Behavioural medicine arose in the 1970s and is defined by the United States National Academy of Science’s Institute of Medicine as: “the field concerned with the development of behavioural science, knowledge and techniques relevant to the understanding of physical health and illness and the application of this knowledge and these techniques to prevention, diagnosis, treatment and rehabilitation”.¹

Behavioural medicine focuses on the effects of individuals’ health-related behaviours on their medical condition, and aims to enable individuals to change certain behaviours in order to achieve improved outcomes and prevent long-term complications. 

Most illnesses are multifactorial in aetiology and treatment, and behavioural medicine focuses on what individuals can do themselves to improve their condition, rather than relying solely on medical interventions such as medication or surgery, or indeed factors which may be more difficult to alter such as genetics or the environment.  

There is now a large body of evidence to show that changing individuals’ health-related behaviours can improve many conditions, including depression and anxiety, substance abuse, pain management, cardiovascular disease and obesity. This article will focus on the use of behavioural approaches in the management of type 2 diabetes. 

Behavioural management in type 2

Type 2 diabetes is a progressive, chronic and complex condition in which patient behaviour influences how the treatment is implemented and the outcomes of treatment to a great extent. 

In order for patients to achieve optimum glycaemic control, and maintain blood pressure and lipids within normal ranges to prevent complications, a number of health-related behaviours must be addressed such as:

• Following a healthy balanced diet

• Undertaking regular physical activity

• Self-monitoring blood glucose levels

• Taking medication as prescribed. 

Patients with diabetes often have other comorbidities such as obesity, hypertension and hyperlipidaemia, which must also be managed. The challenge for health professionals is to support patients in following treatment plans in order to prevent short- and long-term complications. 

For individuals with type 2 diabetes and a BMI above 25, the LOOK AHEAD study has shown that intensive lifestyle intervention incorporating behavioural strategies is more effective in reducing weight, improving HbA1c, cardiovascular risk factors and reducing the use of medications compared to diabetes support and education alone.²

In this study, all participants received initial education on diabetes care, blood glucose self-monitoring, healthy eating, physical activity and usual medical management of their diabetes. The key difference between the two study arms was that the lifestyle intervention group had more frequent contact and included behavioural approaches such as structured diet and activity plans with weight monitoring and self-regulatory skills, whereas the diabetes support and education group received no counselling on behaviour change. 

This study demonstrates that providing knowledge alone does not lead to optimal outcomes and behavioural approaches should be embedded within treatment interventions if individuals are to adopt and maintain dietary and physical activity behaviours necessary to manage their condition. 

Before discussing some common behavioural approaches used in diabetes management, it is important to recognise that the underlying philosophy of a behavioural approach is that of patient-centredness. 

While there are many interpretations of the precise meaning of this term, essentially it encompasses the following domains: 

• Exploring the patient’s experience and expectations of disease and illness

• Understanding the whole person

• Finding common ground between the patient and the health professional regarding management of the condition

• Promoting health

• Enhancing the relationship between the health professional and the patient

• Realistic use of time.³

This approach requires strong communication and interpersonal skills, as well as the core qualities of empathy, genuineness and acceptance, as described by Rogers.⁴

While there are a large number of different models and frameworks within the existing literature relating to health behaviour change interventions, this article will outline some general skills and strategies rather than any one particular model. 

Common behavioural approaches

Self-monitoring

The aim of self-monitoring is to raise awareness of current behaviours and highlight any problem behaviours. Typically, behavioural interventions recommend self-monitoring of:

• Dietary behaviours such as calorie and fat intake, timing of eating episodes and portion size

• Activity behaviours such as step counts, time and type of exercise

• Blood glucose levels in diabetes care.

It can also be helpful to monitor any situations or behaviours that are problematic (eg. hunger, moods, environment, social situations, etc). Self-monitoring can be an onerous task so it is important that the type of self-monitoring is flexible and suits the individual, for example by using mobile phones or computers, tick boxes or other visual aids rather than written diaries. 

Generally, behavioural programmes require self-monitoring at the beginning of the intervention and periodically thereafter, it can be particularly useful following lapses in diet or activity.

Structured meal plans

While current guidance recommends healthy eating for management of type 2 diabetes, it is now becoming evident that providing individualised structured meal plans or portion-controlled diets based on healthy eating guidance, especially during the initial weeks of the programme, is advantageous in establishing new eating behaviours compared with just generic advice on the principles of a healthy diet.

Goal-setting

This is the practice of translating the individuals’ intent to change their behaviour into specific plans. Goal-setting can relate to many behaviours such as calorie intake, fat intake, minutes of exercise or steps per day. It is the role of the health professional to coach the individual in setting goals that:

• Are specific (eg. ‘eat five portions of fruit and vegetables per day’ rather than ‘be more healthy’)

• Can be measured (eg. ‘5,000 steps per day’ rather than ‘increase daily steps’)

• Address the behaviour rather than the outcome (eg . dietary change rather than blood glucose levels)

• Can be realistically achieved by the individual.

When setting goals, it is also important to address any difficulties the individual might have in achieving them, where they will seek support, what they will do if things go wrong, and how they will reinforce their new behaviours. 

Stimulus control

This involves identifying cues in the environment and altering these so that healthy behaviours are more likely and unhealthy behaviours occur less often. 

Examples of stimulus control could be avoiding having tempting foods in sight in the kitchen to avoid snacking; or switching off the television to promote more activity at home. 

Individuals can identify cues to unhealthy behaviours through self-monitoring, and the health professional can help them to formulate a plan for managing these.

Problem-solving

This skill helps individuals deal with difficulties that hinder behaviour change and lead to lapses. Once learned, this skill can be applied to many situations. 

It should be approached as a series of steps, starting with identifying the specific problem, then generating a number of possible ways in which the problem can be dealt with, considering the feasibility of all potential solutions before selecting the best option, devising a plan to carry out the solution and acting on this, and then reviewing the process. 

The problem-solving process should be taught to individuals using a recent difficulty, and then guiding the individual to work through the process as future problems arise.

Other behavioural techniques include stress management skills, forming social support networks, reinforcing new behaviours, and practical behavioural strategies such as providing supervised exercise programmes and cookery classes. 

Supporting behaviour change

As health professionals, it is our role to support people in changing their behaviour in order to comply with current advice to manage their condition. 

Behavioural approaches are interventions that encourage individuals to understand the consequences of their behaviours and to feel optimistic about changing behaviour. Individuals can then plan changes over time, recognise difficulties that might get in the way and plan for how to overcome these, set and record personal goals and if appropriate, share these goals with others. It encompasses lifestyle change, learning new skills and utilising social support. 

Behavioural strategies cannot be taught in a single visit, they are skills which individuals must learn and practice and as such, should be incorporated throughout the intervention rather than in stand-alone sessions. 

Using this approach has been shown to be more effective than providing information alone and should be included within the context of standard diabetes care in all settings. 

Karen Gaynor is a senior dietitian at the Diabetes and Weight Management Centre at St Columcille’s Hospital in Loughlinstown, Co Dublin

References

1. Schwartz GE and Weiss SM (1978). Behavioural medicine revisited: An amended definition. Journal of Behavioural Medicine, 1978; 1: 249-251
2. The Look Ahead Research Group. Reduction in weight and cardiovascular disease risk factors in individuals with type 2 diabetes, one-year results of the Look AHEAD trial. Diabetes Care, 2007; 30: 1374-1383
3. Stewart M, Brown JB, Weston WW, McWhinney IR, McWilliam CL, Freeman TR. Patient-centred medicine transforming the clinical method. Thousand Oaks: Sage Publications 1995
4. Rogers CR. Client-centered therapy; its current practice, implications, and theory. Oxford, England: Houghton Mifflin 1951