‘The Sugar Buddies’: an intervention programme for ‘obese’ patients with poorly controlled...

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Journal of Human Nutrition and Dietetics (1999), 12 (Suppl. 1), 71–78 # 1999 Blackwell Science Ltd. 71 Ahed Bhed Ched Dhed Ref marker Fig marker Table marker Ref end Ref start ‘The Sugar Buddies’: an intervention programme for ‘obese’ patients with poorly controlled diabetes J. Hughes, V. Todorovic and H. Kemp Dietetic and Nutrition Services, Bassetlaw Hospital, Worksop, Notts, UK Background: Within the Bassetlaw Diabetes Clinic population a group of obese patients with poorly controlled diabetes were identified, who appeared to be resistant to standard intervention. An alternative approach, the ‘Sugar Buddies’ programme, was developed, focusing on gradual weight loss and improved glycaemic control. Development of self-care behaviours such as healthy eating, following prescribed testing and medication routines was encouraged. Programme participants attended either individual sessions or a combination of individual sessions and group sessions provided jointly by a diabetes specialist dietitian and diabetes specialist nurse. Aims: To evaluate the effectiveness of the ‘Sugar Buddies’ programme in achieving weight loss and/or improved glycaemic contol in a group of obese patients with poorly controlled diabetes. Method: Measurements of weight and glycosylated haemoglobin (HbA1 c )were made at 6, 12 and 18 months on 50 patients participating in the pilot programme. The programme included patients with Type 1 and Type 2 diabetes. All patients had an initial body mass index (BMI) 4 30 kg/m 2 and HbA1 c 4 7%. Outcome measures: The proportion of patients who were able to achieve gradual weight loss (a minimum of 2.5 kg over 6 months) and sustain this minimum weight loss over 6, 12 and 18 months. The proportion of patients who were able to achieve a reduction in HbA1 c of at least 1% against individual baseline measurements over 6 months, and sustain this reduction over 6, 12 and 18 months. Results: Patients who achieved an initial minimum weight loss of 2.5 kg at 6 months were likely to sustain this weight loss at 12 and 18 months. Patients attending group sessions were more likely to achieve weight loss. Some of the patients who did not achieve weight loss at 6 months but continued in the programme achieved the minimum weight loss goal at 12 and/or 18 months. Patients who achieved a reduction in HbA1 c at 6 months were likely to sustain these improvements at 12 and 18 months. Patients attending group sessions were more likely to sustain improvements in HbA1 c values. Length of participation in sessions had no impact on HbA1 c improvements. At 6 months, three patients (6%) had achieved both a weight loss 5 2.5 kg and a reduction of at least 1% in HbA1 c . Conclusions: The programmes focus on making lifestyle changes achieved a measure of success in weight loss and/or improved glycaemic control among patients previously resistant to intervention. Key words: obese patients, diabetes, weight loss, glycaemic control. Introduction and Background While obesity, and in particular the increasing prevalence of obesity, in the general population is of concern (DH 1992; Knight 1994; Colhoun & Correspondence: Dr V. Todorovic. Paper 12 Disc

Transcript of ‘The Sugar Buddies’: an intervention programme for ‘obese’ patients with poorly controlled...

  • Journal of Human Nutrition and Dietetics (1999), 12 (Suppl. 1), 7178

    # 1999 Blackwell Science Ltd. 71

    Ahed

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    The Sugar Buddies: an intervention

    programme for obese patients with poorly

    controlled diabetes

    J. Hughes, V. Todorovic and H. KempDietetic and Nutrition Services, Bassetlaw Hospital, Worksop, Notts, UK

    Background: Within the Bassetlaw Diabetes Clinic population a group of obese patients

    with poorly controlled diabetes were identified, who appeared to be resistant to standard

    intervention. An alternative approach, the Sugar Buddies programme, was developed,

    focusing on gradual weight loss and improved glycaemic control. Development of self-care

    behaviours such as healthy eating, following prescribed testing and medication routines

    was encouraged. Programme participants attended either individual sessions or a

    combination of individual sessions and group sessions provided jointly by a diabetes

    specialist dietitian and diabetes specialist nurse.

    Aims: To evaluate the effectiveness of the Sugar Buddies programme in achieving weight

    loss and/or improved glycaemic contol in a group of obese patients with poorly

    controlled diabetes.

    Method: Measurements of weight and glycosylated haemoglobin (HbA1c)were made at 6,

    12 and 18 months on 50 patients participating in the pilot programme. The programme

    included patients with Type 1 and Type 2 diabetes. All patients had an initial body mass

    index (BMI) 4 30 kg/m2 and HbA1c 4 7%.Outcome measures: The proportion of patients who were able to achieve gradual weight

    loss (a minimum of 2.5 kg over 6 months) and sustain this minimum weight loss over 6, 12

    and 18 months. The proportion of patients who were able to achieve a reduction in HbA1cof at least 1% against individual baseline measurements over 6 months, and sustain this

    reduction over 6, 12 and 18 months.

    Results: Patients who achieved an initial minimum weight loss of 2.5 kg at 6 months were

    likely to sustain this weight loss at 12 and 18 months. Patients attending group sessions

    were more likely to achieve weight loss. Some of the patients who did not achieve weight

    loss at 6 months but continued in the programme achieved the minimum weight loss goal

    at 12 and/or 18 months. Patients who achieved a reduction in HbA1c at 6 months were

    likely to sustain these improvements at 12 and 18 months. Patients attending group

    sessions were more likely to sustain improvements in HbA1c values. Length of

    participation in sessions had no impact on HbA1c improvements. At 6 months, three

    patients (6%) had achieved both a weight loss 5 2.5 kg and a reduction of at least1% in HbA1c.

    Conclusions: The programmes focus on making lifestyle changes achieved a measure of

    success in weight loss and/or improved glycaemic control among patients previously

    resistant to intervention.

    Key words: obese patients, diabetes, weight loss, glycaemic control.

    Introduction and Background

    While obesity, and in particular the increasing

    prevalence of obesity, in the general population is

    of concern (DH 1992; Knight 1994; Colhoun &Correspondence: Dr V. Todorovic.

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    Prescott-Clarke 1996), there is a segment of the

    population where obesity has a particularly

    detrimental effect. Diabetes is the fourth leading

    cause of death in the UK. Approximately 85% of

    patients diagnosed with diabetes will be classi-

    fied as having type 2 diabetes (Dowse et al. 1989).

    Of these, 80% will be overweight or obese (BMI

    4 25) and up to 50% will be dyslipidaemic ondiagnosis (De Grauw et al. 1995). Cardiovascular

    disease is 24 times more prevalent than in the

    general population and is the major cause of

    death in Type 2 diabetes (De Grauw et al. 1995).

    The Cardiovascular Disease Sub Group report

    to the St Vincent Joint Task Force on Diabetes

    concluded that weight loss is the most important

    change necessary to improve or correct the risk

    factors for Coronary Heart Disease in Diabetes

    (DH/BDA 1995).

    Other benefits of weight loss for obese patients

    with type 1 or type 2 diabetes, range from

    improvements in blood glucose control to pro-

    longed survival (Lean et al. 1990; Ross et al. 1997).

    Thus, weight loss becomes an important goal for

    obese patients with diabetes. However, weight

    loss and in particular sustained weight loss, is an

    elusive goal for most patients with type 2

    diabetes (Uusitupa et al. 1993).

    The Diabetes Control and Complications Trial,

    a large multicentre study in North America,

    established that tight glycaemic control improved

    health outcomes for patients with type 1 diabetes.

    In the study report, it was recommended that

    tight glycaemic control should be a goal for

    patients with type 2 diabetes. The expectation is

    that improved control will lead to improved

    health outcomes (American Diabetes Association

    1998). However, one of the risks of tight control is

    weight gain (Wing et al. 1990).

    Since 1994, The Bassetlaw Hospital Diabetes

    Resource Centre has provided multidisciplinary

    care and education to patients with diabetes

    within a consultant-led clinic. Standard treat-

    ment practice for obese patients with diabetes is

    advice from the consultant to lose weight and a

    referral for weight loss counselling to the

    dietitian working in the clinic. Patients are seen

    by the dietitian during the consultant clinic for

    initial assessment and then are offered follow-up

    care by the dietitian during a consultant clinic or

    in their GP surgery, whichever is most appro-

    priate for the patient.

    Within the clinic population, there are a group

    of patients who have been resistant to interven-

    tion. These patients are obese, with a body mass

    index (BMI) greater than 30 and have elevated

    glycated haemoglobin (HbA1c 4 7.0). Thisdifficult group have been given guidance (includ-

    ing dietetic counselling), on one or more occa-

    sions, to reduce weight. Many have experienced

    continued weight gain and/or a reduction in

    blood glucose control over the past year with

    standard practice. An efficient alternative ap-

    proach was considered essential for this group.

    Several studies have suggested that, in order to

    achieve sustained weight loss and improvement

    in metabolic control in diabetes, a continuous

    care model with gradual lifestyle changes is likely

    to be the most effective strategy (Goodrick &

    Foreyt 1991; DCCT Research Group 1993).

    In September 1995, The Sugar Buddies pro-

    gramme was established to provide an alternative

    treatment approach for a difficult cohort who had

    not achieved satisfactory outcomes with the

    standard treatment approach. The Sugar Buddies

    programme encourages the development of self-

    care behaviours, the tasks and activities that the

    patient takes responsibility for to improve their

    level of health care. The initial focus of the

    programme, for the majority of patients, was to

    stop weight gain and progress to weight loss.

    Aim

    This study was undertaken to evaluate the

    effectiveness of The Sugar Buddies programme

    in achieving weight loss and/or improved glycae-

    mic control in a group of obese patients with

    poorly controlled diabetes.

    The Sugar Buddies Programme

    The Sugar Buddies Programme is based on a

    model of continuing care. It uses a team approach

    with a relaxed environment, to assist in the

    management and care of patients with diabetes

    who have failed to achieve satisfactory outcomes.

    The programme is based on current evidence of

    effective chronic disease management and incor-

    porates behaviour change strategies (DCCT

    Research Group 1993; DEramo-Melkus et al.

    1992). Weight loss theories that support the

    concept of slow but sustained weight loss and

    improved glycaemic control formed the basis for

    programme development (Raz et al. 1988; Man-

    ning et al. 1995; American Dietetic Association

    1997; British Dietetic Association 1997).

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    Group work was incorporated into the pro-

    gramme, as an option, for both peer support and

    to provide an efficient means of frequent on-going

    contact for large numbers of patients (Wilson &

    Pratt 1987; Jones et al. 1989; Campbell et al. 1990).

    The main objectives of the programme are:

    . to help patients achieve gradual weight lossthrough behaviour changes and to sustain or

    improve weight loss over time (Goodrick &

    Foreyt 1991; Harris et al. 1988; American

    Dietetic Association 1997);

    . to help patients achieve a reduction in HbA1cthrough behaviour changes, and sustain or

    improve this reduction over time (American

    Diabetes Association 1998; American Dietetic

    Association 1997).

    Programme structure

    Process. The consultant diabetologist refers

    patients to the programme. Patients typically

    present with weight management concerns (BMI

    4 30) and a high HbA1c (4 7.0%). Entry into theprogramme is open-ended. Initially, the diabetes

    specialist dietitian and the diabetes specialist

    nurse see each patient, on an individual basis, in

    a combined clinic. A nursing and nutritional

    history is completed at initial clinic attendance,

    including information on blood glucose or urine

    glucose self-monitoring, height, weight, medica-

    tions, and usual food and activity patterns.

    Patients are offered the option of individual

    clinic appointments monthly (unless required

    earlier for monitoring of medication therapy),

    and/or weekly group education and support

    sessions which patients may access as desired.

    Patients are encouraged to attend group sessions

    as they offer peer support, educational sessions

    and increased contact frequency. However, pa-

    tients are not required to attend group sessions.

    The group sessions have an open continuing

    format with topics developed on the basis of

    patients need and request. The dietitian facil-

    itates most group sessions with the nurse joining

    in for the drop-in session. The programme is

    flexible, enabling patients who initially may not

    have attended group sessions to do so at any

    point in their programme of care.

    The length of time that patients continue to

    come to group sessions is based on the patients

    perception of their own needs and interest. The

    length of attendance for the individual sessions is

    generally a joint decision by the combined clinic

    staff and patient.

    Programme components

    Individual sessions. The Sugar Buddies indivi-

    dual sessions are based on work by Laurie

    Ruggiero and her interpretation of Prochaska and

    DiClementes Stages of Change Model for practical

    application to help people with diabetes make

    necessary changes (Prochaska & DiClemente 1986;

    Ruggiero 1990). The stage of change is identified at

    the initial session and barriers to progress and

    temptations are discussed. Strategies such as role-

    playing situational temptations may be employed

    to identify coping strategies. Reducing temptation

    and increasing the patients self-confidence in their

    ability to make changes are the main focus of the

    interventions thus; the program encourages pa-

    tients to move through the stages of change.

    Group sessions. The Sugar Buddies group

    sessions are based on increasing knowledge,

    developing skills, and improving attitudes to-

    wards diabetes self-care. The sessions include a

    mixture of interactive discussions, activities, and

    lectures. Each session focuses on a single element

    of diabetes self care and is either knowledge-

    based or skill-based. During the group sessions,

    patients are encouraged to interact, problem-

    solve, and provide support and suggestions for

    each other. The drop-in portion of the group

    sessions provides an opportunity for individual

    queries and a weight check.

    Increasing knowledge. The educational compo-

    nent of the programme focuses on increasing

    knowledge of how diabetes affects the body, the

    treatment and management of diabetes, the

    principles of weight management, and healthy

    eating for weight loss.

    Developing skills. Group and individual activities

    are planned in a manner designed to encourage

    the development of skills. Activities such as a

    supermarket tour help patients develop the skills

    to select appropriate foodstuffs. Label-reading

    exercises help patients choose foods with a lower

    dietary fat content. Meal planning exercises

    based on the patients usual meal habits help

    identify areas for change and help patients plan

    meals that meet their needs, their budgets, and

    their tastes.

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    Improving attitudes. Patients are encouraged to

    develop confidence in their ability to make

    dietary change by keeping records of food intake.

    By assessing their own eating habits and accept-

    ing recommended dietary changes to reduce

    dietary energy intake, patients develop increased

    confidence in their ability to manage their

    self-care.

    Through the process of monitoring blood

    glucose or testing urine, patients are encouraged

    to interpret tests and respond appropriately to

    test results and follow prescribed medication

    regimens. Patients begin to understand the

    impact that activity and stress can have on

    overall diabetes management.

    Healthy eating for weight management. The

    Healthy Eating for Weight Management compo-

    nent of the programme is based on the Healthy

    Eating Guidelines for Diabetes (British Diabetic

    Association 1992). Throughout the programme, in

    both individual and group sessions, patients are

    encouraged to focus on lifestyle changes that may

    lead to weight loss, rather than to focus on

    weight loss.

    Healthy eating stresses changing eating beha-

    viours by reducing dietary fat intake and

    increasing intake of fruit and vegetables. Studies

    indicate that most patients with diabetes, con-

    sume more than 40% of their energy from dietary

    fat (Humphreys et al. 1994) rather than the 35%

    recommended in current dietary guidelines (DH

    1991). This high intake of fat may occur because

    many patients with diabetes continue to focus on

    reducing added sugar in the diet rather than

    reducing and changing the type of dietary fat

    (Pearson 1996). Recent work supports the concept

    that reducing dietary fat may lead to sustained

    weight loss (Carmichael et al. 1988).

    Programme evaluation

    In 1997, an evaluation of The Sugar Buddies

    programme was undertaken to determine the

    effectiveness of the overall programme and to

    determine whether there were differences in

    outcomes for patients attending both group and

    individual sessions compared to those only

    attending individual sessions.

    The outcome measures used to determine

    programme effectiveness were:

    . the proportion of patients who achieved aminimum weight loss of at least 2.5 kg over

    6 months and sustained this weight loss at

    1 year and 18 months;

    . the proportion of patients who reduced theirHbA1c by 1% against individual baseline

    measurements over 6 months and sustained

    this at 1 year and 18 months;

    . the proportion of patients who achieved aminimum weight loss of at least 2.5 kg in 6

    months and a reduction in HbA1c of at least

    1% against individual baseline measurements

    over 6 months and sustained this at 1 year and

    18 months.

    Methods

    The patient population

    The evaluation included all adult patients

    (n=50) involved in The Sugar Buddies pro-

    gramme from January 1996 to December 1997. All

    patients had diabetes, a BMI greater than 30 and

    glycosylated haemoglobin (HbA1c) greater than

    7%. Characteristics of the patient group are

    described in Table 1.

    Table 1. Patient Characteristics at entry to the programme

    Age, range in years 2249.9 5064.9 6575

    Number (%) 14 (28%) 27 (54%) 9 (18%)

    BMI Mean (range), kg/m2 36.6 (30.345.2) 35.5 (30.545.3) 35.0 (30.744.0)

    HbA1c Mean (range),% 8.4 (7.39.8) 8.3 (7.011.1) 8.5 (7.110.8)

    Sex M/F 8/6 14/13 3/6

    Treatment:

    Diet only 1 0 1

    Oral hypoglycaemic agents (OHA) 2 10 1

    OHA & insulin or insulin only 11 17 7

    Type of Diabetes:

    Type 1 4 2 0

    Type 2 10 25 9

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    Measures

    Anthropometric. Patient heights and weights

    were recorded at initial visit. BMI was calculated

    from height and weight data. The clinic staff

    nurse, using a Seca height meter attached to the

    wall, measured height on all participants. Pa-

    tients were weighed on Seca Alpha Model 770

    scales on an uncarpeted floor. The scales are

    under an annual maintenance contract.

    Weights were also taken at 6, 12, and 18

    months follow-ups.

    Somatic. HbA1c assay measurements were

    collected at the beginning of the programme.

    Further HbA1c assay samples collections

    were scheduled for patients at dates close to 6-,

    12-and 18-month programme anniversaries.

    HbA1c assay was measured using a Corning

    Glycomat 765 Analyser with standardized

    laboratory procedures.

    In addition, telephone interviews were under-

    taken to obtain qualitative data on experience of

    group sessions and identify reported dietary

    changes. These results are not presented in

    this paper.

    Data analysis

    Analysis of quantitative data were completed

    using SPSS for Windows (1993) Version 6.

    Relative risk (RR) were calculated using Epi Info.

    (Dean et al. 1994).

    Results

    The data were analysed according to the length of

    time the patient had been involved in the

    programme. Because the programme is open-

    ended and continuing, separate results are

    reported for 6 months, 12 months, and 18 months

    of participation. At the point of evaluation, 22

    patients had participated in the programme for

    18 months, a further 16 had completed 12 months

    and a further 12 patients had completed

    6 months. This provides both a snapshot of

    programme effectiveness after different lengths of

    participation and also how well patients sus-

    tained improvements over time.

    Changes in weight and sustainability

    The numbers and proportions of patients achiev-

    ing a weight loss of 2.5 kg or more at 6, 12 and 18

    months are shown in Table 2.

    Analysis of the 38 patients who had been in the

    programme for one year showed that of the nine

    who had achieved weight loss at 6 months, seven

    sustained weight loss at 12 months. A further

    three who had not achieved weight loss at

    6 months achieved a weight loss at 12 months.

    Analysis of the 22 patients, who had been in

    the programme for 18 months showed that of the

    five patients who achieved a weight loss at

    6 months, three had sustained weight loss at both

    12 and 18 months. A further two achieved weight

    loss by 18 months.

    Changes in HbA1c and sustainability

    Blood samples were routinely collected on or

    within a few weeks of the patients initial visit.

    However, failure to follow up collection of blood

    samples at 6, 12 and 18 months from patient

    visits that were cancelled, rescheduled or not

    attended resulted in incomplete data collection. It

    was not possible to obtain the HbA1c data on

    eight out of 50 (16%) of patients at 6 months,

    11 of 38 (29%) patients at 12 months and on

    seven of 22 (32%) patients at 18 months.

    The numbers and proportions of patients who

    achieved a change in HbA1c of 1% or more at 6,

    12 and 18 months is shown in Table 3.

    Analysis of HbA1c assays of 27 patients, who

    had been in the programme for 1 year showed

    that, of the five who had achieved a reduction in

    Table 2. Patients achieving weight loss 5 2.5 kg at 6, 12 and 18 months (WL)

    Programme length n WL at 6 months n HbA1c n WL at 18 months

    Count (%) Count (%) Count (%)

    6 months 12 4 (33.3)

    12 months 16 4 (25.0) 16 5 (31.3)

    18 months 22 5 (22.7) 22 6 (27.3) 22 7 (31.8)

    Total No. 50 13 (26.0) 38 11 (28.9) 22 7 (31.8)

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    HbA1c at 6 months, three sustained a reduction

    in HbA1c at 12 months. A further two who had

    not achieved a reduction in HbA1c at 6 months

    achieved a reduction in HbA1c at 12 months.

    Analysis of HbA1c assays of the 15 patients,

    who had been in the programme for 18 months

    showed that of the three patients who achieved a

    reduction in HbA1c at 6 months, three had

    sustained a reduction in HbA1c at 18 months.

    Data was only available for one of these patients

    at 12 and 18 months.

    Sustainability of both weight loss and HbA1c

    Three patients achieved both a reduction in

    HbA1c of 1% or more and a reduction in weight

    of 2.5 kg or more at 6 months.

    One patient achieved a sustained weight loss

    and a sustained reduction in HbA1c at 1 year.

    This same patient had sustained weight loss and

    a reduction in HbA1c at 18 months.

    Table 4 shows the numbers and proportions

    who achieved either or both a reduction in HbA1cand weight of 2.5 kg or more according to

    whether they attended group sessions or not.

    Whilst only 19 (38%) of patients attended group

    sessions, a higher proportion of these reduced

    their HbA1c by 1% or more than those who did

    not attend group sessions (32% and 19%,

    respectively). Likewise a higher proportion of

    those attending group sessions reduced their

    weight by 2.5 kg or more than those not attending

    group sessions (37% and 19%, respectively).

    Discussion

    As all patients had been referred to the pro-

    gramme due to failure to achieve satisfactory

    outcomes in standard treatment protocols, any

    positive outcome in this group was viewed as

    success. Patients did not come to the programme

    because they had decided to lose weight, or

    improve their blood glucose control but because

    they were referred to the programme by the

    consultant. In some instances patients were

    pleased to be offered a new source of help, but

    most initial appointments were viewed with

    suspicion. Many patients felt that any effort to

    control their blood sugar or manage their weight

    would be futile. At the point of evaluation the

    pilot programme has been running for 18 months.

    Despite initial scepticism, only two patients were

    no longer attending the sessions demonstrating

    that a good level of commitment to the programme

    had been achieved. However, it must be noted that

    due to the nature of diabetes care, annual clinic

    visits are scheduled for patients so there is some

    pressure to attend if only to assure the consultant

    an effort was made to comply with advice!

    Half of the patients involved in the programme

    experienced either weight loss greater than 2.5 kg

    in 6 months or a reduction in HbA1c of one

    percentage against baseline measurements. For a

    group that had not achieved success previously,

    this seemed a slow but impressive start, particu-

    larly since 72% of the group were over the age of

    50 years and had very reduced or impaired

    physical activity on initial interviews.

    Table 4. Changes in weight, HbA1c at 6 months by attendance at group sessions

    Criteria Attended group sessions Did not attend group

    RR

    n Count (%) n Count (%)

    HbA1c drop 5 1% 19 6 (32) 31 6 (19) 1.63Weight loss 5 2.5 kg 19 7 (37) 31 6 (19) 1.9Both HbA1c drop 5 1%and Weight loss 5 2.5 kg 19 2 (11) 31 1 (3) 3.26

    Table 3. Patients achieving a reduction in HbA1c by 1% or more at 6, 12 and 18 months (c Hb).

    Programme length Na/n* cHb at 6 months n cHb n cHb at 18 months

    Count (%) Count (%) Count (%)

    6 months 11/12 3 (27)

    12 months 15/16 5 (33) 13/16 5 (38)

    18 months 16/22 4 (25) 14/22 2 (14) 15/22 5 (33)

    Total Nos. 42/50 12 (28) 27/38 7 (26) 15/22 5 (33)

    *Na=number of HbA1c assays available, n=number of patients in programme

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    As one would expect with a patient group,

    whose blood glucose values were significantly

    higher than recommended, the first effect of

    dietary intake reduction was to reduce blood

    glucose rather than reduce weight. Only three

    patients were able to fulfil both criteria of weight

    loss and improvement in HbA1c. It often seemed to

    both patients and staff alike that patients, whose

    diabetes control was poor, required an almost

    impossibly high level of co-ordination to achieve

    both goals. Many patients had experienced fre-

    quent episodes of hypoglycaemia as well as

    hyperglycaemia prior to entry into the programme.

    There was considerable reluctance on the part of

    the patient to run any risk of hypoglycaemia and

    there was often a lack of awareness of warning

    signs prior to the onset of hypoglycaemia.

    The small sample size made it unlikely that

    statistically significant results would be found

    even with large effects. The impact of the group

    sessions, although not significant statistically,

    was noticeable. Patients attending groups were

    1.9 times more likely to experience weight loss

    than those who did not attend group sessions.

    Also, although not significant statistically,

    those who attended group sessions were 1.6

    times more likely to achieve an improvement in

    HbA1c values.

    The proportion of patients who achieved the

    modest weight loss goal was small. However,

    those who achieved weight loss were likely to

    sustain their weight loss up to 12 and 18 months.

    It is also of note than success in weight loss for

    some patients was achieved with greater length

    of contact, achieving goals in 12 months rather

    than 6 months.

    Patient commitment to the programme is

    evident, as after 18 months only two patients

    are no longer participating in the programme.

    Continued patient participation is hopefully a

    step towards responsibility for self-care and thus

    the behaviour changes required for continued

    and sustained weight loss.

    Conclusions

    Study results indicate that for a sector of this

    population, group sessions are an acceptable

    method of maintaining contact and, thus perhaps,

    promoting adherence and assisting in sustaining

    weight loss. Study numbers are too small at this

    time to provide any conclusive answers. The

    programme will need to be re-evaluated when

    patient numbers are greater.

    Pre-programme tests of self-care behaviours, as

    well as dietary records should be incorporated

    into the programme. HbA1c assays should be

    scheduled at regular intervals. The present

    practice left gaps in available data.

    The programmes focus on making lifestyle

    changes achieved a measure of success in weight

    loss and/or improved glycaemic control despite

    working with patients resistant to intervention.

    Although it is a slow method of achieving weight

    loss, there appears to be good potential for not

    only sustained weight loss but also further

    weight loss for this patient group. As diabetes

    is a lifelong condition, a programme that sup-

    ports and encourages appropriate self-care beha-

    viours in a continuous model appears to offer

    potential for long-term weight management and

    thus improved health outcomes for patients

    with diabetes.

    Acknowledgements

    The Department of the Health for the grant which

    made it possible to carry out an evaluation of

    The Sugar Buddies programme. Mark Myatt,

    consultant epidemiologist for his invaluable help

    and advice. The Sugar Buddy team Gill French,

    diabetes specialist nurse and Dr Roger Blandford,

    consultant for his tremendous support of the

    programme; Diane, who always tracked down the

    records, Judy for assistance with the typing, and

    all the staff of the Diabetes Centre.

    References

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