An In-depth Exploration of Patient and Provider Experiences of Nutrition Care for Prediabetes in Australia

Abstract

Background: Prediabetes is a state of elevated blood glucose levels that does not yet meet the diagnostic criteria for type 2 diabetes (T2D). Prediabetes significantly increases the risk of developing T2D, cardiovascular disease and microvascular complications. Despite the rising global prevalence of T2D, efforts to decrease T2D by intervening at the prediabetes stage are underexplored. Clear evidence-based recommendations highlight the importance of modifying lifestyle behaviours (i.e. improving diet, physical activity and weight management), during the prediabetes stage. Specifically, nutrition care, which includes any effort by a health care provider (HCP) to improve a person’s diet quality, can significantly reduce blood glucose levels among people with prediabetes. Whether this knowledge is being translated to actual practice, and whether prediabetes is recognised and managed in Australia remains unclear, warranting further investigation. To understand the nutrition care delivery for people living with prediabetes in Australia, four aims were addressed in this PhD: i) to synthesise the literature on prediabetes and nutrition care from patient and provider perspectives; ii) to identify patient-related characteristics, factors and experiences associated with receiving nutrition care for prediabetes; iii) to identify HCP-related factors, practices and experiences associated with providing nutrition care to people with prediabetes; and iv) to identify health consumer informed preferences for future practice change. These aims were addressed in four phases of research, using a multi-methods approach which aligned with the pillars of the integrated Promoting Action on Research Implementation in Health Services (i-PARIHS) implementation framework. The i-PARIHS framework is a conceptual framework which proposes its four pillars: innovation, context, recipients and facilitation, be incorporated to successfully implement health services interventions. Phase 1: An integrative literature review was conducted to synthesise the evidence around nutrition care and prediabetes from both patient and provider perspectives. This involved a search of the literature for several terms that broadly related to nutrition, primary care and prediabetes. This phase contributed to the ‘innovation’ pillar of i-PARIHS, where knowledge of the phenomenon of interest provided foundational evidence for implementing change. A total of 26 studies were included in the review. Majority were conducted in the United States (US) and none were conducted in Australia. A synthesis of the evidence revealed five themes: i) nutrition care is preferable to pharmacological treatment; ii) patients report taking action for behaviour change; iii) HCPs experience barriers to nutrition care; iv) HCPs tend not to refer patients for nutrition care; v) there are contradictory findings around provision and receipt of nutrition care. This study highlighted contradictions between patients and providers in the knowledge, attitudes and practices of nutrition care delivery. With no included studies conducted in Australia, further research was needed to explore the delivery of nutrition care in the Australian context, particularly in terms of patient and provider perspectives. Phase 2: The second phase of research involved an in-depth exploration of patient-related factors associated with receiving nutrition care for prediabetes in Australia. This phase aligned with the ‘recipients’ and ‘context’ pillars of the i-PARIHS framework, as it contributed the viewpoint of patient end-users within an Australian landscape. This phase involved one mixed methods study (Study 2) which sought to understand patient-related factors, characteristics and experiences associated with receiving nutrition care for prediabetes. Participants from a case series study (the “3D Study”) of 225 Australians who were recently diagnosed with T2D were invited to participate in this study. Using a phenomenological approach, semi-structured interviews were conducted with a sub-sample of 3D study participants who reported previously being told they had prediabetes. Participants were asked about their experiences of being diagnosed with prediabetes and receiving nutrition care. Qualitative findings highlighted gaps in the nutrition care provided to people following a prediabetes diagnosis; namely participants felt the diagnosis experience was vague, little dietary advice was provided and they wished they had received recommendations earlier to prevent T2D. A simultaneous descriptive analysis of characteristics (anthropometric, demographic, psychosocial) of all 3D study participants who reported having been previously diagnosed with prediabetes (n=100) were compared to those who had not reported receiving a prediabetes diagnosis. A comparison of characteristics revealed no differences between the two diagnosis groups for demographic or anthropometric variables. However, differences in smoking status and satisfaction with seeing a dietitian were reported. The qualitative and quantitative findings were synthesised and revealed gaps in the prediabetes diagnosis experience of patients in Australia, yet little indication of the likelihood of receiving a prediabetes diagnosis, based on patient characteristics alone. This study highlighted the need to ensure all patients at risk of T2D receive the right care at the right time, including support to improve diet quality, physical activity and weight management. Additional research should investigate the characteristics and preferences of HCPs who provide prediabetes care. Phase 3: In the third phase, a mixed methods case-study was conducted which aimed to explore HCP practices and behaviours related to providing nutrition care to people with prediabetes. Phase three aligned with the ‘recipients’ and ‘context’ pillars of i-PARIHS. The first component of this study involved a retrospective chart review (RCR) of HCPs’ practices within a single general practice clinic. Frequency of ‘diet’ reported in medical charts of patients who met the prediabetes diagnostic criteria were analysed. While the majority of patients had at least one chart entry where diet was recorded, the analysis revealed ‘diet’ was not recorded frequently across all patient chart entries. Few chart entries reported referrals to dietitians. Following the RCR, semi-structured interviews were conducted with HCPs to better understand practice behaviours. Qualitative analysis revealed four themes. HCPs reported barriers to providing consistent nutrition care to patients and identified opportunities for improved care. A synthesis of the qualitative and quantitative findings suggested that overall, nutrition care was provided infrequently to patients who met the prediabetes criteria in the study setting as a result of HCPs facing barriers in the Australian primary care system. Efforts to increase the delivery of nutrition care were viewed as needed, and in particular, strategies which support HCPs and alleviate system-level barriers. Phase 4: Phase four aimed to develop recommendations for improving the current model of nutrition care in the Australian primary care setting. This phase involved a qualitative investigation of specific preferences for nutrition care delivery in Australia, from a national sample of health consumers. This phase aligned with the ‘recipients’, ‘context’ and ‘facilitation’ pillars of i-PARIHS. Health consumers from national and state wide consumer health fora were invited to participate. Between May and August 2020, 25 individuals were interviewed. Consumers shared their preferences for who, what, where, when, and why they would like to receive nutrition care in the primary care setting. Content analysis revealed five themes related to preferences in care. People reported wanting nutrition care that is ongoing, affordable, integrated in primary care settings, tailored to meet individual needs and delivered by qualified HCPs. The preferences reported by health consumers did not align with their previous experiences of receiving nutrition care in Australia, suggesting the need for changes to health service delivery. Therefore, future research should focus on establishing and testing novel models of nutrition care based on these key preferences identified by health consumers. Conclusion: Together, the four phases of research presented within this thesis provide an in-depth understanding of current nutrition care practices for people living with prediabetes in Australia. Patients and HCPs alike value nutrition, particularly its role in preventing T2D and other chronic conditions. However, patients do not receive optimal nutrition care during the prediabetes stage. There are system-level barriers in place which prevent optimal nutrition care delivery by HCPs. Alternate avenues of nutrition care delivery, such as better integration and access to dietitians within the primary care setting, are needed. Additionally, incentives for patients to receive preventive care, such as access to the Medicare-funded Chronic Disease Management (CDM) scheme during the prediabetes stage, could alleviate some financial barriers. Future research should explore health service delivery models that meet the needs of all stakeholders (i.e., patients, HCPs, government, policy makers), to provide optimal nutrition care services to people at risk of chronic disease, including people living with prediabetes.