Another one to file under “stating the obvious”, you might think. Sadly, it’s not that obvious, as many patients would attest.This is also evidenced by the recent randomised controlled trial (RCT) on giving diet and lifestyle advice to try to prevent diabetes. The paper in the Lancet reported a reduction in body weight in people of South Asian origin who were at risk of developing diabetes if they received a culturally sensitive intervention by dieticians instead of usual care.
Whilst this is a promising story, a little critical examination reveals some important limitations.
People of South Asian ethnic origin with impaired glucose tolerance were randomised in family units to receive usual care or a culturally-adapted intervention.
The intervention consisted of regular (3-monthly) visits from a dietician, who gave advice and practical demonstrations on diet, cooking and exercise. The families also had exercise classes and annual meetings.
The control group received annual visits with standard advice and information on weight reduction.
The primary outcome was body weight.
- patients in the intervention group lost, on average, 1.64 kg (95% CI −2·83 to −0·44) more weight than the control group
- 39% of them lost more than 2.5kg, compared with 14% of the control group (NNT = 4, p 0.036).
There are some concerns with this research, and we need to consider some important issues before applying it to practice.
- The details of the intervention are provided in a separate paper, which makes it hard for us to report exactly what the intervention was.
- The primary outcome of this research was modified after the start. Originally, they wanted to study the effect on incidence of type 2 diabetes. However, they changed this after starting the trial to look at body weight because of problems with recruitment and sample size. This may well have been the only appropriate action they could have taken, but it does reduce the impact of the study. It would have been much better to have evidence on the impact on type 2 diabetes.
- Did “usual care” provide a realistic comparison? Again, this is hard to judge from the paper. It may also be hard to adjudicate in principle. We would not want to deliberately design any intervention as lacking in cultural sensitivity, for example, so how is it possible to get a fair comparator for “cultural sensitivity”?
- It seems likely that the experimental group would have received additional co-interventions. But again, we have the same issue. This is discussed below.
- The researchers reported poor response to their initial attempts to recruit participants. This may indicate some selection bias.
- There were some adverse events, including arthritic pain after exercise and worries about changes in lifestyle.
- The cost of programme, including indirect costs to the patients was reported as £1126 per participant.
However, let’s not throw any babies out with the bathwater. This study should also be seen in the wider context of diabetes education. There is a steadily growing body of evidence showing how important it is that professionals talk to patients in ways that they can relate to.
This is such an important issue in diabetes that the Diabetes Elf had a rummage in his drawers and came up with some key papers:
- culturally sensitive diabetes education improved glycaemic control in type 2 diabetes, albeit only at six months of follow-up (Hawthorne 2010, Ivey 2012)
- a systematic review found that culturally competent diabetes education also improves cholesterol and blood pressure (Zeh 2012)
Importantly, Sacco et al (2012) found that educational attainment affected type 2 diabetes patients’ ability to respond to diabetes education.
Of course, it is difficult to take one particular element, such a “cultural sensitivity” or “patient-centredness” out of context and study its effect on its own. It could be argued that doing so would impair the potential effectiveness of the intervention. Cultural sensitivity may only be effective if we are sufficiently patient-centred to act on it.
This holistic aspect is supported by the findings of Seitz et al (2012), who found that integrated interventions that combine multiple elements – personal, professional and organisational – are more likely to be successful.
Bophal R, Douglas A, Wallia S et al. Effect of a lifestyle intervention on weight change in south Asian individuals in the UK at high risk of type 2 diabetes: a family-cluster randomised controlled trial. Lancet Diabetes and Endocrinology 2013; Early Online Publication, 23 December 2013.
Ivey SL, Tseng W. Evaluating a Culturally and Linguistically Competent Health Coach Intervention for Chinese-American Patients With Diabetes. Diabetes Spectrum 2012 vol. 25 no. 2 93-102.
Sacco WP, Bykowski CA et al. Educational attainment moderates the effect of a brief diabetes self-care intervention. Diabetes Research and Clinical Practice, 2012 Jan;95(1):62-7
Seitz P, Rosemann T, Gensichen J & Huber CA. Interventions in primary care to improve cardiovascular risk factors and glycated haemoglobin (HbA1c) levels in patients with diabetes: a systematic review. Diabetes, Obesity and Metabolism 2011 Jun;13(6):479-89.
Zeh P, Sandhu HK, Cannaby AM, Sturt JA. The impact of culturally competent diabetes care interventions for improving diabetes-related outcomes in ethnic minority groups: a systematic review. Diabetic Medicine 2012; 29(10):1237-52