Type 2 diabetes mellitus affects approximately one million individuals in the Netherlands and this number will increase substantially in the coming years. Major risk factors are unhealthy lifestyle and overweight. Diabetes care focuses on decreasing blood glucose levels by encouraging patients to do regular physical activity, lose weight and quit smoking.
In the Netherlands diabetes care is provided largely in primary care, and is protocol- and supply-driven. The success of diabetes care on lifestyle factors such as diet, weight and exercise is relatively low. There is evidence that type 2 diabetes patients who participate in groups succeed better in making lifestyle changes. A group based approach without much interference from care professionals might also be able to achieve lifestyle behavior change. Less focus on professionals might displace the attention from ‘illness and care’ to ‘health and behavior’. Another assumption is that self-recognition, self-determination and self-control can improve quality of life, and patients can be more successful in achieving and maintaining personal goals.
The combination of the above-mentioned elements led to the idea of ‘Herstelcirkel in de wijk / Recovery circles’. We started the project with 3 focus groups with diabetes patients in which we mapped patients’ deeper wishes and priorities for diabetes care. It appeared that patients were motivated to invest in their own health. We set up a co-operative group in order to let patients manage their diabetes and change their lifestyle behavior themselves. Our project started with 20 patients with type 2 diabetes, who were in the lead for one year. A coach outside of the primary care environment assisted them in setting and achieving personal goals in change of lifestyle. Together with the co-operative group of peers they searched for best ways to achieve and maintain those goals.
According to current policy, patients with type 2 diabetes visit their practice nurse every three months to monitor blood-glucose, blood pressure and weight. Participants in the cooperative group however, monitor these values themselves. They are sending the clinical data by a software program (E-Vita) or by an app (MijnHuisarts), which records them automatically in the electronic patient record (EPR). Participants will visit their GP only for one annual control, and will induce other contacts only if they want to. They are also allowed to change their diabetes drug treatment themselves, as long as they inform their GP.
Hypothesis was that this method would lead to better maintenance of lifestyle changes, improvement of self-efficacy, better perceived health and diabetes state, less medication use and lower health care costs.
The 20 patients in the first group aged 43-74 year, 13 were male. Two participants did not use diabetes medication at the start, the others used oral medication, insulin or a combination of both. They all were patients of two general practices in Nijmegen Noord (Zorggroep STIELO). Participants were approached by the practice nurse.
The project began with a kick-off meeting in which participants met each other and got information about diabetes type 2, healthy diet, and opportunities for self-management. A new meeting was planned to make action plans. The cooperative group installed a board and participants decided to pay a contribution monthly. This was used for sessions and activities on health themes, for example a session with a dietitian. Also, they formed four smaller groups based on the individual goals: change of diet (there is a great need for knowledge and practical tips), physical activity, awareness of negative emotional patterns that lead to unhealthy behavior and decrease or stop medication use.
We focused on clinical outcome measures such as weight, HbA1c, cholesterol and blood pressure. Moreover, we studied medication use, personal goals, self-efficacy and perceived health at the start of the project and after one year. Also, we looked at the group process and development in general and the achievement of personal goals and maintenance of lifestyle change.
Results in the first group
- Nineteen participants were positive about the co-operative group. They mentioned recognition of obstacles and the experiences and tips of peers increased motivation.
- After three months, twelve of eighteen explicitly declared they felt better since the start of the initiative. Most important arguments were having more energy, the feeling of self control in relation to diabetes, being satisfied with new lifestyle and achieved personal goals.
- Together, participants set 47 goals at the beginning of the project. After one year 37 were achieved. All patients except one achieved at least one of their goals.
- Weight decreased significantly. Thirteen participants lost weight.
- At the start, seventeen participants used oral medication for diabetes. After one year eight participants lowered their oral medication and four were even able to stop their medication. One participant stopped with insulin, the other three decreased the dose.
- Fifteen participants used cholesterol lowering medication. During the project three stopped medication, four decreased and eight maintained the dose.
- Nineteen changed their diet to a low carbohydrate diet.
- HbA1c and cholesterol levels did not change substantially.
The success of the first group has resulted in the start of 4 new groups in the region, two in the same district, two others in other districts. We have by now established a foundation that continues to train life strength coaches and will be able to support exponential scaling up of the project. We will continue to be in contact with professionals groups (GP cooperatives delivering diabetes care) to collbaorate. In the past year, we built a network with other players in the field, such as the Diabetes Challenge, Stichting Voeding Leeft and TNO.