Our data suggest that contrary to common assumptions, patients enrolling in primary care-based prediabetes interventions are well-informed about their condition and exhibit high levels of risk perception, self-efficacy and motivation to change. Moreover, participants reported poor eating and physical activity habits despite their well-recognized risk for diabetes and positive attitudes towards diabetes prevention. These observations are particularly relevant considering the diversity of the sample and their high burden of diabetes risk factors including obesity, family history of diabetes, and cardiovascular comorbidities, however, they are not surprising. A 2009 study by Hivert et al. demonstrated that primary care patients with higher perceived risk scores on the RPS-DD questionnaire (“high risk” vs. “low risk”) were truly at increased risk of diabetes development, yet higher perceived risk did not result in adopting healthier behaviors.34 These findings suggests that the sample, recruited using practical trial methods, represents an ideal target for a prediabetes lifestyle intervention and would likely resemble the typical patient seen in urban primary care practices. The data were used to redirect the development of the ADAPT intervention away from enhancing patient knowledge, perceptions and attitudes and instead leverage the participants’ existing positive attitudes to replace less healthy behaviors with more healthy ones.
Barriers often cited for patients being unable to modify behaviors to prevent disease include the absence of health education, poor understanding of risk of disease and complications, and lack of motivation to change.37, 38, 39 Individual cultural beliefs, lack of community connection, and misperceptions about diabetes education programs also pose challenges to lifestyle change.40, 41, 42 However, this group of patients demonstrated adequate knowledge about their disease, appropriate risk perception for developing diabetes and its accompanying complications, and an overall high level of awareness of their unhealthy behaviors. Overall, patients had an accurate perception of the natural progression of prediabetes and diabetes. The fact that despite these factors they have been unsuccessful at making appropriate lifestyle changes emphasizes that cognitive awareness is not necessarily correlated with behavioral changes. ADAPT was therefore targeted to primary care patients presenting with adequate levels of knowledge and motivation, but who need a structured path to enact change.
Interestingly, participants who reported higher levels of physical activity were in fact walking less according to pedometer data. This discrepancy between impressions of versus actual physical activity level illustrates that patients often have inaccurate perceptions of their physical activity throughout the day.43 Additionally, participants who reported healthier eating habits (lower REAPS) had higher BMIs than those who reported poor eating habits. Again, this finding suggests that participants are either not good at judging their diet change efforts or are not accurately reporting their behaviors. These findings suggest a gap between patient intentions or self-perceptions about their behavior and their actual behaviors. The ADAPT tool may be valuable in bridging this gap between intentions to exercise and eat healthfully and taking action to adopt healthy behaviors.
Participants demonstrated high levels of self-efficacy and asserted their confidence in their ability to successfully change their eating habits and physical activity to prevent getting diabetes. Despite that, they have not been successful at making changes in the past. This disconnect between how confident people feel and how successful they have been highlights the need for an intervention such as ADAPT to support people in implementing change. Goal setting, action planning and other simple cognitive behavioral change methods are designed to help link intentions and actions.44 The SMART (specific, measurable, attainable, relevant, time-bound) goals based action planning used in ADAPT can help patients focus their intentions into concrete actions to achieve their goals.45, 46, 47
ADAPT incorporates the self-management support component of the Chronic Care Model, which includes goal setting, action planning, and problem solving,48, 49 and features a patient-centered approach to care that facilitates patient-selected short-term, specific goals coupled with provider feedback, which has been effective for patients at risk for or suffering from chronic diseases.44, 50, 51, 52 ADAPT is valuable to providers and patients because it provides the framework for shared goal setting and implementation during the clinical encounter. Barriers to patient adoption of lifestyle changes are also commonly attributed to the provider side of the patient-provider interaction. Effective counseling is challenging and providers often lack knowledge and successful strategies for helping their patients change behavior; there is much room for improvement of behavioral counseling rates.53, 54, 55, 56, 57 Data from the 2005-2006 National Health and Nutrition Examination Survey showed that only 34.6% of adults with prediabetes receiving health care reported that they had been told by their physician in the past year to control or lose weight; 36.8% reported being told to reduce calories in their diet and 39.4% reported being told to increase physical activity.58 Less than half of adult patients with diabetes are receiving provider advice on how to reduce risk. Clearly, providers could more actively counsel healthy lifestyle changes, especially in a group similar to this study population who are in the preparation/action stages of change. ADAPT presents providers with a workflow embedded simple shared goal setting platform and framework to guide patients who are ready for change through an iterative action planning process.
Study limitations include small sample size, single institution, and urban setting, thus generalizability is limited. Participants were recruited randomly from a clinical database and so there was a significant degree of selection bias; patients who answered their phones, responded to emails, had active insurance and ultimately enrolled in the study were likely more motivated at baseline to change their behaviors to prevent diabetes than the average person. However, this selection process was designed to identify the type of primary care patients who are sufficiently engaged with their healthcare team to benefit from a primary care based behavior change program.
ADAPT promotes action plan discussions between patients and providers for patient-selected behavior change goals during the outpatient visit. This study demonstrated that the recruited sample were already knowledgeable about their health and risk for developing diabetes, demonstrated high levels of self efficacy, placed value on being more active and losing weight, and strongly felt that they could successfully make lifestyle changes to prevent diabetes. This suggests that typical primary care patients are candidates for simple and efficient primary care based action planning interventions. The ADAPT tool was tailored to meet this population’s needs to structure/facilitate behavior change to reduce diabetes risk.