DWELL: Offering Renewed Hope to Long-standing T2D Patients

Liam Davenport

November 01, 2019

LONDON — Patients who have been living with type 2 diabetes for many years and have become non-compliant with treatment could experience a turnaround in their health with a novel programme that focuses on motivation and their life experience, the results of an early analysis suggest.

The Diabetes and WELLbeing (DWELL) programme, presented at Diabetes Professional Care 2019, is a European programme that incorporates traditional physical activity and dietary advice with patient education and empowerment and optional support groups.

Still in its infancy and only rolled out to eight partners in four countries, it has nevertheless resulted in significant reductions in HbA1c levels and mean body mass index (BMI) among participants, as well as improvements in eating habits and scores on mental health and quality of life measures.

'Getting on Top of Diabetes'

Alice Chapman-Hatchett is director of the Health and Europe Centre, which is the lead organisation for DWELL in the UK.

She told Medscape News UK that the aim of the project from the outset was to target patients with long-standing type 2 diabetes who were not compliant with treatment, although they have expanded the intake recently "because we've seen what a difference it's made".

She said that, apart from the objective benefits of DWELL, one of the most important outcomes is the way that patients have been able to "get on top of their diabetes".

Alice Chapman-Hatchett gave the example of a woman who had told the organisers in her motivational interview that her aim was to go to the hairdresser, as she hadn't been in around 15 years due to feeling self-conscious about her body image.

"At the end of the 12-week programme, she went and had a complete restyling, and that was fantastic because she felt she could go and do that and we'd given her the confidence to say: 'I can do this'."

Giving the opening presentation, Alice Chapman-Hatchett said that DWELL is funded by the European Union and works with eight organisations in the UK, Belgium, The Netherlands, and France.

She explained that "we're all facing a similar problem around the management of type 2 diabetes and particularly of patients who are not compliant".

The project aims to change the way people with type 2 diabetes are supported to improve their health and wellbeing, empower patients, and reduce the costs associated with the disease.

"We summarise this as saying we're putting patients in the driving seat," she said.

"We really wanted to take that medical aspect away from type 2 diabetes care and make the patients far more in control of their diabetes."

Support Tools

The programme consists of a 12-week support programme, delivered to 1000 patients, in groups of approximately eight, across the four countries, accompanied by a training programme for staff.

There are also tools to support patients during and after the intervention, as well as a comprehensive evaluation of the intervention, including patient outcomes and staff training, and a cost–benefit analysis.

Julie Webster, DWELL programme lead for Medway Community Healthcare, in south-east England, took over, explaining that the 12-week programme is designed to be holistic and cover all aspects of patients' lives.

This includes the standard areas of physical activity and nutrition, but also wellbeing, education, individual tailored support, peer support, and motivational interviews, with the aim of "dramatically reducing their risk of developing long-term complications".

Alongside the core programme, there are also a range of "pick and mix" options that patients could take part in, such as cooking sessions and food shopping trips, craft groups, a community choir, music groups, alternative therapies, food care education, and walking groups.

Crucial to that was the recruitment and training of patient ambassadors, who helped in the design of DWELL and app testing for online support tools, as well as in promoting the programme in the community, supporting participants and training new staff.

Once patients complete the 12-week course, they have ongoing support in the form of information on the DWELL website, a directory of services, and contact with the DWELL patient ambassadors.

'Life-changing'

Kevin Jasper, who is a DWELL patient ambassador for Medway Community Healthcare, then took to the podium and talked the audience through his experience since being diagnosed with type 2 diabetes in 2008.

He said that his first doctor used the "scare tactic approach", after which he went through a number of healthcare providers, with numerous changes in medication and fluctuations in his weight, and "erratic" blood glucose levels.

In March 2017, he was invited to take part in the DWELL programme and help in its design and planning, at which point, he said, "my life changed".

Describing the programme as the "most useful series of meetings I had ever attended", he said he saw his HbA1c level drop from 109 mmol/mol at the start of the 12 weeks to 58 mmol/mol by the end.

In addition, his weight decreased substantially and he went from taking 36 units of insulin every morning and 36 units every evening to just 12 units per day, a change he ascribed to switching to porridge for his breakfast.

For him, being a patient ambassador is "key to helping others through the system," as "you spend time with other people who have got diabetes".

He and his wife run craft classes as one of the additional options for patients, in which they make things such as cards or Christmas decorations.

"Sometimes, we actually finish a project," he said, "because…we often find that we're chatting about issues with diabetes and not actually concentrating on craft, but that to some degree is exactly how it should be, because it means we're continuing with that support system."

'Very Exciting'

Finally, Eleni Hatzidimitriadou, professor of community psychology and public mental health at Canterbury Christ Church University, presented the interim analysis of patient outcomes on DWELL, up to 12 months' follow-up.

She said that a number of validated tools were used to assess several domains associated with patient outcomes:

  • Illness perceptions

  • Physical health

  • Eating behaviours

  • Use of health services

  • Mental health and quality of life

  • Self-care and empowerment

The UK sample was 63% female, and 85% white, reflecting the local populations, with a representative spread of body mass index categories and HbA1c levels, as well as age ranges.

In terms of physiological outcomes, the interim analysis, in around 90 patients, showed that DWELL was associated with significant reductions in both body mass index and HbA1c levels (p<0.001 for both).

There were also significant reductions in waist circumference between baseline and the post-DWELL analysis (p<0.001).

Prof Hatzidimitriadou noted that, in the approximately 70 patients for whom eating behaviour data was available, there was a significant increase in restrained eating and a decrease in external and emotional eating (p<0.001 for both).

Scores on the Diabetes Empowerment Scale, which measures an individual's perceived ability to self-manage their diabetes, also significantly improved between the pre- and post-DWELL assessments (p<0.001).

The researchers found significant increases in illness coherence (p<0.001), treatment control (p<0.05), and personal control (p<0.05) domains on the Illness Perception Questionnaire.

Prof Hatzidimitriadou said that it was "very exciting" to observe patient feedback showing improvements in mental health and enhanced knowledge of the illness, as well as "how they are changing things in their lives, which is really important".

Brexit Uncertainty

Julie Webster said that the DWELL programme will run until March/April 2020, and that funding has been secured for a further 3 months after that.

It is also the intention that the project will spread to other parts of the UK.

Alice Chapman-Hatchett told Medscape News UK that "it would be very much our hope that in five, ten years' time the whole of the UK was delivering DWELL".

However, one factor outside of their control that could affect the UK's future participation in DWELL is the impending departure from the European Union, particularly if that is without an ongoing Brexit deal.

She said that, had she been asked about the potential impact of Brexit "about 3 or 4 weeks ago, I'd have said we could be cut at any point".

"However, what has recently come out is that the UK government has agreed to underwrite all European funding, even in the event of a no-deal."

Alice Chapman-Hatchett added: "What we're not certain of is how that will interact with our continental partners because obviously in a no-deal situation we will be receiving funding from the UK government rather than the EU…but at least we know the delivery will still continue."

No conflicts of interest or funding declared.

Diabetes Professional Care 2019: The DWELL Project: Development & Evaluation of an Innovative Psychoeducational Programme for People with Type 2 Diabetes. Presented 30th October.

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