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  • Writer's pictureAllan Fjelmberg, lege

Motivational interviewing for Diabetes type 2

Updated: Mar 19, 2023



Introduction

Diabetes type 2 is one of the fastest growing chronic diseases in the world today. Over the last 30 years the incidence has tripled in Norway and it is estimated that today there are about 265,000 Norwegians, or about 5% of the population which have diabetes type 2. Worldwide, there are around 350 million people with diabetes, and each year there are over seven million people who develop the disease (Claudi, & Løge, 2014). Diabetes was previously most common in Western countries and associated with prosperity and abundance, but it is expected that the largest increase in the future will occur in developing countries, especially in Asia and Africa. In China, the incidence (in percent) of Diabetes has increased tenfold since 1980 and today there are about 98 million Chinese with this disease (Hu, 2011). In some countries in the Gulf and ion certain Pacific islands the prevalence of Diabetes is at 20-35% of the adult population.

Type 2 diabetes was for a long time known as aldersdiabetes (Norwegian: Diabetes in older age) because it was essentially a disease was observed in older people. However, the disease has also begun to affect teenagers and children. It does not end there. Also among pets, we see an increase of diabetes. In England it is estimated that 25 percent of dogs ​​and every three cats are now overweight, which increases the risk of diabetes, cardiovascular disease and other lifestyle diseases (Orr, 2012).


Diabetes and Disease

Even in our modern times with continual development of better medication options for Diabetes patients the disease remains a serious disease that can cause a variety of chronic, debilitating, and potentially fatal complications and increases the risk of several diseases. Diabetes increases the risk of morbidity and mortality from cardiovascular disease 3-4 times, including coronary heart disease and stroke. Furthermore, Diabetes increases the risk of developing infections, neuropathies, dementia, kidney and eye disease.


Risk Factors

The main reasons for the sharp increase in Diabetes type 2 during the recent decades are mainly (Claudi, & Løge, 2014), increase in obesity, less physical activity, changed diet, older population (mainly due to age-related obesity and inactivity)

Beyond this heredity also plays a role. If one parent has type 2 Diabetes there is a 40 percent increased lifetime risk of developing Diabetes. However, it is largely lifestyle factors that determines whether the person develop the disease.

Obesity is one of the most important risk factors for Diabetes type 2. A BMI > 35 increases the risk of developing the disease by 93 times. Especially abdominal obesity is associated with a high risk of Diabetes. Gestational diabetes, impaired glucose tolerance, daily smoking and serious mental illness are also risk factors for diabetes. In addition, certain medications increase the risk of diabetes, such as for example corticosteroids and cholesterol-lowering medications (9 percent) (Sattar, Preiss, Murray, Welsh, Buckley, de Craen, ... & Ford, 2010).


Diabetes and lifestyle

There are few other diseases in which lifestyle plays a more important role in prevention and treatment than in Diabetes type 2. About 90 percent of all cases of Diabetes type 2 can be explained by 5 lifestyle factors: Activity level, diet, smoking, alcohol intake and weight/fat% (Mozaffarian, Kamineni, Carnethon, Djoussé, Mukamal, & Siscovick, 2009).


People at high risk of developing Diabetes type 2 may reduce their risk of developing the disease by at least 50% through reduce weight by 5 percent, reduce total fat intake to below 30 percent of daily calories, reduce saturated fat below 10 percent of total calories per day, eat 15g of fiber per 1000kcal of food, minimum 150 minutes of physical activity per week.

The same lifestyle factors (diet, activity, optimize weight, stop smoking, etc.) are also very important in managing Diabetes and may sometimes reverse the condition


Literature review

For most people behavior change is one of the most important factors in prevention and management of Diabetes type 2. However, for many people it is a challenge to change lifestyle, including activity level, diet, weight reduction, and others. As a physician I and my colleagues in primary or relevant specialized healthcare may often find ourselves with limited success in helping our patients to adopt a healthier lifestyle. There is often a shortage of time available for dealing with lifestyle factors in a regular visit. What can a physician do in order to optimize behavioral change in the patient suffering from or at high risk of developing Diabetes?


Research into the field of motivational interviewing style has investigated the effect motivational interviewing has on various aspects of Diabetes type 2 patients, and it is the intention of this review to review the findings from the scientific literature.


What do Diabetes patients think about MI?

What are the experience and feelings among people with Diabetes type 2 about being exposed to MI by their health providers? In a qualitative study of 19 adults with Diabetes type 2 Dellasega and colleagues (2012) set out to answer this question. The setting was a family or internal medicine practice clinic. The participants stated that standard care was associated with negative experiences, several individuals describing demeaning and paternalistic attitudes. The participants associated MI with the following:

  • Non-judgmental

  • Accountability

  • Being heard

  • Being responded to as a person

  • Encouragement and empowerment

  • Collaborative action planning and goal setting

  • Coaching rather than critiquing

Participants experienced MI as more patient centered and empowering compared to standard care. Knowing that Diabetes patients prefer an MI style intervention rather than standard care should encourage physicians to consider learning MI and educate themselves about in which areas of medicine MI has documented effects.


MI, Diabetes and beyond

Motivational interviewing (MI) style has been shown to have positive effects over a range of medical conditions. Reviews on MI has focused most on mental health outcomes and outside primary care settings. In a systematic review and meta-analysis of randomized controlled trials investigating the effects of motivational interview in medical care settings, Lundahl and colleagues (2013) included 48 studies (9618 participants) and found that the effect of MI was statistically significant with a modest advantage for MI (odd ratio = 1.55). The authors found particularly positive effect in areas including HIV viral load, detal outcomes, death rate, body weight, use of tobacco and alcohol, activity level, confidence in change, self-monitoring and approach to treatment. MI was not found to be effective for eating disorders or self-care behaviors healthy eating behaviors and blood glucose. Thus MI seems to be beneficial to a variety of conditions and markers of positive health outcome in a time limited consultations. Some of the findings from this review is of particular interest to Diabetes, as MI had positive effect on

  • Body weight

  • Activity level

  • Self-monitoring

These are three important factors relating to Diabetes management. On the other side eating behaviors and blood glucose did not seem to improve with MI in a brief primary care setting.

Motivational interviewing and weight loss

One of the most important impact on Diabetes type 2 is weight. Weight reduction is often the most effective and sometimes the only treatment necessary to control and even reverse the condition. In a systematic review and meta-analysis of randomized controlled trials which investigated the effect of MI on weight loss in overweight/obese adults, Armstrong and colleagues (2011) included 11 studies and found that MI was associated with a statistically significant greater weight loss in body mass compared to controls (-1.47kg). MI sessions lasted in total between 50-323 minutes. The authors could not conclude on optimal dose of MI and which patients benefit the most from MI. Thus, MI may significantly enhance weight reduction among overweight and obese people.


In a review of the potential for MI to improve outcomes in the management of Diabetes and obesity, Christi and Channon (2014) searched the literature between 2006-2011. The authors concluded that MI may be effective in weight and Diabetes control, particularly if more sessions are delivered using an individualized approach. For adult obesity MI alone over 4 sessions has been shown in one study to signficantly improve BMI and self-efficacy in overweight and obese women. MI has also been shown to improve HbA1c.


Do all people with Diabetes type 2 respond equally to MI where weight loss is the focus? In a randomized controlled trial of women with Diabetes type 2 West and colleagues (2007) conducted an 18 month group based behavioral obesity treatment with MI as an adjunct to the weight loss program. They observed that women receiving MI intervention had increased weight loss through an enhanced adherence to the weight loss program. African-American women lost less weight than white women and had less benefit from the addition of MI to the weight loss program. The authors also found that MI at 6 months gave more HbA1c reduction compared to 18 months.


In a second study also including Afro-American obese women, Befort and colleagues (2008) wanted to examine if adding MI to a 16-week weight loss program plus MI sessions improved weight loss among obese African-American women. The control group received health education classes instead of MI sessions. The authors found that both groups lost a significant amount of weight. However, adherence to the behavioral weight loss program and changes in diet, physical activity, and weight did not differ across MI and health education groups. The authors mentioned that sustained motivation for weight loss may be particularly challenging for Afro-American women because of socioeconomic and cultural factors.


Weight loss is one of the most important factors in diabetes prevention. In a single-blind randomized controlled trial Greaves and colleagues (2008) assessed the effectiveness of MI delivered to 141 persons with BMI of 28 kg/m2 or higher. The primary outcomes were proportions of participants meeting predefined targets for weight loss (5%) and moderate physical activity (150 min/week) after 6 months. The authors found that in the MI intervention group 24% reached their weight loss target. Only 7% of the controls achieved 5% weight loss. There was no statistically significant difference in physical activity levels between the two groups after 6 months. The authors concluded that short-term weight loss is achievable in primary care using MI.


MI, self-management, HbA1c and antidiabetic medication adherence

Many patients with Diabetes type 2 use antidiabetic medications to regulate the blood sugar, and self-management is an important aspect living optimally with Diabetes. Does MI improve self-management? In a randomized controlled trial Chen and colleagues (2012) included 250 people with type 2 Diabetes. The intervention was based on MI and took into account the readiness to change for each person. The control group received usual care. After three months the authors observed that MI improved significantly both self-management, self-efficacy, quality of life, and HbA1c.


In another study Pladevall and colleagues (2015) wanted to investigate the effect of MI on adherence to antidiabetic medications among people with Diabetes type 2. 556 people received MI and adherence information, 569 received adherence information, while 567 received usual care. MI was provided up to six sessions and outcomes were measured after 18 months. The authors found that neither adherence information nor MI did significantly improve Diabetes control (HbA1c) compared to controls. In addition patient participation was a barrier for MI.


Smoking reduces insulin sensitivity and thus worsens diabetes. In addition it is an independent risk factor for atherosclerosis, a condition diabetics are more prone to due to increased blood glucose levels. Smoking cessation among diabetics will therefore be very beneficial and reduce the risk of complications of Diabetes.


In a study by Hokanson and colleagues (2006) they investigated the impact of a tobacco cessation intervention using MI on smoking cessation rates during diabetes self-management training. They included 114 persons undergoing type 2 diabetes adult education program. One group received standard education while the other group also received MI. Outcomes were tobacco cessation rates, mean number of cigarettes smoked, HbA1c, weight, blood pressure and lipid levels. The authors found a trend toward increased abstinence at 3 months of follow up in the MI group. This trend was not observed after 6 months. MI did not negatively affect either diabetes education or other outcomes measured including HbA1c. However, including MI into the program was no more effective in helping diabetics stop smoking after 6 months.


In a study by Rubak and colleagues (2011) they investigated the effect of MI on target driven intensive type 2 diabetes treatment. GPs were randomized to learn MI or not and the MI was provided by the GPs during the study. After one year HbA1c was significantly improved in both patient groups. There was no significant difference between the groups. Medication adherence was close to 100% within both treatment groups. The authors explain the result by suggesting non-MI GPs may have taken up core elements of MI and that GPs providing MI only used less than planned (1.7 or 3) planned MI consultations.


As noted from the cited studies above the effect of MI on HbA1c is mixed. As a physician it would be relevant to use interventions which has documented effect on the core treatment goal among diabetes patients, namely a good control of HbA1c. In a systematic review and meta-analysis of the effect of MI on HbA1c levels, Jones and colleagues (2014) reviewed the literature in this area. They included 13 studies with a total of 1223 participants diagnosed with type 1 Diabetes and 1895 participants diagnosed with type 2 Diabetes. Duration of intervention lasted between 3 to 18 months. They observed that among people who received motivational intervention had a 0.17% reduced HbA1c level compared to controls. However, the effect was not statistically significant. This meta-analysis thus support the mixed findings in the cited studied above. The authors does not conclude on the effect of MI on HbA1c levels, but asks for more research in this field.


Summary and recommendations

Diabetes patients exposed to MI find it more patient centered and empowering compared to standard care. MI seems to improve self-monitoring and self-confidence in behavior change. MI has further shown to be effective in improving activity level, and also weight reduction through modulation of diet and activity level . On the other hand, a recent meta-analysis did not show effect of MI on HbA1c levels. MI does also not seem to have positive effects on antidiabetic medication adherence. Thus, based on the current research findings I recommend that physicians who want to use MI focus on areas such as self-efficacy, self-monitoring and weight reduction.


Personal application

In my clinical practice at the rehabilitation center where I currently work I have a relatively long admission consultation lasting 45 minutes, and a brief 15 min discharge consultation. During the admission consultation I will have up to 10-15 min available for MI intervention. During the shorter discharge consultation my focus will be on how the patient will follow up on diet and physical activity after he or she leaves our rehabilitation center. However, I usually discuss lifestyle issues most extensively during the longer admission consultation.


Lifestyle change is not always the primary focus, but do come up frequently. It is natural to bring up physical activity level as exercise is a main part of their program during the 3-4 weeks the patients stay with us.

In addition the rehabilitation center serves vegetarian food, which makes talk about dietary factors fairly easy.


MI Introduction questions (not introduction to the consultation)

Exercise

  • "How is your activity level?"

  • "How do you take care of your self in terms of being physically active?"

Diet

  • "How is your typical diet?"

  • "Tell me a little about how you might improve your diet?"

Smoking

(All patients answer whether they smoke, how much, if they have considered quitting, if they want to attend smoking cessation classes during their stay)


1) If the person has ticked «not considered quitting smoking»

  • "I see that you have answered questions about smoking. Would you like to share why you have answered the way you did?"


2) If the person has ticked «Considered quitting smoking», but not «want to attend smoking cessation classes»

  • "I see that you have ticked «I have considered quitting smoking», but have not ticked «I want to attend a smoking cessation class» Would you like to share your thought about why you answered in this way?"


Opening questions during the discharge consultation

Exercise

  • "How was your experience with physical activity during these (3-4) weeks?"

  • "In what way will you be able to follow up on physical activity when you get home?"

Diet

  • How was your experience with a plant based diet?

  • In what way will you be able to include things you have learnt here into your own diet when you get home?



References

  • Armstrong, M. J., Mottershead, T. A., Ronksley, P. E., Sigal, R. J., Campbell, T. S., & Hemmelgarn, B. R. (2011). Motivational interviewing to improve weight loss in overweight and/or obese patients: a systematic review and meta‐analysis of randomized controlled trials. Obesity reviews, 12(9), 709-723.

  • Befort, C. A., Nollen, N., Ellerbeck, E. F., Sullivan, D. K., Thomas, J. L., & Ahluwalia, J. S. (2008). Motivational interviewing fails to improve outcomes of a behavioral weight loss program for obese African American women: a pilot randomized trial. Journal of behavioral medicine, 31(5), 367-377.

  • Chen, S. M., Creedy, D., Lin, H. S., & Wollin, J. (2012). Effects of motivational interviewing intervention on self-management, psychological and glycemic outcomes in type 2 diabetes: a randomized controlled trial. International journal of nursing studies, 49(6), 637-644.

  • Christie, D., & Channon, S. (2014). The potential for motivational interviewing to improve outcomes in the management of diabetes and obesity in paediatric and adult populations: a clinical review. Diabetes, Obesity and Metabolism, 16(5), 381-387.

  • Claudi, T., & Løge, I. (2014). Diabetes type 2. Norsk Elektronisk Legehåndbok

  • Dellasega, C., Añel-Tiangco, R. M., & Gabbay, R. A. (2012). How patients with type 2 diabetes mellitus respond to motivational interviewing. Diabetes research and clinical practice, 95(1), 37-41.

  • Dellasega, C., Gabbay, R., Durdock, K., & Martinez-King, N. (2010). Motivational Interviewing to change type 2 diabetes self-care behaviours. Journal of Diabetes Nursing, 14, 116

  • Greaves, C. J., Middlebrooke, A., O'Loughlin, L., Holland, S., Piper, J., Steele, A., ... & Daly, M. (2008). Motivational interviewing for modifying diabetes risk: a randomised controlled trial. British Journal of General Practice, 58(553), 535-540.

  • Hokanson, J. M., Anderson, R. L., Hennrikus, D. J., Lando, H. A., & Kendall, D. M. (2006). Integrated tobacco cessation counseling in a diabetes self-management training program a randomized trial of diabetes and reduction of tobacco. The Diabetes Educator, 32(4), 562-570.

  • Hu, F.B. (2011). Globalization of Diabetes. The role of diet, lifestyle, and genes. Diabetes Care, 34(6)

  • Jones, A., Gladstone, B. P., Lübeck, M., Lindekilde, N., Upton, D., & Vach, W. (2014). Motivational interventions in the management of HbA1c levels: A systematic review and meta-analysis. Primary care diabetes, 8(2), 91-100.

  • Lundahl, B., Moleni, T., Burke, B. L., Butters, R., Tollefson, D., Butler, C., & Rollnick, S. (2013). Motivational interviewing in medical care settings: a systematic review and meta-analysis of randomized controlled trials. Patient education and counseling, 93(2), 157-168.

  • Mozaffarian, D., Kamineni, A., Carnethon, M., Djoussé, L., Mukamal, K. J., & Siscovick, D. (2009). Lifestyle risk factors and new-onset diabetes mellitus in older adults: the cardiovascular health study. Archives of internal medicine,169(8), 798-807.

  • Orr, J. (2012). Millions of fat cats and dogs are being «killed with kindness». Telegraph, Mar 29

  • Pladevall, M., Divine, G., Wells, K. E., Resnicow, K., & Williams, L. K. (2015). A Randomized Controlled Trial to Provide Adherence Information and Motivational Interviewing to Improve Diabetes and Lipid Control. The Diabetes Educator, 41(1), 136-146.

  • Rubak, S., Sandbæk, A., Lauritzen, T., Borch-Johnsen, K., & Christensen, B. (2011). Effect of “motivational interviewing” on quality of care measures in screen detected type 2 diabetes patients: a one-year follow-up of an RCT, ADDITION Denmark. Scandinavian journal of primary health care, 29(2), 92-98

  • Sattar, N., Preiss, D., Murray, H. M., Welsh, P., Buckley, B. M., de Craen, A. J., ... & Ford, I. (2010). Statins and risk of incident diabetes: a collaborative meta-analysis of randomised statin trials. The Lancet, 375(9716), 735-742.

  • West, D. S., DiLillo, V., Bursac, Z., Gore, S. A., & Greene, P. G. (2007). Motivational interviewing improves weight loss in women with type 2 diabetes.Diabetes care, 30(5), 1081-1087.


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