Diabetes Prevention - An in-depth case study exploring the complexity of lifestyle change in those with ‘pre-diabetes’.

Problem

Due to the personal impact on the individuals and the economic impact on the NHS, type 2 diabetes is a national health priority; in the UK, five million people are living with diabetes, 90% of whom have type 2 diabetes. A further 2.4 million people are estimated to be at risk of diabetes. 10% of the NHS budget is spent on diabetes and related conditions, and the cost is anticipated to rise from £23.7 billion to £39.8 billion by 2035/2036. GPs are incentivised through the NHS GP contract to diagnosis people with a HbA1c between 42-47mmol/l with ‘pre-diabetes’ and offer referrals to interventions. Despite the introduction of the NHS Diabetes Prevention Programme and other disease prevention initiatives the incidence of diabetes continues to rise. There is limited evidence on how receipt of a pre-diabetes diagnosis influences a patient’s health-related lifestyle choices. The aim of this qualitative study was to understand how people interpret and internalise the pre-diabetes diagnosis and how this influences their health-behaviours.

Approach

An in-depth case study of twenty-five people with pre-diabetes was undertaken using narrative interviews, a cultural probe exercise (collecting observational data) and follow up reflective interviews. A thematic and theoretical analysis was undertaken using Bourdieu’s theory of practice.

Findings

Participants diagnosed with pre-diabetes accepted it without resistance but discussed difficulties in lifestyle change. Lifestyles are complex social constructs and people found it difficult to adapt their lifestyles if their habitus (embodied traits and behaviours) didn’t align with health promotion messages from interventions and primary care teams. We identified three different life-worlds which interacted with an individual’s habitus and led to the production of different health behaviours (figure 1). The first was the social context of the home and work – people were strongly influenced by health beliefs of the people immediately around them (e.g. spouse, children, work colleagues). The second comprised wider experiences and settings (e.g. birthday party, going out for dinner). Going against social norms in either life-world risked an individual’s social positioning, cultural belonging and sometimes, job security. This risk was greater than a hypothetical future risk of diabetes. The third life-world was the wider environmental pressures which influence the ability to eat well and exercise (e.g. commercial food environment, access to green spaces, housing insecurity, rising cost of living, food affordability).

Consequences

Current diabetes prevention policies emphasise the individual reducing their own diabetes risk and downplay social and contextual influences on health. Individuals able to sustain long-term lifestyle change were those whose habitus and social context aligned with prescribed behaviour change. They also needed the financial means to effect change and live in communities which encourage health promoting practices.