Introduction

Obesity is a major world-wide epidemic that is contributing to a variety of diseases, including type 2 diabetes. Diabesity (diabetes associated with obesity) has reached epidemic proportions, both worldwide and in the Middle East [1, 2]. In Kuwait, the prevalence of obesity was reported to be 40.3%, and approximately 8 in 10 adults are living with overweight or obesity [3]. Kuwait has the second highest rates of obesity in the Eastern Mediterranean Region, following Qatar [4]. In terms of diabetes, the prevalence in Kuwait has been found to be 18.8%; this has doubled over the past 20 years [5]. This increasing trend requires immediate attention to reduce the prevalence and address the impact of diabesity on morbidity, mortality and healthcare costs in Kuwait.

Interventions focusing on weight loss are available and wide-ranging, from dietary and lifestyle interventions to pharmacotherapy and surgeries [6–8]. A variety of factors exist that may hinder the uptake and continuation of weight loss interventions; these include personal barriers (such as patients accepting and normalizing their obesity), healthcare system barriers (such as workforce reduction), and community barriers (such as weather conditions and cultural and social norms) [9].

The role of behaviour and psycho-social support is also integral to weight loss services. A systematic review found that patients living with obesity regarded healthcare providers (HCPs) as ambivalent towards them, which affected their willingness to access services [10]. Patients living with obesity also faced stigma and discrimination in daily life, which fed-back into negative psycho-behavioural responses [10]. In the United Arab Emirates, focus groups with 75 women living with obesity and a risk of developing type 2 diabetes found a variety of personal, social, and environmental challenges to managing their weight [11]. Some of these barriers include low motivation, lack of social support, and socio-cultural factors. Another study in Iran with 204 women who were living with overweight or obesity also found stress and depression, as well as education as barriers to the application of weight loss interventions [12].

The implications of weight loss on type 2 diabetes have been recently illustrated, with patients achieving remission of their diabetes after losing weight, using total dietary replacement (TDR), and maintaining their weight loss for a year, as well as stopping their anti-diabetic and hypertension medications [13]. Remission of type 2 diabetes is defined as “HbA1c of less than 6.5% (48 mmol/mol) measured at least 3 months after cessation of glucose-lowering pharmacotherapy” [8]. This dietary intervention was also recently studied in Qatar in a randomized controlled trial, with 61% of participants achieving remission and 33% achieving normoglycaemia, indicating the feasibility of this intervention in the region [14]. The TDR intervention utilizes formula low-energy diet meal replacement products that are consumed by patients 3–4 times per day for a period of 12 weeks, followed by a 12 weeks structured food reintroduction phase and long-term weight-loss maintenance with behavioural support [15].

Many countries are gradually introducing remission programmes, such as the United Kingdom [16], and with the high prevalence of type 2 diabetes and obesity in Kuwait and the region, it is timely to consider how healthcare professionals perceive the TDR approach for weight loss and remission of type 2 diabetes. In Kuwait, patients with obesity and/or diabetes are referred to dietitians in primary and secondary healthcare facilities for nutrition consultations and health promotion. As little is known about how weight loss advice and diet implementation in Kuwait occurs, the current study aimed to explore and understand the topic of remission of type 2 diabetes and the use of TDR from the perspectives of dietitians to identify challenges and recommend solutions to implement in Kuwait and ultimately, the Gulf region.

Methods

A qualitative approach was undertaken using focus groups to achieve the study aim. Focus groups were chosen for their time-effectiveness and the ability to explore wide-ranging views by eliciting discussions between participants [17]. Ethical approval was sought from Dasman Diabetes Institute (DDI) in Kuwait where the study took place (RA HM-2018-048).

Results

Themes

Three major themes emerged from the findings; motivation to use the TDR approach, perceived challenges of TDR, and suggestions to improve and adapt approaches. Table 1 lists the themes, sub-themes, and quotes to illustrate them indicating each participants’ number, age, and speciality for context.

Download:

• PPT
  PowerPoint slide
• PNG
  larger image
• TIFF
  original image

Table 1. Themes and sub-themes regarding diabetes remission and using TDR.

https://doi.org/10.1371/journal.pone.0276679.t001

Motivation to use TDR.

Dietitians discussed the topic of remission of type 2 diabetes, which they considered a positive outcome of using TDR. Achieving better glycaemic control and stopping antidiabetic medications were stated as powerful motivators for potential patients, alongside the considerable weight loss. When discussing products, the majority stated they are easy and fast to prepare, especially for people with a busy lifestyle who do not want to think about what to eat. Furthermore, using the products would make it easy to verify a total of 800 calories per day, which would be difficult to ascertain accurately with food. Some dietitians stated that using the TDR approach for 3 months will help patients change their behaviour and sustain this lifestyle change for the long-term. It was also mentioned across groups that it would be a great way to market the approach as an alternative to bariatric surgery, which many people with obesity are resorting to for weight loss.

Perceived challenges of TDR.

There were multiple challenges with the TDR approach that emerged from the discussions. A few dietitians felt hesitant to approach patients with this intervention, as they feared their reaction. Another reason was that dietitians felt they could not try it themselves, so they were wary of promoting it to their patients. In addition, the lack of food was felt as barrier; some TDR approaches depend solely on soups and shakes while others have bars. The dietitians all agreed patients will want some solid food, such as bars, or they will not be able to commit. Furthermore, they felt that the minimal variety of flavours may lead patients to be bored easily. The length of the intervention (3 months) was also deemed as discouraging to patients as it was felt patients would not be able to tolerate being without solid food for that long.

Patient demographics, such as age, gender, and background, were also brought up as playing a major role in accepting TDR. Based on their experiences promoting lifestyle changes to their own patients, the dietitians suggested that younger patients would commit better, with older patients regarded as more difficult to engage with. Regarding gender, male patients were seen to be more committed than female patients. This was due to a variety of factors such as having more family/spousal support and seeing better weight loss results, which increased motivation. In addition, as the majority of dietitians are female, male patients may feel embarrassed if they do not commit and/or show weight loss results. Furthermore, the majority of dietitians stated that female spouses supported their husbands with weight loss, whereas the opposite was not seen frequently in their practice. Background was mentioned in one group, where patients from a Bedouin culture (conservative) were deemed resistant to interventions.

Social life and the cultural environment were stated across all groups as a major barrier. Issues like easy access to junk food, lack of family support, social gatherings and obligations where large amounts of food are consumed, and the negative impact of social media were all discussed by dietitians. Following influencers through social media where erroneous weight loss methods and bariatric surgery experiences are shared may negatively influence people. Changes in routine, such as travelling, and fasting in Ramadan, are also setbacks that affect the weight loss journey. Some cultural aspects were seen in a fraction of the population (Bedouin); men do not like their wives eating differently than them, losing weight and changing their appearance, which the dietitians said made the patients’ spouses controlling and unsupportive.

The dietitians all stated that many of their patients with type 2 diabetes have a lack of education and awareness. Examples include thinking bariatric surgery will cure their diabetes permanently, eating large portions of healthy food will not make them gain weight, fasting and eating one huge meal will help them lose weight, using fad diets, not counting drinks within their daily calories, and thinking being on anti-diabetic medication is enough. Education is key, and this needs better methods of implementation.

Patient motivation and commitment to not only the dietary intervention, but also to attending consultations was deemed a challenge by all the dietitians. Patient behaviour and habits play a role in whether they are motivated and committed to a diet. Dietitians found it difficult changing behaviour, as it was seen to be linked with culture and the patients’ social life. Some are used to eating alongside family members even when they are not hungry, only because it is mealtime, and everyone is eating. The dietitians suggested that support from family and friends also affected behaviour, with a lack in this area enforcing sabotaging behaviour. Changing these behaviours requires a psychological understanding to fix the root of the problem.

Patient beliefs and preferences were also discussed as a challenge. Dietitians stated that people with type 2 diabetes are looking for the newest and easiest way to lose weight, whether it is through medications like Saxenda, bariatric surgery, or a fad diet as opposed to a lifestyle intervention that helps them maintain their weight loss. Also, it was stated that patients have to be ready themselves to see a dietitian and make a lifestyle change, where in reality many patients are being pressured to attend by their family or physician referral without any discussion regarding their readiness and motivation. Many patients seen by the dietitians had unrealistic or short-term expectations; examples include losing weight for a wedding or to get pregnant. Patients’ expectations and motivation should be assessed before embarking on a weight loss intervention, such as TDR, to ensure they are committed and to meet their needs. Another finding from the discussions was the majority of patients’ refusal to see a psychiatrist due to stigma associated with mental health issues.

Suggestions to improve and adapt approaches.

To be able to implement the TDR intervention, the dietitians suggested ways to tailor the intervention to meet the needs of their patients, based on their own clinical experience. It was suggested that focus should be placed on newly diagnosed patients who were deemed as more motivated and able to fully commit. Some dietitians recommended the addition of an exercise programme to compliment the intervention and to motivate patients who may feel more engaged. Support was regarded as imperative; this was required from HCPs, family members, and other patients on the same journey. A few dietitians suggested having patient support groups, even if through WhatsApp, to encourage each other and share experiences to enhance commitment.

Patient engagement needs to be improved. Dietitians discussed how this can be achieved, by having a shared agreement on goals and reaching concordance. It was also stressed that the right relationship was one where there is mutual respect between the dietitian and patient; this fosters trust and therefore the patient is more honest. One solution was using the first consultation for the patient to talk about themselves and their history and what they hope to achieve. Dietitians that do not connect with patients from the first appointment and erect barriers were deemed as unsuccessful by the dietitians. Consultations need to take the individual patient into consideration by assessing their expectations and priorities, their readiness to lose weight, tackling their misconceptions, and possibly involving their family and caregiver in sessions to enhance support.

Dietitians discussed the importance of ensuring patients are motivated and ready to lose weight, and that this needs to be assessed by dietitians before embarking on a dietary intervention. Various methods were brought up to enhance this, such as understanding the patient’s life, history, and their relationship with food to help tailor motivation techniques. They should also not be dependent on dietitians as they need to sustain their lifestyle changes on their own. One dietitian lets patients evaluate themselves on the first day, then compares again after a month to see how far they have come. Others give incentives such as how their weight loss is leading to better blood glucose control, lowering medication doses or stopping them, and decreasing hospital admissions. Some relied on fear tactics to motivate patients to commit, while others try and target patient behavior.

Frequent follow-up was recommended as it would help facilitate commitment and weight loss, with 2 weeks between appointments suggested as standard. However, it was highlighted that not all patients can attend due to work constraints, and this was one reason they did not commit. Dietitians proposed that patients who frequently missed appointments should be focused on.

Physicians have an important role and dietitians discussed how they were ignorant of the importance of the dietitian and lifestyle interventions. Most physicians were seen as focusing on medications and increasing doses to control blood glucose. This is also one reason why referral to dietitian consultations in general is low. As patients place physicians above dietitians, physicians are able to encourage patients to visit a dietitian and try TDR.

The need for psychological assessment and support was echoed across all focus groups. Many patients are depressed or are emotionally binge eating. Dietitians felt unable to deal with psychological issues, such as depression, to help people lose weight, and there is no mental support for patients. They felt there is a need for a psychiatrist for obesity and diabetes, which is not available. Support for dietitians to deal with such cases is also non-existent, even though most of their consultations deal heavily on psychology. In addition, not all dietitians felt comfortable referring to a psychiatrist, and those who do say patients refuse to go due to stigma and other reasons such as using this information for divorce proceedings.

All the participating dietitians expressed that dietitian training needed improvement regarding implementing TDR. By improving dietitian education with continuing professional development programmes to enhance their knowledge and training, specifically focusing on psychological interventions, this may help in improving their approach and motivating patients. Dietitians were all in agreement that they needed psychological training, such as cognitive behavioral therapy, to help them meet patients’ needs.

Discussion

Dietitians may encounter a variety of challenges and facilitators when trying to provide education regarding remission of type 2 diabetes and interventions to attain this, like TDR; the current findings have shed light on what these are in the Kuwaiti context. To our knowledge, this is the first study to approach this subject in Kuwait and the Gulf region. Although there were some discrepancies in views, certain aspects were shared by the majority of dietitians in this study.

Dietitians agreed that attaining remission of type 2 diabetes was a positive outcome of using TDR; nevertheless, there is a need to adapt the approach to overcome the challenges identified. Age, flexibility of intervention, and social and cultural environment were discussed as barriers for acceptability of the intervention. Previous literature supports socio-cultural norms as a challenge [9, 11, 29, 30]. In Kuwait, social gatherings and obligations are part of the culture, and for the approach and intervention to be successful, the patients’ social environment needs to be understood and the correct support provided. Social pressure may exacerbate the patient’s adherence to a dietary intervention, and patients with the ability to cope with eating differently from those around them adhere better [29].

With the higher obesity prevalence in the region and the resultant normalization of obesity [31] and greater uptake of surgical interventions for weight loss [32], dietitians may feel dietary interventions would not be acceptable, which is the case with the dietitians in the current study. Furthermore, less frequent follow-up and unavailability of outcome data also play a role. Dietitians also lacked the proper training to deliver interventions achieving remission. In a previous study from the UK, patients highlighted the importance of the dietitians’ approach and behavior on their commitment [33]. This included tailoring the consultation (prescriptive Vs. nonprescriptive), establishing a partnership, supporting behavior change, and listening to their needs. This was similarly reflected in the current findings, although behavior change was difficult for the dietitians as they lacked the tools and knowledge to implement this confidently. Behavior change is deemed essential when developing effective dietary interventions [34]. One study surveying dietitians found that they felt inadequate regarding behavior change techniques and needed training [35].

Previous literature has indicated that healthcare professionals may not always be focusing on the barriers encountered by their patients, or share the same priorities in terms of care [29, 36]. The current findings show that dietitians in our sample are striving to identify their patients’ needs and establishing a partnership with them, with agreement on shared goals and expectations, which is reassuring, as these assist in establishing the correct foundation for interventions to be successful [37]. Nevertheless, this may not be representative of the profession as a whole in Kuwait and in the Gulf region. Dietitians require professional support to achieve optimal patient care, as they are limited by workplace restrictions and processes [38].

Studies using surveys to gain insight into HCP views regarding meal replacement products and their use in very low energy diets within their practice showed there was some concern regarding the safety of these products and the long-term effectiveness of this intervention [39, 40]. In addition, adherence by patients was identified as a barrier, as was the need for comprehensive training. Another study using interviews with HCPs following the TDR intervention in the UK highlighted that some HCPs felt apprehensive towards stopping their patients’ anti-diabetic and anti-hypertensive medications [41]. These concerns and barriers were also discussed by the dietitians in the current study; these points need to be addressed in any future education and training of HCPs delivering this intervention, as their personal beliefs, perceptions, and confidence in the intervention are integral towards adopting it.

Dietitians highlighted that psychological support is lacking and this issue needs addressing, as they felt inadequate in that regard. Stigma towards psychological support and the lack of accessible support in primary healthcare is known in Kuwait [42]. Stigma was attributed to cultural factors, such as familism and the importance of reputation [43]. This was similarly professed by the dietitians in this study, and it was suggested that dietitians be trained to perform evaluations to overcome this challenge and ensure patient outcomes are achieved.

The DIADEM study demonstrated that the TDR intervention is feasible in Qatar, which may translate to the Kuwaiti population, although North African participants made up a higher proportion than Middle Eastern participants which may indicate the reduced uptake of the intervention in patient population from the Gulf region [14, 44]. This study also included an exercise component, which was advocated by the dietitians in the current study as a motivator.

Frequency of follow-up and support are deemed important for the success of the intervention, with a biweekly follow-up echoed across studies [13, 14], although one trial took a more patient-centered approach with weekly support with a counselor either by phone or face-to-face [45].

Results highlight the enthusiasm to use lifestyle interventions to achieve remission, but that the intervention should be adapted by focusing on patient support needs, with a flexible approach that takes culture and social life into consideration. By understanding dietitians’ thoughts, an adapted approach can be implemented to meet the needs of the Kuwaiti population, which can also be translated to the Gulf region. Furthermore, comprehensive dietitian training should be implemented before piloting the TDR intervention.

Conclusions

Findings have identified dietitians’ perspectives on the acceptability of using TDR to achieve diabetes remission in Kuwait. Various challenges were identified and suggestions to tailor approaches to meet patient needs were provided. This work has assisted in setting a framework to pilot a TDR intervention in Kuwait to assess the acceptability from the patients’ views. Understanding patient and HCPs’ perspectives and preferences is imperative to develop and deliver an acceptable intervention to achieve remission of type 2 diabetes in Kuwait and the region. By meeting patient and dietitians’ needs, health outcomes can be achieved and satisfaction with care can be improved.

Supporting information

Acknowledgments

We would like to thank Hidaya Abdullah for coordinating all the focus groups and her transcribing services. We wish to also thank all the participating dietitians for agreeing to join the study.