Process evaluation of a primary care-based type 2 diabetes remission project in the North East of England.

A type 2 diabetes remission project, Remission in Diabetes (REMI.D), funded by Sport England, was developed by stakeholders based in the North East of England and begun in early 2020. This local delivery pilot sought to tackle health inequalities by working with multiple organisations to demonstrate a way of scaling up an effective type 2 diabetes remission strategy which included both physical activity and dietary components. The intended delivery of the original project was impacted by the COVID-19 pandemic and changes were made to the project delivery in 2022. The aim of this process evaluation was to learn from the reactive decisions taken by stakeholders which altered the REMI.D project in response to the COVID-19 pandemic. Twelve stakeholders (from local authorities, secondary care, universities, NHS England commissioning, Diabetes UK, Sport England, Everyone Active and Active Partnerships) involved in the design and delivery of the intervention took part in a semi-structured interview lasting up to 60 min. Interviews were recorded and transcribed verbatim. Thematic analysis used the pre-determined 'core content' themes from the Medical Research Council and National Institute for Health Research framework for developing and evaluating complex interventions. Three topics for discussion emerged as follows: (a) lack of effective collaboration, (b) perception of change and (c) scalability of the intervention. Hierarchy within the stakeholder group initially hampered collaboration. Change was reactive as a result of the COVID-19 pandemic. Project changes reduced project sustainability and scalability but offered valuable learning about the need for explicit project theory for partnership working, co-production with service users and project flexibility for long-term health behaviour change.

A systematic review examining the impact of blended diets on the gastrointestinal symptoms of people who are enterally fed.

BACKGROUND: Adults and children who are enterally tube-fed can experience adverse gastrointestinal symptoms (GIS). Observational data suggests that blended diets (BD) could mitigate such symptoms, with potential to improve quality of life and clinical outcomes. We present a novel systematic review examining the impact of BD, compared to commercial feeds, on GIS of adults and children who are tube-fed. METHODS: The protocol was registered with PROSPERO (CRD42021261147). Four electronic databases were searched from inception to August 2021. Search terms included 'tube-fed', 'blended diet' and 'formula'. Inclusion criteria were intervention studies comparing blended and commercial feeds using quantitative measures of GIS. Heterogeneity of outcome measures precluded meta-analysis; therefore, a narrative synthesis was conducted. RESULTS: Six papers (n = 219), including two randomised control trials (RCT) and four single arm pre-post studies, were identified. Equal numbers studied in- and out-patients, adults and children. Risk of bias was notable for all studies. Equivocal and insufficient evidence prevented consensus on outcomes of vomiting, gagging, oral intake, bloating and constipation. However, one RCT and two single arm pre-post studies suggest that diarrhoea symptoms may be improved on BD. CONCLUSIONS: Diarrhoea is prevalent in tube-fed populations and associated with adverse outcomes. Improvements in diarrhoea symptoms attributed to BD may be clinically important. Our findings are congruous with the wider observational evidence base, and support recommendations of the British Dietetic Association. BD may pose a viable alternative to commercial formula, and may mitigate symptoms of diarrhoea for adults and children who are tube-fed.

Clinicians' perceived barriers and enablers to the dietary management of adults with type 2 diabetes in primary care: A systematic review.

BACKGROUND: Dietary management of type 2 diabetes is considered as a key remission and management strategy. This review explored clinicians' perceived barriers and enablers to the dietary management of adults with type 2 diabetes in primary care. METHODS: MEDLINE, EMBASE, CINAHL, PsycINFO and ASSIA were searched from 1980 to 16 June 2020. RESULTS: Of 2021 records, 14 studies met the inclusion criteria, describing the 14 domains of the refined Theoretical Domains Framework. The data synthesised to the domains of environmental context and resources, intentions and beliefs about capabilities were considered most trustworthy, closely followed by knowledge, behavioural regulation and beliefs about consequences. Two-thirds of studies cited time for staff training or patient education as major constraints to type 2 diabetes management. Clinicians also identified lack of patient engagement and poor dietary adherence as issues. Despite this, clinician confidence about giving dietary advice to patients was high. With further exploration, knowledge gaps were apparent and feelings of despondency as a result of poor outcomes were visible. CONCLUSIONS: This review revealed four clinician behaviours: (2) the perception of the dietitian; (2) the definition of a clinician qualified to give dietary advice; (3) clinician belief in dietary management as a treatment; and (4) clinician belief in a patient's capability to change dietary behaviour. These behaviours, if challenged and changed, have the potential to improve dietary management and outcomes for people with type 2 diabetes in primary care.