British Journal of Diabetes

Supporting remission of type 2 diabetes in the real world

Jonathan Valabhji — 2024-04-16

The Re:Mission study. Evaluating the NHS Low Calorie Diet pilot - an overview of service user data collection methods

Catherine Homer — 2024-04-16

Introduction: The National Health Service (NHS) Low Calorie Diet (LCD) pilot programme aimed to support people with type 2 diabetes (T2DM) to lose weight, reduce glycaemia and potentially achieve T2DM remission using total diet replacement alongside behaviour change support. The Re:Mission study seeks to provide an enhanced understanding of the long-term cost-effectiveness of the programme and its implementation, equity, transferability and normalisation across broad and diverse populations. This article presents an overview of the methods used in the Re:Mission study.

Methods and analysis: A mixed method approach was used to draw together service user insights from across longitudinal and cross-sectional online surveys and semi-structured interviews supported by a modified photovoice technique. Insights were captured from active service users across the three phases of the programme (total diet replacement, food reintroduction and maintenance) in addition to those discharged prematurely. Survey data were analysed using descriptive statistics and qualitative data were thematically analysed and interpreted through a realist informed lens to understand which aspects of the service work and do not work, for whom, in what context and why.

Results: Results from the study are presented elsewhere, with recommendations for policy practice and research.

A fresh start with high hopes: a qualitative evaluation of experiences of the Total Diet Replacement phase of the NHS Low Calorie Diet Programme pilot

Catherine Homer — 2024-04-16

Background: The National Health Service (NHS) Low Calorie Diet (LCD) programme in England aims to support people with type 2 diabetes (T2DM) to lose weight, improve glycaemic parameters and potentially achieve diabetes remission. The programme pilot launched in 2020 using three different delivery models: one-to-one, group and digital via an App. Service users begin the programme with 12 weeks of Total Diet Replacement (TDR). This study aims to understand the experience of this TDR phase from the service user perspective.

Methods: This was a co-produced qualitative longitudinal and cross-sectional study, underpinned by a realist informed approach using semi-structured interviews and photovoice techniques. Service users (n=45) from the NHS LCD programme were recruited across the three delivery models and 21 pilot sites in England. Data were analysed using a thematic approach.

Results: Participant demographics were representative of the overall LCD pilot population sample and included experiences from a mix of delivery models and providers. Three themes were presented chronologically. 1) life pre-LCD: the LCD programme was viewed as an opportunity to reset eating behaviours and improve quality of life; 2) experience of TDR: flexibility in allowing supplementary non-starchy vegetables and adapting the flavour and texture of TDR products supported adherence; 3) looking ahead to food reintroduction: at the end of the TDR phase, weight and glycaemia had reduced, while subjective energy levels and mobility improved. Some participants were concerned about progressing to the food reintroduction phase and the possibility of weight regain. Conclusions: The paper reports insight from the TDR phase of the LCD programme. The co-production of this work has resulted in several recommendations for policy and practice which have informed the national roll out of the programme.

“Trying to make healthy choices”: the challenges of the food reintroduction phase of the NHS Low Calorie Diet Programme pilot for type 2 diabetes

Catherine Homer — 2024-04-16

Background: The food reintroduction phase of the NHS Low Calorie Diet (LCD) programme aims to support service users to reintroduce food gradually back into their diet. Understanding experiences of food reintroduction from a broad and diverse range of service users is critical in helping to improve service delivery and commissioning and equity in care.

Methods: This was a co-produced qualitative study underpinned by a realist informed approach, using interviews and photovoice techniques. Service users (n=43) of the NHS LCD Programme were recruited from three delivery models across 21 pilot sites in England. Data were analysed using a thematic approach.

Results: The food introduction phase required control and planning that challenged the behaviours of participants. Around a third of participants continued use of Total Diet Replacement products, or considered doing so, for convenience and to maintain calorie control. The coach–service user relationship was important to understanding of session content and translation into behaviour change. Physical activity increased during this phase, which contributed to positive health outcomes.

Conclusions: The paper reports insights from the food reintroduction phase of the LCD programme. Key messages include the need for increased frequency of support and the need for tailored and culturally representative education.

‘Life changing or a failure’? Qualitative experiences of service users from the weight maintenance phase of the NHS Low Calorie Diet Programme pilot for type 2 diabetes

Catherine Homer — 2024-04-16

Background: The weight maintenance phase of the NHS Low CalorieaDiet (LCD) programme focuses on embedding long- term dietary and physical activity changes. Understanding individual experiences of this phase is crucial to exploring long- term effectiveness and equity of the intervention approach.

Methods: This was a coproduced qualitative study underpinned by a realist informed approach, using interviews and photovoice techniques. Service users (n=25) of the NHS LCD programme were recruited from three delivery models, across 21 sites in England. Data were analysed using a thematic approach.

Results: The experiences reported were largely positive, with many participants reporting changes in their diet and physical activity. Some service users expressed a need for additional support and there appeared variation in their experiences of the service providers and the wider available support network. Fear of weight regain and its glycaemic consequences was expressed by many; various mitigations were employed, including participating in other weight loss services and continuing use of Total Diet Replacement products.

Conclusions: The NHS LCD programme has been life-changing for some people. However, service user insights suggest that a stronger person-centred focus might further improve effectiveness and service user experience.

A qualitative study of the experiences of individuals who did not complete the NHS Low Calorie Diet Programme Pilot

Kevin J Drew — 2024-04-16

Background: Attrition remains a significant public health challenge as individuals who do not complete programmes are likely to have poorer programme outcomes. On calorie- restricted diets, including the NHS Low Calorie Diet (LCD) Programme pilot, approximately 50% of people are discharged prematurely, and thus do not complete the programme. Reducing attrition therefore has the potential to improve programme efficacy, impact and cost-effectiveness.

Methods: Ten semi-structured interviews were conducted with purposively sampled individuals who did not complete the NHS LCD programme. Interviews explored service user experiences of the programme and experiences of being discharged. Interview data were analysed thematically.

Results: Four core themes were identified: 1) the pre- programme struggles of service users and their route to LCD; 2) a positive and impactful programme; 3) life gets in the way; and 4) a perceived lack of support from the provider. These findings show that individuals had pre-programme struggles and a series of life events that constrained their good intentions, and whilst they were positive about the programme, they were critical of the support they received from providers to deal with their life circumstances.

Conclusions: Policy makers and providers can act proportionately to ensure that programmes, such as the NHS LCD Programme pilot, recognise the circumstances and context of people’s lives, and take a more person-centred approach.

Participant experiences during the NHS Low Calorie Diet Programme pilot. Findings from an online survey

Duncan Radley — 2024-04-16

Background: In 2020, NHS England commissioned independent commercial service providers to deliver a Low Calorie Diet Programme pilot, offering Total Diet Replacement alongside behavioural support.

Methods: This paper presents participant experiences of the programme using both quantitative and qualitative data derived from four cross-sectional surveys, and examines differences by sociodemographics, delivery model and provider.

Results: The majority of participants reported a positive experience with the referral process, with a small proportion feeling that insufficient information was provided and that they did not feel respected or listened to by their healthcare professional. Participants’ relationship with their coach was generally positive throughout each phase of the programme, and highlights the importance of coach-participant relationships. The relationship with the coach via digital delivery was less favourable compared to other delivery models, as was the perceived adequacy of support provided.

Conclusions: The experience of the referral from general practice and the relationship with the coach are key elements of the participant experience. They demonstrate the importance of, and need for, person-centred care.