The patients were overweight (mean value of BMI = 29.9). Their fasting blood glucose level varied from 5.9 to13.3 mmol/l; OGTT was not done.

The physicians, general practitioners (4 women and 3 men), and women nurses were recruited among health professionals responsible for diabetes counselling in four different primary care organizations. Two of the nurses were employed, full time, in diabetes counselling while others combined it with other duties, but were responsible for diabetes care in their units. The nurses had from 9 to 25 years of work experience in diabetes care in different settings. The physicians’ work experience varied from 1 to over 20 years in primary healthcare. The numbers of patients’ visits with one nurse varied from 8 to 48 and with one physician from 1 to 10.

Ethical approval for the study was obtained from the ethics committee of the health care district. All participants gave their written consent to videotaping and to the publication of collected data.

Content analysis was carried out by identifying the verbal comments and reactions of participants concerning both physical activity and nutrition. Excerpts that involved nutrition, diet, quantity of fat, type of fat, fats for cooking, dairy, meat products, cheeses, cold cuts, and pastries were determined as dietary fat talk. Discussions on fibre, fruit, vegetables, cereals, alcohol, and soft drinks were included in all counselling sessions but they were not the specific focus of this study. Physical activity talk was recognized in excerpts that involved interest or disinterest in physical activity, sporting events, possibilities for or barriers to physical activity, recommendations about and attitudes towards physical activity.

The frequency and duration of fat and physical activity speech were calculated from the transcribed data, accurate to minutes and seconds (Table I). In addition, the content of dietary fat and physical activity counselling, the initiations of counselling, and feedback given were identified in the transcribed data (Tables II and III).

Table I.  Summary of dietary and physical activity counselling sessions with physicians and nurses (number, percentage, duration and talk acts of counselling).

Counselling sessions	Counselling with nurses	Counselling with physicians
Total number of health counselling sessions	97	32
Total duration of health counselling sessions	63 h 35 min 53 s	16 h 40 min 58 s
Dietary
Counselling sessions with dietary counselling	77	20
Percentage of sessions devoted to dietary counselling	79%	63%
Percentage of the duration of dietary counselling session devoted to fat counselling	11%	5%
Total duration of dietary fat counselling in sessions	9 h 16 min 54 s	55 min 39 s
Mean duration of dietary fat counselling during a dietary counselling session	5 min 10 s	3 min 1 s
Longest talk act of dietary fat counselling	10 min 50 s	5 min 12 s
Shortest talk act of dietary fat counselling	5 s	14 s
Physical activity
Counselling sessions with physical activity counselling	75	16
Percentage of sessions devoted to physical activity counselling	77%	50%
Percentage of the duration of physical activity counselling devoted to physical activity counselling	3%	0.2%
Total duration of physical activity counselling in sessions	2 h 29 min 31 s	17 min 6 s
Mean duration of physical activity counselling during a physical activity counselling session	4 min 26 s	1 min 30 s
Longest speech act of physical activity counselling	9 min 33 s	4 min 44 s
Shortest speech act of physical activity counselling	13 s	10 s

Table II.  Breakdown of verbal comments and reactions in the opening of patients’ dietary counselling sessions with nurses (N) and physicians (P) and participants’ feedback.

Themes of dietary fat talk	Patients’ expressions N/P	Professionals’ feedback minimal* comments** N/P N/P	Professionals’ expressions N/P	Patients’ feedback minimal* comments** N/P N/P
Quantity of fats	3/3	1/2 2/1	19/1	13/– 6/1
Type of fats	19/2	5/2 14/–	43/2	15/1 28/1
Diet	14/4	6/3 8/1	32/1	10/1 22/–
Weight loss	5/–	2/– 3/–	5/1	2/1 3/1
Cholesterol levels	3/1	1/– 2/1	53/12	25/7 28/5
Cholesterol medicine	–	– –	6/4	3/1 3/5
Fats in diabetes care	3/–	1/ 2/–	10/1	5/– 5/1
Total	47/10	16/7 31/3	168/22	73/11 95/14

*Minimal feedback such as “yeah, well, hmm”; **comments such as “it is, it is – but I do”.

Table III.  Breakdown of verbal comments and reactions in the opening of patients’ physical activity counselling sessions with nurses (N) and physicians (P) and participants’ feedback.

Themes of physical activity talk	Patients’ expressions N/P	Professionals’ feedback minimal* comments** N/P N/P	Professionals’ expressions N/P	Patients’ feedback minimal* comments** N/P N/P
Amount of physical activity	15/3	5/3 –/–	38/10	17/4 21/6
Barriers to physical activity	2/2	2/1 1/1	1/–	1/– –/–
Physical activity in diabetes care	5/–	3/ 2/–	13/1	10/1 3/–
Total	22/5	20/4 3/1	52/11	28/5 24/6

*Minimal feedback such as “yeah, well, hmm”; **comments such as “I've exercised”.

Results

Amount and duration of counselling

In these data, the physicians and nurses often devoted little time to dietary and physical activity counselling. Dietary and physical activity counselling was present in two encounters out of three with nurses and in one half of encounters with physicians. Dietary counselling focused mainly on dietary fats and physical activity counselling on the amount of exercise (see Tables II and III).The significance of nutrition and physical exercise for the care and prevention of diabetes was referred to only briefly. The openings of conversations and feedback were often formulated as minimal feedback or comments supporting the patients’ talk. Although the patients brought up factors during the counselling that encouraged or discouraged health habit changes, the health professionals failed to sustain conversations.

Opening counselling sessions

The nurses were especially inclined to initiate both dietary and physical activity discussions but patients also initiated discussions (see Tables II and III). The physicians were not active initiators in these discussions. The patients’ cholesterol levels and recommended values frequently served as the openings of dietary fat counselling by the health professionals (see Table II). These openings were mainly short descriptions or monitoring statements, which consisted of statements on the quantity, type, and frequency of use of fat in the diet. Quite often the content of fat discussions included dietary spreads, cheeses, cooking fats, and the quantity and type of fats in the diet (see Table II). Also, the opening of physical activity discussions consisted of short monitoring statements and expressions, which involved brief comments on physical activity (see Table III).

Opening themes of counselling sessions and participants’ feedback

In dietary discussions, the feedback of patients often consisted of comments on the opening statements of nurses or physicians. Thus, as in physical activity counselling, the feedback of patients was equally minimal in expression and commentary. The feedback of health professionals during physical activity counselling was mostly minor (see Tables II and III). The example, “Type of fat, quantity, does the wife say anything about that?” (Nurse 2) describes how the nurse opened the extensive theme of discussion on the quantity and type of fats, but the details of implementing this were left to the patient.

The participants expressed their minimal feedback as “yeah, well, hmm” (see Tables II and III). The feedback of the patient [11] might be a comment on not being able to exercise, a clarification, or short responses to indirect questions.

The health professionals did not emphasize the crucial significance of nutrition and physical activity for diabetes care (see Tables II and III). The patients were already aware of the significance of fats for diabetes care, yet they downplayed the role of fats somewhat. The experts did not specify in detail the causes of high cholesterol levels but turned the discussion to other themes such as blood sugar levels. Physical activity in the care and prevention of diabetes was only rarely mentioned (see Table III).

The patients also expressed, through their verbal reactions and comments, the fact that they had previously received advice on dietary fats and physical activity. They knew the quantity and type of fats in dietary spreads and cheeses but remained unwilling to adopt new health habits, which they honestly admitted. The patients were already aware of the facts but they did not know the consequences. Besides, the patients avoided discussing nutrition and changed the topic of conversation to themes more agreeable to themselves.

Discussion

In this study, as in earlier studies [10], [12], the physicians and nurses often devoted little time to dietary and physical activity counselling. In Finland, diabetes counselling for outpatients is organized in primary healthcare units and nurses and physicians play a major role in health counselling [22]. Appreciation should be shown in order to motivate health professionals to carry out health counselling. The resources in primary healthcare are limited and supporting the health behaviour changes of patients requires time for counselling sessions by health professionals and also, occasionally, cooperation between several health professionals [5], [23].

The results indicate that merely increasing time or personnel resources is not sufficient for the development of dietary and physical activity counselling. While the feedback of patients often consisted of comments on the opening statements of the nurses or physicians, the health professionals were not eager to discuss the subjects. Perhaps they did not want to appear to propagate “health terrorism” or did not have sufficient knowledge of nutrition and physical activity counselling. The patients may be in an unfamiliar situation, such as being recently diagnosed with diabetes or IGT, and their competence to discuss this kind of information may be insufficient.

The discussions revealed the limitations of the conversational skills of both the patient and the health professional. In individualized treatment and counselling, motivational interviewing, shared decision-making, concrete written goal-setting, and problem definition are important motivational tools in achieving the best possible blood glucose, blood pressure, and lipid levels [24], [25].

The patients reported that they had already received information on nutrition and physical activity. The nurses and physicians did not advise the patients in detail on how to implement their knowledge. The patients need information about the consequences of inactivity and an unhealthy diet. An assessment of the patients’ knowledge is necessary because their state of health may change. On the other hand, with the food industry continually introducing new products, the sources of fat are changing [7]. The monitoring of dietary fats, snacks, sweets, and salty pastries should be carried out in more detail, making the content of counselling more effective, personal, and relevant to the patients’ needs.

In interpreting the results of this study, one needs to consider that no special arrangements were made for data collection because the consultations were an integral part of the patients’ diabetes or IGT care. Some concern may arise regarding selection bias because the patients and the healthcare professionals participated in this videotaping study voluntarily. The accuracy of the data interpretation was ensured by investigator triangulation with debriefing sessions in which the researcher (MP) and a research trainee read the transcripts and categorized the expressions of nutrition and physical activity speech. Their interpretations were in agreement [26]. The content analysis has already illuminated many aspects of diabetes counselling. At a later stage, data analysis by Conversational Analysis (CA) [27] could yield more information on participants’ interpretation of the nature and meaning of words.

The cultural differences and the number of persons participating in this study were small, weakening the ability to generalize the results. However, the videotaped encounters are comparable with earlier research data [13]. Furthermore, analysis of other aspects of the discussions, namely the duration and opening of the consultations and the participants’ responses to them, will give more detailed information regarding the skills of healthcare professionals in supporting lifestyle changes.

The results of this study recommend more detailed videotaped studies to determine what counselling content, practices, and skills would lead to positive lifestyle changes in the long term. Achieving improved implementation of dietary and physical activity counselling in healthcare settings will require the education and training of communication skills for healthcare professionals. The great challenge of healthcare is to develop new action models that support high-quality counselling based on current resources.