Medical Nutrition Therapy, In-Person, or Telephone Group Lifestyle Intervention for Type 2 Diabetes? A Qualitative Study of Patient Perceptions and Treatment Preferences

Abstract

Purpose:

The purpose of the study was to explore the thoughts, feelings, motivations, and assignment preferences of community health center patients with type 2 diabetes considering participation in a 2-year lifestyle intervention trial aimed at weight loss and increased physical activity. The reasons for patients’ delivery mode preferences were also explored to aid in the design of future interventions for controlled trials.

Methods:

Using structured telephone interview guides, 57 patients with type 2 diabetes receiving primary care at 3 community health centers affiliated with an academic medical center were interviewed regarding the perceived pros and cons of each of the 3 possible treatment assignments: telephone conference group, in-person group, or individual medical nutrition therapy. The interview data were organized using NVIVO and analyzed using content analysis. Findings on whether preferences varied by age, gender, or diabetes duration were also examined.

Results:

Six categories related to patient treatment preferences were identified: (1) perception of time, (2) learning style, (3) comfort, (4) prior experience with weight loss programs and conference calls, (5) desire for support/idea exchange, and (6) accountability. Preferences did not seem to vary by age, gender, or diabetes duration.

Conclusions:

Key factors influencing preference of treatment assignment included schedule demands, belief about learning style, and past experiences. These findings demonstrate the importance of having a variety of nutrition and lifestyle treatment options available to meet the needs of people with type 2 diabetes.

Dietary modification and physical activity are foundational but underutilized components of diabetes care.¹ Medical nutrition therapy (MNT), or individual counseling sessions with a dietitian, is the current recommended standard of care for nutritional management of type 2 diabetes. Randomized controlled trials have demonstrated that MNT is associated with reduction in A1C of up to 2% in patients with type 2 diabetes.² Group lifestyle intervention programs that incorporate nutrition, activity, behavioral change components, and support are another evidence-based treatment option to enhance diabetes self-management skills in patients with type 2 diabetes. Intensive lifestyle intervention resulting in weight loss in people with prediabetes, as seen in the Diabetes Prevention Program, has been shown to reduce the risk of developing type 2 diabetes by 58% over 3 years.² Studies such as Look AHEAD, (Action for Health in Diabetes), IDOLc (Improving Diabetes Outcomes Through Lifestyle Change), and the REAL HEALTH-Diabetes trial have also demonstrated the effectiveness of lifestyle interventions as a treatment option for people with type 2 diabetes to promote weight loss, increase physical activity, and improve glycemia with simultaneous reductions in medications and costs to treat these conditions.^3–5

The REAL HEALTH-Diabetes trial was conducted at community health centers affiliated with Massachusetts General Hospital (MGH) involving primary care patients with type 2 diabetes.

The goal of this trial was to further expand on Look AHEAD and IDOLc lifestyle interventions by comparing an in-person group lifestyle program, an added telephone conference call lifestyle group program, and individual referral to a dietitian for MNT over a 2-year period.⁶ Many patients with type 2 diabetes have participated in group weight loss programs or MNT. However, most have not participated in a group telephone conference remote format.⁶ Previous research comparing in-person interventions versus remote interventions for the treatment of obesity has shown similar weight loss results; however, most of these studies were not conducted with people who had type 2 diabetes exclusively.^7–9 Thus, another goal of the REAL HEALTH-Diabetes trial was to explore and understand treatment assignment preferences of people with type 2 diabetes to help inform future interventions for them.

The purpose of this article is to report results of a qualitative evaluation performed prior to launching the REAL HEALTH-Diabetes trial intervention. The goal of the structured interviews was to refine REAL HEALTH-Diabetes trial intervention design and understand participant views and preferences prior to study launch. Specifically, potential trial participants (community health center patients with type 2 diabetes) were queried regarding their views of a 2-year lifestyle intervention via an innovative telephone conference call group compared to an in-person group program or individual MNT counseling. The same population of patients who met minimal eligibility requirements for the REAL HEALTH-Diabetes trial were targeted to better understand their preferences and willingness to participate in any of the 3 arms: group in-person lifestyle format, group telephone format, or individual MNT. Understanding the barriers and facilitators to joining a lifestyle change program with various delivery formats was also of interest. Special attention was paid to determine whether preferences varied by age, gender, or diabetes duration. Here, the results are reported, which may guide others planning, designing, or refining lifestyle interventions or MNT programs for this population.

Methods

Research Design

A qualitative approach using a structured interview guide was utilized to understand preferences for various intervention formats for people with type 2 diabetes. The advantage to this approach was that it allowed for better understanding of the reasoning behind the willingness and/or barriers to participate in any of the 3 treatment arms and how and why these individuals had certain preferences over others, which is information that is not easily quantifiable. The study protocol was approved by the MGH Brigham Institutional Review Board.

Study Sample

The target recruitment population was primary care patients with type 2 diabetes who received primary care at 1 of 3 community health centers affiliated with MGH: MGH Charlestown, MGH Chelsea, and MGH Revere. These are federally qualified health centers that work closely with local schools and community organizations to provide comprehensive primary medical care, some specialty care, and many programs that benefit their culturally and socioeconomically diverse anchor communities. Inclusion criteria were: (1) patients receiving primary care at 1 of the 3 affiliated community health centers, (2) diagnosis of type 2 diabetes confirmed via electronic medical record, and (3) English speaking. The REAL HEALTH-Diabetes trial co-investigators from the 3 community health centers identified eligible patients and sent names to study staff. Study staff then sent opt-out letters to the identified patients and contacted those who did not opt out. The aim was to interview 20 patients from each health center for a total of 60 participants, with 50% men and 50% women.

Data Collection

A structured interview guide was developed that included both open- and closed-ended questions. The goal of the structured interview was to explore preferences for and barriers to participating in an in-person group lifestyle program, a group telephone conference lifestyle program, and/or individual nutrition counseling. Sample questions are shown in Figure 1. All interviews were one-on-one conversations conducted by telephone, audio recorded, and lasted 15 to 20 minutes. Reasons for preferences and whether preferences varied by age, gender, or diabetes duration were also explored. Three study staff were trained by an experienced qualitative researcher to conduct the audiotaped interviews. Each interviewer practiced the structured interview on 2 to 3 staff members prior to use on the patient population. Interviews were conducted in 2014 to 2015. While interviews were being conducted, study investigators met with interviewers to ensure standardization and listened to transcripts as needed to ensure consistency and quality control. Changes were made to the interview regarding patients’ internet access via phone and computer to see if videoconference would be a preferred method versus telephone. This change occurred after some interviews were conducted; therefore, only 22 participants were asked about computer internet access, and 27 were asked about phone internet access. All participants were compensated with either a $25 check or gift card. Demographic information was collected using both the structured interview guide and the electronic health record.

Figure 1.

Interview guide.

Data Analysis

All interviews were audiotaped and transcribed. A content analysis approach was used to analyze data and determine categories and themes.¹⁰ The advantage of this approach was that it allowed for understanding of the different factors and reasons behind patient preferences. Interviewers reviewed a sample of the transcripts to identify categories among the responses to develop a coding framework. Once the framework was developed, data were organized and coded using NVivo 10 software by a primary and secondary coder. The primary coder reviewed and coded all transcripts; the secondary coder reviewed and coded one third of the transcripts, 6 to 7 from each of the 3 health centers. Coders met regularly to review consistency of coding and to resolve discrepancies, maintaining an audit trail of all discussions. Themes were extracted from within categories.

Participant responses were sorted by age, gender, and diabetes duration. Age was categorized as <60 years old and ≥60 years old. Diabetes duration was categorized by less <2 years, 2 to 5 years, 6 to 10 years, and >10 years. The results of treatment preference based on these characteristics were explored.

Results

Across all 3 community health centers, a total of 168 patients were contacted, and 57 were interviewed, 7 of whom went on to enroll in the REAL HEALTH-Diabetes trial. The 7 that enrolled in the REAL HEALTH-Diabetes trial participated in the informed consent process, during which it was explained that if they were to consent to the REAL HEALTH-Diabetes trial, they would be assigned by chance to 1 of 3 programs. Those who were not interested in being randomly assigned to a treatment group opted out and chose not to enroll in the trial.

Reasons for declining to participate in the interview included: not being interested in a weight loss program, inability to participate in the interview due to work schedule demands, and family commitments. Baseline characteristics of participants are shown in Table 1. There was an even distribution of participants from each of the 3 community health centers. Fifty-six percent of participants were 60 years or older with a mean age of 60.6 years old, and more than half of the participants were female (56.1%). For race/ethnicity, 80.7% of participants were White, 7% were Latino, 7% were Black, and 5.3% identified as other. The majority of participants (64.2%) reported having diabetes for 10 years or less. Approximately half of the participants had never participated in a weight loss program, but the majority (64%) had seen a clinician in the past for weight loss. Of those queried, 68% had access to a computer with internet, and 59% had access to a phone with internet capability. Pros and cons of each treatment assignment are described in addition to preferences for intervention delivery; these are shown in Table 2.

Table 1.

Baseline Characteristics of Structured Interview Participants

Demographics	n (%) or Mean (SD)
Age, mean (SD)	60.6 (9.7)
<60 y, n (%)	25 (43.9)
≥60 y, n (%)	32 (56.1)
Sex, n (% female or male)
Female	32 (56.1)
Male	25 (43.9)
Race/ethnicity distribution, n (%)
White	46 (80.7)
Black	4 (7)
Latino	4 (7)
Other	3 (5.3)
Diabetes duration, n (%)
<2 y	3 (5.7)
2-5 y	17 (32.1)
6-10 y	14 (26.4)
>10 y	19 (35.8)
Health center site (Charlestown, Chelsea, Revere), n (%)
Charlestown	20 (35.1)
Chelsea	17 (29.8)
Revere	20 (35.1)
Prior participation in a weight loss program, n (%)	22 (44.9)
Prior experience with a clinician for weight loss, n (%)	32 (64.0)

Table 2.

Pros and Cons of the 3 Proposed Weight Loss Programs for People With Diabetes

	In-Person Group Program	Telephone Group Program	Medical Nutrition Therapy
Pros	Group support (N = 30) Information exchange (N = 22) Diet/weight loss (N = 16) Health Reasons (N = 11) Accountability (N = 7)	Convenience (N = 20) Information exchange (N = 7) Anonymity (N = 6) Group support/social contact (N = 5)	Personalized attention (N = 25) Flexible schedule/convenience (N = 15) More accountable (N = 8) More comfortable (N = 5)
Cons	Logistics (N = 14) Nothing new/no new knowledge (N = 7) Prefers one-on-one attention (N = 4) Uncomfortable in group (N = 3)	Impersonal (N = 23) Interruptions/distractions (N = 11) Dislike talking on the phone (N = 9) Lack of accountability (N = 8) Length of time on the phone (N = 4) Crowd control (N = 3)	Group interaction is more beneficial (N = 9) Negative prior experience (N = 7) Yes, but more interested in group (N = 5) Not worth the commute (N = 1)

Treatment preferences varied based on current schedule, perceptions regarding the type of delivery format that provided for best learning, accountability, and prior experiences with weight loss efforts or conference calls. Six categories of influencing factors were identified: time considerations, preferred learning style, comfort, prior experience with weight loss programs and use of conference calls, desire for support and need for accountability. Themes were extracted from within categories (Table 3).

Table 3.

Interview Themes

Theme	Common Points
Time considerations influenced perception of treatment modality	Participant’s perception of availability and flexibility of intervention scheduling influenced treatment preferences.
Preferred styles of learning influenced preferences	Some participants preferred to learn while surrounded by others in a group, whereas others felt that a one-on-one approach would better suit their needs.
Comfort level when sharing personal information	Some participants felt more comfortable one-on-one, whereas others felt more comfortable in a group setting. Some also felt more comfortable with the sense of anonymity that the telephone group provided.
Past experiences with programs informed preferences	Both positive and negative prior experience in group programs, conference calls, and seeing a clinician for weight loss influenced treatment preferences.
Desire for support among groupmates	Many participants wanted the opportunity for support and exchange of ideas as part of a group interaction.
Need for accountability influenced preferences	Many participants felt the sense of accountability with in-person interaction was an important factor. Many felt as though the phone group lacked accountability.

Time Considerations

Time considerations influenced participants’ perception of treatment delivery in 2 ways: time spent traveling to and from in-person groups or MNT visits and time spent on group telephone conference calls. A preference for telephone-based groups or individually scheduled MNT emerged for participants with competing time demands, such as work schedules and various caretaking responsibilities.

People of all ages had differing logistical concerns about attending the in-person group. Those younger than 60 were concerned about scheduling the group around work and family obligations. Older patients were concerned about scheduling the group around medical visits and caretaking responsibilities and transportation to attend the in-person group.

Specifically, some participants felt as though attending an in-person group on a regular basis would be too difficult to coordinate with work schedules, commutes, and childcare.

No, it’s just work, and my schedule changes, so I wouldn’t know when I’d be available and that sort of thing. (M, 62, >10 years)

For me it’s too long. It’s too long in the sense that it will be 60 to 90 minutes, because people have stuff they have to do, especially if it’s on a weekday. (F, 54, >10 years)

Although many participants felt as though traveling to an in-person group would be challenging, there was a level of interest expressed when discussing the telephone conference call program because this format eliminates any travel in general and in cases of inclement weather.

It’s nice because you don’t have to go anywhere. You can just sit at home and put your phone on speaker, and you’re part of the meeting without actually having to get ready and get out and travel. (M, 59, 6-10 years)

I think for people who work long hours, that’s a wonderful option, because then you would not have to take the time to travel somewhere. And it’s less of a time investment, but it seems to me that you still get the benefit of the teaching. I think that that probably would be a good thing for people who don’t live close by, or it’s difficult for them to get there, or someone could be driving another half an hour at the end of the day, that sort of thing. (F, 58, 6-10 years)

Overall, more women were interested in the telephone group for convenience.

Although many participants showed interest in the group programs, some participants preferred MNT, perceiving this format as more convenient. More participants under 60 compared to those older than 60 were interested in MNT for the flexibility in scheduling.

With my schedule, I think I could probably negotiate that and make sure that I could attend those more readily, when a whole group of people is not involved. (F, 58, 6-10 years)

What’s great about it is the flexibility itself. (M, 59, 7-10 years)

Although some participants desired the convenience of scheduling individual visits for MNT, one participant was discouraged by the commute and did not feel as though the value/information gained from the MNT visit was worth the time spent commuting.

That wouldn’t be beneficial to me, because like I said, it’s an hour for me to get there, for 30 minutes? No. (F, 49, >10 years)

Learning Style

Preferred learning styles influenced participants’ preferences. Participants who reported learning best in a social setting preferred either group program format so that they would be able to share ideas and learn from their peers. Many participants anticipated value in the ability to exchange information, ideas, and tips with other group participants and felt that it would help to enhance their overall understanding. Many women, specifically, felt that group interaction was more beneficial than individual MNT.

I like the other people. Because, like I said, you learn more, you learn little things from other people that you would never even think of doing yourself. (F, 49, >10 years)

I understand it’s always good to have—two heads are better than one, and eight are certainly better than two, and you can learn from each other, and there were no bad ideas that get tossed around. You can see an idea that might not fit one particular endeavor, but you know someone else will come out with something and you can innovate two of them together and come up with something really great. (M, 59, unknown)

Many participants preferred individual MNT that could provide a more personalized approach and attention versus a group format.

You narrow yourself down to speaking about your issues … you get a lot more out of it, even if you don’t meet as much … the dietitian will get to actually know you a little bit better and when you speak about what your issues are, they can have an idea of the lifestyle or whatever is going on a lot better than the whole group and everybody’s speaking a short period of time. (M, 47, 2-5 years)

If you get somebody good, it would be helpful. One-on-one, it’s more personal, and you get to know the person and you could ask more questions. (M, 69, 13 years)

A small number of participants also expressed that a one-on-one style of learning would better suit their needs because it would not only provide a more personalized approach but also help enhance overall understanding.

I prefer a one-to-one than a group because sometimes listening to a group … I might not understand as much that another person can, or everyone will pick up something a little different than the other. So, I’d rather be with a one-to-one where a person can actually directly talk to me about my needs, not about everybody else’s needs. (F, 56, >10 years)

Because when you’re talking to a person individually … they can explain a little bit more. (F, 64, <1 year)

Comfort

Participants’ comfort level with sharing personal information about one’s health and wellness emerged when discussing being with others in a group setting. Some participants felt discomfort discussing health concerns and other personal information with a group due to the lack of privacy. Several participants also mentioned more comfort with participation in a telephone group rather than an in-person group because they would feel a sense of anonymity.

I just don’t like sitting and being in a group discussing everything like that. (M, 59, 2-5 years)

Well, it’s yourself, you’re on the phone and you’re at home, you’re more relaxed, and you could probably feel open to talk. (F, 64, >10 years)

Other participants felt more comfortable discussing topics and asking questions in a face-to-face setting because this setting can feel more personable, especially when discussing health matters one-on-one.

Face-to-face, you feel more free to ask questions. You’re not afraid to talk about it. You’re not afraid to ask questions. (M, 52, 2-5 years)

Participants also had concerns about the telephone group format. Some lacked confidence in their ability to succeed in a telephone group setting due to concerns with the potential lack of crowd control and/or difficulty preventing others from interruption, causing distraction and inability to pay attention. Several mentioned their dislike of talking on the phone, especially for long periods of time.

Again, it has to be something where as a group, it’s a little difficult speaking over the phone. You’ll notice that I have not interrupted you. That I have waited and listened to you speak. Even as well as we’re doing, there are going to be times when we step on each other’s foot. It does happen. We’re not looking at each other. So that is something, again, that has to be controlled … that’s one of the reasons I would prefer much more the in person. (M, 59, unknown)

That wouldn’t work for me. Every time I get on the phone, somebody needs me here for something. There’s no way I could do that. (F, 60, 6-10 years)

I do conference calls, meetings, but I’d rather do it in person. Personally, I’d rather be an in-person meeting, even though it makes it easier sometimes when I do a conference call. I get distracted. I’m one of those guys, I’ll get distracted a little easily, so I like the in-persons. (M, 66, 2-5 years)

Past Experiences

Past experiences with MNT, conference calls, and in-person group programs influenced participants’ preferences. Some had positive experiences in the past with weight loss programs and seeing a dietitian for MNT and felt that they would benefit from ongoing accountability offered by these modes of education.

The reason I went back to my nutritionist is because … “You know, I need to give them a tip of the hat.” I said, “It’s probably due to their input that has really helped me keep on track, so I do want to continue.” … I requested to go back to see my nutritionist. I said, “I need to get back on track.” I know the importance of all this stuff. Even as repetitive as it may be, you’ve got to have that engagement. (M, 59, unknown)

Other participants, and specifically more men, felt they would not gain any new knowledge from participating in a group weight loss program.

For one thing, I know about nutrition. I know what I’m supposed to eat. I know what I’m not supposed to eat. I know what I’m supposed to do for my diabetes as far as diet and exercise. It’s just a question of implementing what I know, and the hardest part is the food, not eating what you know—when I eat things that I know I’m not supposed to eat, I know that I’m not supposed to be eating them but sometimes I just like them too much to not eat them. So, I don’t know if talking about it would help me, or if I would be interested in doing that because I already know what I’m supposed to do. I just have a hard time doing it in practice. (M, 59, 6-10 years)

Many participants had previously seen a dietitian for MNT, some of whom had a negative prior experience and did not feel as though they would benefit from going again.

It’s not going to sound right, but it’s just where it’s not worked for me before … I just feel in my head that it won’t work for me again. And I can’t tell you how to fix it. (F, 67, 2-5 years)

I’ve done it a few times before. … It’s more disappointing because it’s like you don’t get any other ideas. They’re just telling you blah-blah, do this, that, and the other thing. It’s like, “Okay.” Whereas, with the group, maybe there was somebody in the group who’d say, “Oh, I do it this way.” Or “I found that this did best for me.” Giving me more ideas and stuff. (F, 64, >10 years)

More women had previously participated in a clinician-guided weight loss program yet mentioned that the experience did not provide enough support for them. It was more common for men to have seen a clinician for weight loss versus participating in a weight loss program. When asked whether previous experience with weight loss programs had any influence on current treatment preference, more women said that previous experience in weight loss programs and prior clinician visits did in fact influence their program preference.

Many participants who had previously participated in a weight loss program had diabetes >6 years; however, they were not any less interested in the treatment options than those with shorter diabetes duration and still valued having the experience.

Because I’d like to really kind of hear other people’s ideas and struggles too, because it might really help me and might put those into my head. As far as, they might be going through the same thing and might have different options or alternatives that I haven’t thought of as far as dieting and planning a diet, and setting it up, and so that would help. (M, 54, 6-10 years)

Support

A desire for support from other group members that comes from exchanging information with other participants emerged when discussing the group programs. Some expressed that having support from group members was valuable and would offer a sense of encouragement and motivation and might lessen the feeling of being “alone.” Some participants thought this kind of support was only achievable via an in-person group program and that the telephone group would not have that added benefit.

I feel that if you do it by yourself, you’re more apt to cheat. But if you’re in a group, maybe you could call somebody and say, “I’m really depressed, and I really want this big piece of chocolate cake.” These other people that are feeling the same thing you’re feeling. It’s like you’re not alone. (M, 61, 2-5 years)

One participant felt that she would be able to support other people who were going through the same experience by exchanging new ideas and tips and that they would be able to reciprocate and support her as well.

I might be able to glean something from them and maybe I can lend some thoughts to someone else who needs some help. (F, 72, <2 years)

When discussing the telephone group program, many participants were concerned that the lack of face-to-face contact would not offer the same support as an in-person group.

It’s just I think you lose something by just being on the phone. When I was there at the first one, I did, you meet people—at least I’m very funny with people—and you get to know them, and you see them every week. It’s not like they become your friends, but for that time frame, you just enjoy sitting down and talking to them, and on the phone I think you’d miss that. (M, 69, 2-5 years)

Some participants also felt that the lack of group support with individual MNT was a disadvantage.

The drawback on it is that you’re not sharing the best practices that you can glean from other participants. (M, 59, unknown)

Accountability

The need for accountability influenced participants’ preferences, stating that the need to show up somewhere would enhance responsibility for their actions. They felt it necessary to have someone else (facilitator or group mates) hold them accountable rather than attempting to lose weight on their own and that attending an in-person group program would help them stick with diet and weight loss behaviors. More participants under 60 were interested in the in-person group for the accountability aspect, whereas more participants over 60 were interested in the in-person group as an “activity,” that is, something for them to do for a change of scenery.

To help me lose weight because I’m not doing a very good job of it myself, to be honest. (F, 55, 2-5 years)

I guess there’s more awareness, more tips of how to keep myself straight as far as not cheating on my diet, or whatever. … It makes you honest, accountable to what you are doing. (M, 48, 6-10 years)

Just as I see, because it would be something that you would feel obliged to go to once you start this, and you would make yourself go. I think it would have that effect to make you feel motivated. (F, 55, 2-5 years)

Others felt having one-on-one personalized attention (MNT) would make them feel more accountable.

If I didn’t lose weight or if I was keeping track of my numbers and if they weren’t getting better, then I would be held more accountable with the one-on-one. That’s what I need. I really need a kick in the butt to be more responsible. (M, 54, 6-10 years)

Some participants felt that the telephone conference group would not help to hold them accountable because of the lack of face-to-face contact. More men found the phone group to be impersonal and felt there was a lack of accountability.

Well, if all of a sudden it becomes a phone conversation, you could be running around in your pajamas and it won’t make any difference, you just aren’t locked into it, mentally or emotionally. (M, 69, 2-5 years)

I just think I’d end up falling off the wagon. I’d call a couple of times and end up not calling again. (M, 48, 8 years)

Conclusions

The purpose of this study was to determine whether patients with type 2 diabetes would be interested in a weight loss program with 3 different treatment options and to explore factors that influenced barriers to and facilitators of each intervention modality: individual MNT or in-person or telephone group lifestyle intervention. Six categories influenced treatment preferences and emerged from the structured telephone interviews: time considerations, preferred learning style, comfort, prior experience with weight loss programs and use of conference calls, desire for support/idea exchange, and need for accountability. Overall, schedule demands, preferred style of learning, and past experiences with group programs, individual counseling, and use of conference calls had the greatest influence over preferences. The need for accountability in the form of one-on-one meetings or group meetings with follow-up was another motivator for participating in treatment. The ability and desire to exchange information with others was mentioned when describing both preferred style of learning and the desire for support among group mates. This created some overlap among the 2 categories; however, there are some important distinctions to be made. When discussing preferred style of learning, participants were interested in exchanging ideas with people who were going through a similar experience to help enhance overall understanding, which could then help them to be successful. When discussing group support, participants were more interested in exchanging ideas with others to help them feel less alone and for social contact and emotional support.

Reasons for treatment preference based on age, gender, and diabetes duration were also explored. Older and younger patients had logistical concerns pertaining to the in-person group program, although the reasons for concern differed between age groups, with younger patients facing more competing commitments with work and family obligations and older patients concerned about transportation and medical visits. Overall, more women had participated in a weight loss program in the past that they felt had influenced their current treatment preference. Many people who had a prior experience with weight loss programs also had diabetes for a longer duration, which one might expect given that weight reduction is an effective treatment method for those with type 2 diabetes.

There is now good evidence that patients with diabetes can benefit from a variety of treatment programs, including individual MNT, diabetes self-management education programs, and lifestyle interventions programs.¹¹ The 1-year results of the REAL HEALTH-Diabetes trial have demonstrated that MNT and lifestyle group programs, whether delivered via in-person group or telephone conference call, all promote weight loss and improved glycemia in patients with type 2 diabetes. The in-person lifestyle group program, telephone conference call group program, and MNT arm resulted in weight losses of 4.6%, 4.8%, and 2.0%, respectively; however, the time commitment for the lifestyle programs was much greater than for MNT, which had more flexible scheduling.⁵ The 2- and 3-year results of the REAL HEALTH-Diabetes trial demonstrated similar weight loss results among all 3 arms at the end of the intervention and 1 year after the conclusion of the intervention, again showing that both MNT and lifestyle group programs can help to promote weight loss.¹² Consideration of factors influencing patients’ treatment preferences and tailoring treatment plans depending on these preferences is important and may help to enhance success among patients. However, research shows that although patients want to be involved in making treatment choices, many are not.¹³

The process of shared decision-making involves discussing the various treatment options (including the option to do nothing), the objective benefits and risks of each option, the patient’s pros and cons of each option, and their concerns and preferences. This process can help ensure that the right treatment is matched to the right patient at the right time. Evidence has shown that shared decision-making may improve a patient’s engagement in treatment and their health outcomes.¹¹ A review of the literature on patient-centered decision-making has also shown that patients who are able to self-select treatment modality are more likely to sustain positive health outcomes such as weight loss.¹⁴ The themes that emerged during the structured interviews, related to preferred learning style, prior experience with programs of various formats, and the desire for support and exchange of information among group mates, represent important factors that should be discussed with patients during a shared decision-making process to better help the clinician and the patient identify the best fit treatment option.

The study has several limitations. First, the interview guide was constructed to ask about prior clinician visits for weight loss, and in some interviews, it was difficult to determine whether the clinician was a dietitian, nurse/nurse practitioner, or doctor. Thus, when discussing previous experience with MNT, visits with a dietitian were not explicitly queried. Another limitation includes the fact that not all participants had gone through each treatment experience previously, so responses were sometimes reflective of anticipated perceptions of the treatment program. For example, some had no prior experience with group conference calls and therefore could not make an informed decision as to whether that would work for them or not. However, perception of what will work could influence real-world preferences. Video conferencing was not discussed in detail, which also could have influenced participant perceptions of the treatment program. The interviews were conducted prior to the COVID-19 pandemic.

In today’s world, feasibility and acceptability of the telephone conference call format will likely be influenced by people’s experience with telehealth visits during the COVID-19 pandemic. However, it is expected that there will be those who have become more comfortable with remote formats and others who will continue to prefer in-person group meetings, which makes shared decision-making an important part of the process.

In the meantime, diabetes educators and clinicians can consider the results of this qualitative examination in concert with the evidence on the effectiveness of various treatment approaches for diabetes management to guide a more patient-centered approach. Incorporating insights about the factors that influence treatment preference into a shared decision-making process can improve quality of care by helping patients become more informed about their treatment options and ensuring that their voice is incorporated to optimize health care decisions.¹⁵