How is the NHS Low-Calorie Diet Programme expected to produce behavioural change to support diabetes remission: An examination of underpinning theory
Keywords:theory, intervention design, logic model, behaviour change, type 2 diabetes, diabetes remission, low-calorie diet, total diet replacement
Background: In 2020, the National Health Service Low-Calorie Diet Programme (NHS-LCD) was launched, piloting a total diet (TDR) replacement intervention with behaviour change support for people living with Type 2 Diabetes (T2D) and excess weight. Four independent service providers were commissioned to design and deliver theoretically grounded programmes in localities across England.
Aims: 1) to develop a logic model detailing how the NHS-LCD programme is expected to produce changes in health behaviour, and (2) to analyse and evaluate the use of behaviour change theory in providers’ NHS-LCD Programme designs.
Methods: A documentary review was conducted. Information was extracted from the NHS-LCD service specification documents on how the programme expected to produce outcomes. The Theory Coding Scheme (TCS) was used to analyse theory use in providers’ programme design documents.
Results: The NHS-LCD logic model included techniques aimed at enhancing positive outcome expectations of programme participation and beliefs about social approval of behaviour change, to facilitate programme uptake and behaviour change intentions. This was followed by techniques aimed at shaping knowledge and enhancing the ability of participants to self-regulate their health behaviours, alongside a supportive social environment and person-centred approach.
Application and type of behaviour change theory within service providers’ programme designs varied. One provider explicitly linked theory to programme content; two providers linked 63% and 70% of intervention techniques to theory; and there was limited underpinning theory identified in the programme design documents for one of the providers.
Conclusion: The nature and extent of theory use underpinning the NHS-LCD varied greatly amongst service providers, with some but not all intervention techniques explicitly linked to theory. How this relates to outcomes across providers should be evaluated. It is recommended that explicit theory use in programme design and evidence of its implementation becomes a requirement of future NHS commissioning processes.
Skivington K, Matthews L, Simpson SA et al. A new framework for developing and evaluating complex interventions: update of Medical Research Council guidance. BMJ 2021;374:n2061. https://doi.org/10.1136/bmj.n2061
Rimmer BK, Glanz K. Theory at a glance: A guide for health promotion . Washington. DC: National Institutes for Cancer, Department of Health and Human Services. 2005.
Glanz K. Theory at a glance: A guide for health promotion practice: US Department of Health and Human Services, Public Health Service, National Institutes of Health, National Cancer Institute; 1997.
Funnel SC, Rogers PJ. Purposeful program theory: Effective use of theories of change and logic models. John Wiley & Sons; 2011;1:95-148.
Michie S, Prestwich A. Are interventions theory-based? Development of a theory coding scheme. Health Psychology 2010;29(1):1. https://doi.org/10.1037/a0016939
Escoffery C, Lebow-Skelley E, Haardoerfer R et al. A systematic review of adaptations of evidence-based public health interventions globally. Implementation. Science 2018;13(1):1-21. https://doi.org/10.1186/s13012-018-0815-9
Glanz K, Bishop DB. The role of behavioral science theory in development and implementation of public health interventions. Ann Review Public Health 2010;31:399-418. https://doi.org/10.1146/annurev.publhealth.012809.103604
McSharry J, Byrne M, Casey B et al. Behaviour change in diabetes: behavioural science advancements to support the use of theory. Diabetic Medicine 2020; 37(3):455-63. https://doi.org/10.1111/dme.14198
Painter JE, Borba CPC, Hynes M et al. The use of theory in health behavior research from 2000 to 2005: a systematic review. Annals Behavioral Medicine 2008;35(3):358-62. https://doi.org/10.1007/s12160-008-9042-y
Prestwich A, Sniehotta FF, Whittington C et al. Does theory influence the effectiveness of health behavior interventions? Meta-analysis. Health Psychology 2014;33(5):46. https://doi.org/10.1037/a0032853
Ebenso B, Manzano A, Uzochukwu B et al. Dealing with context in logic model development: reflections from a realist evaluation of a community health worker programme in Nigeria. Evaluation Program Planning 2019; 73:97-110. https://doi.org/10.1016/j.evalprogplan.2018.12.002
Hawkes RE, Miles LM, French DP. The theoretical basis of a nationally implemented type 2 diabetes prevention programme: how is the programme expected to produce changes in behaviour? Int J Behavioral Nutrition Physical Activity 2021;18(1):1-12. https://doi.org/10.1186/s12966-021-01134-7
Greenwell K, Sivyer K, Vedhara K et al. Intervention planning for the REDUCE maintenance intervention: a digital intervention to reduce reulceration risk among patients with a history of diabetic foot ulcers. BMJ Open 2018; 8(5):e019865. https://doi.org/10.1136/bmjopen-2017-019865
Lake AJ, Browne JL, Abraham C et al. A tailored intervention to promote uptake of retinal screening among young adults with type 2 diabetes-an intervention mapping approach. BMC Health Services Research 2018; 18(1):1-18. https://doi.org/10.1186/s12913-018-3188-5
NHS England. Low calorie diets to treat obesity and Type 2 diabetes. 2020. https://www.england.nhs.uk/diabetes/treatment-care/low-calorie-diets. Accessed 12 Feb 2022.
Steven S, Lim EL, Taylor R. Population response to information on reversibility of type 2 diabetes. Diabetic Medicine 2013;30(4):e135-e8. https://doi.org/10.1111/dme.12116
Steven S, Hollingsworth KG, Al-Mrabeh A et al. Very low-calorie diet and 6 months of weight stability in type 2 diabetes: pathophysiological changes in responders and nonresponders. Diabetes Care 2016;39(5):808-15. https://doi.org/10.2337/dc15-1942
Lim EL, Hollingsworth KG, Aribisala BS et al. Reversal of type 2 diabetes: normalisation of beta cell function in association with decreased pancreas and liver triacylglycerol. Diabetologia 2011;54(10):2506-14. https://doi.org/10.1007/s00125-011-2204-7
Lean MEJ, Leslie WS, Barnes AC et al. Primary care-led weight management for remission of type 2 diabetes (DiRECT): an open-label, cluster-randomised trial. Lancet 2018;391(10120):541-51. https://doi.org/10.1016/S0140-6736(17)33102-1
Lean MEJ, Leslie WS, Barnes AC et al. Durability of a primary care-led weight-management intervention for remission of type 2 diabetes: 2-year results of the DiRECT open-label, cluster-randomised trial. Lancet Diabetes Endocrinol 2019;7(5):344-55. https://doi.org/10.1016/S2213-8587(19)30068-3
Churuangsuk C, Hall J, Reynolds A et al. Diets for weight management in adults with type 2 diabetes: an umbrella review of published meta-analyses and systematic review of trials of diets for diabetes remission. Diabetologia 2022;65:14-36. https://doi.org/10.1007/s00125-021-05577-2
NHS England. Service Specification No. 1: NHS Low Calorie Diet Programme. [Version 01]. 2021.
Hawkes RE, Cameron E, Bower P, French DP. Does the design of the NHS diabetes prevention programme intervention have fidelity to the programme specification? A document analysis. Diabetic Medicine 2020;37(8):1357-66. https://doi.org/10.1111/dme.14201
Renger R, Foltysova J, Becker KL, Souvannasacd E. The power of the context map: Designing realistic outcome evaluation strategies and other unanticipated benefits. Evaluation Program Planning 2015;52:118-25. https://doi.org/10.1016/j.evalprogplan.2015.04.003
Rogers PJ. Using programme theory to evaluate complicated and complex aspects of interventions. Evaluation 2008;14(1):29-48. https://doi.org/10.1177/1356389007084674
Leslie WS, Ford I, Sattar N et al. The Diabetes Remission Clinical Trial (DiRECT): protocol for a cluster randomised trial. BMC Family Pract 2016;17(1):1-10. https://doi.org/10.1186/s12875-016-0406-2
National Institute for Health and Care Excellence. Behaviour change: general approaches [Internet]. [London]: NICE, 2007 [updated 2017 Dec]. (Public Health Guideline [PH6]). Available from: https://www.nice.org.uk/ Guidance/PH6.
National Institute for Health and Care Excellence. Behaviour change: individual approaches [Internet]. [London]: NICE, 2014. (Public Health Guideline [PH49]). Available from: https://www.nice.org.uk/guidance/ph49.
Funnell SC, Rogers PJ. Purposeful program theory: Effective use of theories of change and logic models. John Wiley & Sons; 2011.
Landis JR, Koch GG. The measurement of observer agreement for categorical data. Biometrics 1977;33:159-74. https://doi.org/10.2307/2529310
Public Health England. The Eatwell Guide. [Internet]. 2016 [updated 2018]. Available from: https://www.gov.uk/government/publications/the-eatwell-guide.
Department of Health and Social Care. Physical activity guidelines: UK Chief Medical Officers' report. [Internet. 2019 [updated Sep 2020]. Available from: https://www.gov.uk/government/publications/physical-activity-guidelines-uk-chief-medical-officers-report.
Ajzen, I. (1985) From intentions to action: a theory of planned behavior. In: Kuhl J and Beckmann J, Eds, Action-Control: from cognition to behavior, Springer-Verlag, Heidelberg, 11-39. http://dx.doi.org/10.1007/978-3-642-69746-3_2
Schwarzer R. Modeling health behavior change: How to predict and modify the adoption and maintenance of health behaviors. Applied Psychology 2008;57(1):1-29. https://doi.org/10.1111/j.1464-0597.2007.00325.x
Cs C. Scheier MF. On the self-regulation of behaviour. Cambridge, UK: Cambridge University Press; 1998.
Prochaska JO, Velicer WF. The transtheoretical model of health behavior change. Am Journal Health Promotion 1997;12(1):38-48. https://doi.org/10.4278/0890-1171-12.1.38
Michie S, Atkins L, West R. The behaviour change wheel: a guide to designing interventions. Silverback Publishing; 2014.
Rosenstock IM. Why people use health services. Milbank Quarterly 2005;83(4). https://doi.org/10.1111/j.1468-0009.2005.00425.x
Beck A. Cognitive therapy and the behavioral disorders. New York: Meridian; 1967.
Beck AT. Cognitive therapy: Nature and relation to behavior therapy. J Psychotherapy Practice Research 1993;2(4):342.
Bijou SW, Peterson RF, Ault MH. A method to integrate descriptive and experimental field studies at the level of data and empirical concepts 1. J Applied Behavior Analysis 1968;1(2):175-91. https://doi.org/10.1901/jaba.1968.1-175
Bandura A. Social foundations of thought and action. Englewoods Cliffs. NJ: Prentice-Hall; 1986.
McHugh ML. Interrater reliability: the kappa statistic. Biochemia medica 2012;22(3):276-82. https://doi.org/10.11613/BM.2012.031
Swanson V, Maltinsky W. Motivational and behaviour change approaches for improving diabetes management. Practical Diabetes 2019;36(4):121-5. https://doi.org/10.1002/pdi.2229
Public Health England. Behaviour change: guides for national and local government and partners. [Internet]. 2020. Available from: https://www.gov.uk/ government/publications/behaviour-change-guide-for-local-government-and-partners.
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