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‘I could have made those changes years earlier’: experiences and characteristics associated with receiving a prediabetes diagnosis among individuals recently diagnosed with type 2 diabetes

‘I could have made those changes years earlier’: experiences and characteristics associated with... Abstract Background Prediabetes increases the risk of developing type 2 diabetes (T2D). Improving diet quality is key in preventing this progression, yet little is known about the characteristics of individuals with prediabetes or the nutrition care they receive. Objectives This study aims to identify characteristics and experiences associated with receiving a prediabetes diagnosis prior to developing T2D. Methods A mixed methods study encompassed a quantitative subanalysis of participants with newly diagnosed T2D from The 3D Study, and semi-structured telephone interviews with a subsample of participants who were previously diagnosed with prediabetes. Interviews were thematically analysed and survey data synthesized using SPSS statistical software. Results Of the 225 study participants, 100 individuals were previously diagnosed with prediabetes and 120 participants were not. Those with prediabetes were less likely to be smokers (P = 0.022) and more likely to be satisfied with seeing a dietitian (P = 0.031) than those without a previous prediabetes diagnosis. A total of 20 participants completed semi-structured interviews. Thematic analysis revealed three themes: (i) experiencing a prediabetes diagnosis; (ii) receiving nutrition care during prediabetes and (iii) reflecting on the experience of receiving care for prediabetes versus T2D. Conclusions There are gaps in the current management of prediabetes in Australia. Low rates of prediabetes diagnosis and an ambiguous experience of receiving this diagnosis suggest an area of health service improvement. With no difference in diet quality between individuals with and without a previous prediabetes diagnosis, the nutrition care during prediabetes may be more important than the diagnosis itself in delaying the onset of T2D. diabetes mellitus, diet, health personnel, patients, prediabetic state, primary health care, type 2 Key Messages Prediabetes presents a significant health risk but it is under diagnosed. Patient characteristics are not predictive of being diagnosed with prediabetes. In prediabetes, nutrition care is rarely provided and is limited in its content. Improved prediabetes management to delay type 2 diabetes is needed in Australian settings. Background Prediabetes presents a significant global health burden. Prediabetes is characterized by elevated blood glucose levels and increased cardio-metabolic risk (1–3) and 5–10% of individuals with prediabetes will develop type 2 diabetes (T2D) each year (4). The prevalence of both prediabetes and T2D is increasing globally, with over 350 million people living with prediabetes, and over $727 billion USD spent annually on all forms of diabetes (1). Despite this rising prevalence, effective treatment approaches are clear, with a review of randomized controlled trials finding weight loss, improved diet quality and physical activity to delay the progression from prediabetes to T2D in approximately 60% of individuals (5). These positive outcomes have been observed in diverse populations and replicated in real-world settings (6–9), forming the basis of national and international practice guidelines (10–14). Guideline recommendations have not been widely adopted into practice and rates of prediabetes diagnosis remains low (15,16), clearly representing a gap in care. Primary care is the optimal setting for implementing lifestyle interventions for prediabetes (10). Screening tools, such as AUSDRISK, may assist with early identification but there are limitations in using these tools exclusively to detect prediabetes (17). Furthermore, challenges to implementing practice guidelines remain. Our recent review found health care providers’ (HCPs) views about prediabetes vary, with nutrition care irregularly provided and dietary advice inconsistent in its content (18). Despite the evidence in support of early intervention, the risk of over medicalizing prediabetes has also been argued (19). The perceived inability by HCPs to provide lifestyle support in primary care may further limit their management behaviours (20). Clearly, HCP-led decisions impact the level of care that individuals with prediabetes receive. Patients want to receive nutrition care for prediabetes that is individualized, consistent and accessible, despite this not being standard practice (18). A national US study found that certain patient characteristics are associated with receiving a prediabetes diagnosis, such as being middle-aged, female and having a high body mass index (BMI) (21). However, the reasons why some at-risk individuals are not diagnosed and managed warrants further investigation. The aims of this study are to: (i) identify characteristics associated with receiving a prediabetes diagnosis in Australia and (ii) explore the past experiences of receiving nutrition care for prediabetes among a population of people with newly diagnosed T2D. The synthesized findings will provide data on current prediabetes management practices with the added insight of patient perspectives around receiving a prediabetes diagnosis. Methods Study design A mixed methods design (22,23) was used to understand the phenomenon of receiving a prediabetes diagnosis in a sample of Australian adults. Participants were from an existing case-series study, The 3D Study (changes to Diet with a Diagnosis of Diabetes) (24). Quantitative baseline measures from 225 study participants were analysed to compare the characteristics of those with and without a previous prediabetes diagnosis. Qualitative semi-structured interviews of a subsample of participants were completed in parallel. The 3D study was approved by the Griffith University Human Research Ethics Committee (Protocol Number: 2017/951) and was registered with the Australian New Zealand Clinical Trials Registry (ref: ACTRN12618000375257) (24). The Good Reporting of A Mixed Methods Study tool was used to guide this study (25). Surveys Sample and data collection. The 3D study recruited non-pregnant adults recently diagnosed with T2D (24). In May 2018, Diabetes Australia emailed individuals who had registered with the National Diabetes Services Scheme within the preceding 6 months. Those willing to participate contacted the research team to request a participant information and consent form. Telephone surveys were conducted by trained research assistants. Baseline demographic, lifestyle and dietary data were collected from June to September 2018 as described in the methodology protocol (24). Prediabetes status. Participants were asked whether they had ever been told by a HCP that they had prediabetes, based on the National Health and Nutrition Examination Survey (26). Individuals who responded affirmatively were classified as ‘previously diagnosed with prediabetes’ (PD) and individuals who said ‘no’ were classified as ‘never diagnosed with prediabetes’ (no-PD). Individuals who were unsure about receiving a diagnosis were labelled as ‘unsure’. Demographic and health characteristics. Participants’ self-reported age, gender, income, education level and socio-economic status were collected (24). Income was calculated using total household earnings and categorized into quartiles. Level of highest education was recorded in five categories and collapsed into three: (i) high school diploma or less, (ii) diploma or certificate and (iii) university or post-graduate degree. Socio-economic Indexes for Areas (SEIFA) (27) and Accessibility/Remoteness Index of Australia (ARIA) (28) scores were allocated based on postal code. SEIFA was analysed in quintiles and ARIA scores were collapsed into three categories: (i) major city, (ii) inner regional and (iii) outer regional and remote. Weight in kilograms, height and waist circumference in centimetres was collected, and BMI was calculated. Physical activity data were collected and scored using the International Physical Activity Questionnaire (29). Smoking status was also collected. Diet quality and HCP interaction data. Research assistants conducted 24-hour diet histories using the Australian version of the ASA-24 food history tool (30). Diet quality was assessed using the Dietary Approaches to Stop Hypertension (DASH) scoring system (31). Mean serves of fruit, vegetables and whole grains were also analysed. Data on frequency and type of care provided by HCPs were collected. Participants ranked HCP satisfaction using a five-point Likert scale which was collapsed into two categories. Data analysis. Survey data were analysed with SPSS Version 22 statistical software. Demographic, lifestyle, dietary and HCP interaction variables were compared for the PD versus no-PD groups. Continuous variables were analysed using independent t-tests. Non-normally distributed data were analysed using Mann–Whitney U tests and presented as median and inter-quartile range. Categorical data were analysed using chi-square tests. Differences were considered significant at a P-value <0.05. Interview substudy Recruitment. The 3D study participants classified as ‘PD’ were asked: ‘Would you be willing to be contacted for a future study looking at experiences of people with prediabetes?’ Participants who agreed were sent an information and consent form by email and contacted to arrange an interview. Participants provided recorded verbal consent before participating in a one-on-one, semi-structured telephone interview. A phenomenological approach was used to understand patients’ lived experiences of receiving nutrition care after a diagnosis of prediabetes. Interview protocol. A semi-structured interview protocol was developed after a review of the literature (32,33). Interview questions were pilot tested with three individuals who met the study criteria. One research team member with significant qualitative research experience (LTW), listened to the audio-recordings to ensure the protocol was effective in producing valuable responses and to ensure credibility of the interviewer. The protocol was refined after discussions and feedback from the research team and patient interviews were conducted using the finalized, validated protocol. Data collection. Data were collected between August and September 2018 by the first author (MS). Interviews lasted between 30 and 60 minutes and were audio-recorded. Field notes were taken during interviews to add rigour to the data collection process. Data collection and analysis was conducted simultaneously until data saturation occurred. Participants received a copy of their interview transcript and were asked to return the transcript with corrections and feedback to ensure that interviews reflected participants’ true attitudes and opinions. Alterations were incorporated into the final transcripts. After completing the interview, participants received a $20 gift voucher as a reimbursement for their time. Data analysis. Interviews were transcribed verbatim and thematic analysis conducted manually. To ensure reliability of the data, two researchers (EB and MS) independently coded the transcripts. Codes were arranged based on commonly recurring phrases and keywords. The researchers reviewed the independently identified codes and determined the main themes. The research team collaboratively determined the final list of themes and subthemes and reached agreement that data saturation had occurred (Table 1). Table 1. Themes and corresponding patient quotes related to receiving nutrition care upon a prediabetes diagnosis from 2018 data Theme Description Indicative quotes 1. Experiencing a prediabetes diagnosis Participants report receiving a vague diagnosis of prediabetes He said I was on the spectrum, that’s how he described it. (P09) He gave me a dirty look, waved his finger and said oh I was pre-diabetic but he didn’t give any number at that time and he just said to me just stay off the baked biscuits and that was about it. (P20) A vague diagnosis implies that prediabetes should not be taken seriously She said yeah you’re diabetic [type 2] and so my head kicked in and went crikey, I better take this serious. So up until then it was just like oh you know you’ve got the flu. (P09) But nothing was sort of taken any further so I didn’t really take it sort of as anything serious, so you know I just sort of brushed it off. (P10) 2. Receiving nutrition care during prediabetes Nutrition advice received is inconsistent, general and not evidence based [The GP said] Do away with the colour white. No white pasta, no white potatoes, no white bread…You’ve got to cut back on carbs, no salt and no sugar. (P13) We never really sat down and talked about what I should and shouldn’t eat (GP). A general conversation, he just sort of said ‘you’ve got to watch the sugar you eat’. (P15) Dietary focus on carbohydrates and sugar but no other foods or nutrients, leading to misinformation about diet The thing I should have been more careful about so not eating as much rice and bread and that type of thing, so not only the cutting down the sugar. (P01) And it sort of rang in my ears when she sort of said to me ‘bread and potatoes are your worst enemy’. (P04) I avoid fried foods altogether only because of being told about the carbohydrates turning into sugar. (P18) Limited dietary advice makes patients feel unsupported in their nutrition care I changed a few things but nothing major, I didn’t understand how the diet sort of stuff worked. (P02) I just googled prediabetes. When I was diagnosed with prediabetes, I got very little information. (P05) 3. Reflecting on the experience of receiving care for prediabetes versus T2D Being diagnosed with T2D highlights the seriousness of prediabetes and the lack of support that was received at that time Like once you are pre-diabetic, it doesn’t seem to me to be a lot of help until you are actually diagnosed [with T2D]. Well that’s how it was for me anyway. (P04) I think there should be more support at the prediabetes stage. (P05) It should be impressed upon people where this leads to and the consequences. You know the amputation and the circulation and the eyesight and all that stuff. (P10) Reflecting on the diabetes journey leads patients to suggest ways that prediabetes could have been better managed Well had I known to change my diet before, I wouldn’t have reached the diabetic level. (P17) I wish they had told me what to do then and I could have done something to stop it. If I had help 2.5 years ago, maybe I wouldn’t have got to the state of being diabetic. (P19) Theme Description Indicative quotes 1. Experiencing a prediabetes diagnosis Participants report receiving a vague diagnosis of prediabetes He said I was on the spectrum, that’s how he described it. (P09) He gave me a dirty look, waved his finger and said oh I was pre-diabetic but he didn’t give any number at that time and he just said to me just stay off the baked biscuits and that was about it. (P20) A vague diagnosis implies that prediabetes should not be taken seriously She said yeah you’re diabetic [type 2] and so my head kicked in and went crikey, I better take this serious. So up until then it was just like oh you know you’ve got the flu. (P09) But nothing was sort of taken any further so I didn’t really take it sort of as anything serious, so you know I just sort of brushed it off. (P10) 2. Receiving nutrition care during prediabetes Nutrition advice received is inconsistent, general and not evidence based [The GP said] Do away with the colour white. No white pasta, no white potatoes, no white bread…You’ve got to cut back on carbs, no salt and no sugar. (P13) We never really sat down and talked about what I should and shouldn’t eat (GP). A general conversation, he just sort of said ‘you’ve got to watch the sugar you eat’. (P15) Dietary focus on carbohydrates and sugar but no other foods or nutrients, leading to misinformation about diet The thing I should have been more careful about so not eating as much rice and bread and that type of thing, so not only the cutting down the sugar. (P01) And it sort of rang in my ears when she sort of said to me ‘bread and potatoes are your worst enemy’. (P04) I avoid fried foods altogether only because of being told about the carbohydrates turning into sugar. (P18) Limited dietary advice makes patients feel unsupported in their nutrition care I changed a few things but nothing major, I didn’t understand how the diet sort of stuff worked. (P02) I just googled prediabetes. When I was diagnosed with prediabetes, I got very little information. (P05) 3. Reflecting on the experience of receiving care for prediabetes versus T2D Being diagnosed with T2D highlights the seriousness of prediabetes and the lack of support that was received at that time Like once you are pre-diabetic, it doesn’t seem to me to be a lot of help until you are actually diagnosed [with T2D]. Well that’s how it was for me anyway. (P04) I think there should be more support at the prediabetes stage. (P05) It should be impressed upon people where this leads to and the consequences. You know the amputation and the circulation and the eyesight and all that stuff. (P10) Reflecting on the diabetes journey leads patients to suggest ways that prediabetes could have been better managed Well had I known to change my diet before, I wouldn’t have reached the diabetic level. (P17) I wish they had told me what to do then and I could have done something to stop it. If I had help 2.5 years ago, maybe I wouldn’t have got to the state of being diabetic. (P19) Open in new tab Table 1. Themes and corresponding patient quotes related to receiving nutrition care upon a prediabetes diagnosis from 2018 data Theme Description Indicative quotes 1. Experiencing a prediabetes diagnosis Participants report receiving a vague diagnosis of prediabetes He said I was on the spectrum, that’s how he described it. (P09) He gave me a dirty look, waved his finger and said oh I was pre-diabetic but he didn’t give any number at that time and he just said to me just stay off the baked biscuits and that was about it. (P20) A vague diagnosis implies that prediabetes should not be taken seriously She said yeah you’re diabetic [type 2] and so my head kicked in and went crikey, I better take this serious. So up until then it was just like oh you know you’ve got the flu. (P09) But nothing was sort of taken any further so I didn’t really take it sort of as anything serious, so you know I just sort of brushed it off. (P10) 2. Receiving nutrition care during prediabetes Nutrition advice received is inconsistent, general and not evidence based [The GP said] Do away with the colour white. No white pasta, no white potatoes, no white bread…You’ve got to cut back on carbs, no salt and no sugar. (P13) We never really sat down and talked about what I should and shouldn’t eat (GP). A general conversation, he just sort of said ‘you’ve got to watch the sugar you eat’. (P15) Dietary focus on carbohydrates and sugar but no other foods or nutrients, leading to misinformation about diet The thing I should have been more careful about so not eating as much rice and bread and that type of thing, so not only the cutting down the sugar. (P01) And it sort of rang in my ears when she sort of said to me ‘bread and potatoes are your worst enemy’. (P04) I avoid fried foods altogether only because of being told about the carbohydrates turning into sugar. (P18) Limited dietary advice makes patients feel unsupported in their nutrition care I changed a few things but nothing major, I didn’t understand how the diet sort of stuff worked. (P02) I just googled prediabetes. When I was diagnosed with prediabetes, I got very little information. (P05) 3. Reflecting on the experience of receiving care for prediabetes versus T2D Being diagnosed with T2D highlights the seriousness of prediabetes and the lack of support that was received at that time Like once you are pre-diabetic, it doesn’t seem to me to be a lot of help until you are actually diagnosed [with T2D]. Well that’s how it was for me anyway. (P04) I think there should be more support at the prediabetes stage. (P05) It should be impressed upon people where this leads to and the consequences. You know the amputation and the circulation and the eyesight and all that stuff. (P10) Reflecting on the diabetes journey leads patients to suggest ways that prediabetes could have been better managed Well had I known to change my diet before, I wouldn’t have reached the diabetic level. (P17) I wish they had told me what to do then and I could have done something to stop it. If I had help 2.5 years ago, maybe I wouldn’t have got to the state of being diabetic. (P19) Theme Description Indicative quotes 1. Experiencing a prediabetes diagnosis Participants report receiving a vague diagnosis of prediabetes He said I was on the spectrum, that’s how he described it. (P09) He gave me a dirty look, waved his finger and said oh I was pre-diabetic but he didn’t give any number at that time and he just said to me just stay off the baked biscuits and that was about it. (P20) A vague diagnosis implies that prediabetes should not be taken seriously She said yeah you’re diabetic [type 2] and so my head kicked in and went crikey, I better take this serious. So up until then it was just like oh you know you’ve got the flu. (P09) But nothing was sort of taken any further so I didn’t really take it sort of as anything serious, so you know I just sort of brushed it off. (P10) 2. Receiving nutrition care during prediabetes Nutrition advice received is inconsistent, general and not evidence based [The GP said] Do away with the colour white. No white pasta, no white potatoes, no white bread…You’ve got to cut back on carbs, no salt and no sugar. (P13) We never really sat down and talked about what I should and shouldn’t eat (GP). A general conversation, he just sort of said ‘you’ve got to watch the sugar you eat’. (P15) Dietary focus on carbohydrates and sugar but no other foods or nutrients, leading to misinformation about diet The thing I should have been more careful about so not eating as much rice and bread and that type of thing, so not only the cutting down the sugar. (P01) And it sort of rang in my ears when she sort of said to me ‘bread and potatoes are your worst enemy’. (P04) I avoid fried foods altogether only because of being told about the carbohydrates turning into sugar. (P18) Limited dietary advice makes patients feel unsupported in their nutrition care I changed a few things but nothing major, I didn’t understand how the diet sort of stuff worked. (P02) I just googled prediabetes. When I was diagnosed with prediabetes, I got very little information. (P05) 3. Reflecting on the experience of receiving care for prediabetes versus T2D Being diagnosed with T2D highlights the seriousness of prediabetes and the lack of support that was received at that time Like once you are pre-diabetic, it doesn’t seem to me to be a lot of help until you are actually diagnosed [with T2D]. Well that’s how it was for me anyway. (P04) I think there should be more support at the prediabetes stage. (P05) It should be impressed upon people where this leads to and the consequences. You know the amputation and the circulation and the eyesight and all that stuff. (P10) Reflecting on the diabetes journey leads patients to suggest ways that prediabetes could have been better managed Well had I known to change my diet before, I wouldn’t have reached the diabetic level. (P17) I wish they had told me what to do then and I could have done something to stop it. If I had help 2.5 years ago, maybe I wouldn’t have got to the state of being diabetic. (P19) Open in new tab Data synthesis Quantitative data were collected prior to qualitative but analysis occurred in parallel. Quantitative results descriptively compared the two diagnosis groups while qualitative data added patient perspectives to support the differences observed. Results were synthesized in a table according to study aims (Table 2). Table 2. Synthesized findings from qualitative and quantitative results comparing participants with type 2 diabetes who were previously diagnosed with prediabetes versus those undiagnosed from 2018 data Study aims Quantitative result/s Qualitative result/s Synthesized finding Aim 1. To identify characteristics associated with receiving a prediabetes diagnosis in Australia 100/225 (44.4%) of participants received a prediabetes diagnosis Theme 1: Prediabetes diagnosis experience is vague The majority of individuals with prediabetes are undiagnosed, and among those who do receive a diagnosis, the experience is vague which leads to little action being taken No patient characteristics are associated with receiving a prediabetes diagnosis No statistically significant differences in characteristics between groups except for smoking status (P = 0.022) Aim 2. To explore the past experiences of receiving nutrition care for prediabetes among a population of people with newly diagnosed T2D No significant difference found between PD versus no-PD diagnosis groups for DASH score or food group serves Theme 2: Limited nutrition care received by individuals after a prediabetes diagnosis The diet quality of individuals who were previously diagnosed with prediabetes did not differ from individuals who were not previously diagnosed. Both groups eventually developed T2D, suggesting the nutrition support currently provided for prediabetes is ineffective in delaying the onset of T2D Aim 2. To explore the past experiences of receiving nutrition care for prediabetes among a population of people with newly diagnosed T2D PD versus no-PD diagnosis group had higher satisfaction with a dietitian interaction (P = 0.031) after being diagnosed with T2D Theme 2: Limited nutrition care received by individuals after a prediabetes diagnosis Individuals report wishing they had received more, individualized nutrition support during prediabetes and only four were referred to a dietitian at that time Participants previously diagnosed with prediabetes who visit a dietitian after T2D may feel they receive more individualized nutrition care and may build upon the general knowledge received during prediabetes, resulting in greater satisfaction with the health care interaction Theme 3: Comparing prediabetes to T2D diagnosis experiences Study aims Quantitative result/s Qualitative result/s Synthesized finding Aim 1. To identify characteristics associated with receiving a prediabetes diagnosis in Australia 100/225 (44.4%) of participants received a prediabetes diagnosis Theme 1: Prediabetes diagnosis experience is vague The majority of individuals with prediabetes are undiagnosed, and among those who do receive a diagnosis, the experience is vague which leads to little action being taken No patient characteristics are associated with receiving a prediabetes diagnosis No statistically significant differences in characteristics between groups except for smoking status (P = 0.022) Aim 2. To explore the past experiences of receiving nutrition care for prediabetes among a population of people with newly diagnosed T2D No significant difference found between PD versus no-PD diagnosis groups for DASH score or food group serves Theme 2: Limited nutrition care received by individuals after a prediabetes diagnosis The diet quality of individuals who were previously diagnosed with prediabetes did not differ from individuals who were not previously diagnosed. Both groups eventually developed T2D, suggesting the nutrition support currently provided for prediabetes is ineffective in delaying the onset of T2D Aim 2. To explore the past experiences of receiving nutrition care for prediabetes among a population of people with newly diagnosed T2D PD versus no-PD diagnosis group had higher satisfaction with a dietitian interaction (P = 0.031) after being diagnosed with T2D Theme 2: Limited nutrition care received by individuals after a prediabetes diagnosis Individuals report wishing they had received more, individualized nutrition support during prediabetes and only four were referred to a dietitian at that time Participants previously diagnosed with prediabetes who visit a dietitian after T2D may feel they receive more individualized nutrition care and may build upon the general knowledge received during prediabetes, resulting in greater satisfaction with the health care interaction Theme 3: Comparing prediabetes to T2D diagnosis experiences Open in new tab Table 2. Synthesized findings from qualitative and quantitative results comparing participants with type 2 diabetes who were previously diagnosed with prediabetes versus those undiagnosed from 2018 data Study aims Quantitative result/s Qualitative result/s Synthesized finding Aim 1. To identify characteristics associated with receiving a prediabetes diagnosis in Australia 100/225 (44.4%) of participants received a prediabetes diagnosis Theme 1: Prediabetes diagnosis experience is vague The majority of individuals with prediabetes are undiagnosed, and among those who do receive a diagnosis, the experience is vague which leads to little action being taken No patient characteristics are associated with receiving a prediabetes diagnosis No statistically significant differences in characteristics between groups except for smoking status (P = 0.022) Aim 2. To explore the past experiences of receiving nutrition care for prediabetes among a population of people with newly diagnosed T2D No significant difference found between PD versus no-PD diagnosis groups for DASH score or food group serves Theme 2: Limited nutrition care received by individuals after a prediabetes diagnosis The diet quality of individuals who were previously diagnosed with prediabetes did not differ from individuals who were not previously diagnosed. Both groups eventually developed T2D, suggesting the nutrition support currently provided for prediabetes is ineffective in delaying the onset of T2D Aim 2. To explore the past experiences of receiving nutrition care for prediabetes among a population of people with newly diagnosed T2D PD versus no-PD diagnosis group had higher satisfaction with a dietitian interaction (P = 0.031) after being diagnosed with T2D Theme 2: Limited nutrition care received by individuals after a prediabetes diagnosis Individuals report wishing they had received more, individualized nutrition support during prediabetes and only four were referred to a dietitian at that time Participants previously diagnosed with prediabetes who visit a dietitian after T2D may feel they receive more individualized nutrition care and may build upon the general knowledge received during prediabetes, resulting in greater satisfaction with the health care interaction Theme 3: Comparing prediabetes to T2D diagnosis experiences Study aims Quantitative result/s Qualitative result/s Synthesized finding Aim 1. To identify characteristics associated with receiving a prediabetes diagnosis in Australia 100/225 (44.4%) of participants received a prediabetes diagnosis Theme 1: Prediabetes diagnosis experience is vague The majority of individuals with prediabetes are undiagnosed, and among those who do receive a diagnosis, the experience is vague which leads to little action being taken No patient characteristics are associated with receiving a prediabetes diagnosis No statistically significant differences in characteristics between groups except for smoking status (P = 0.022) Aim 2. To explore the past experiences of receiving nutrition care for prediabetes among a population of people with newly diagnosed T2D No significant difference found between PD versus no-PD diagnosis groups for DASH score or food group serves Theme 2: Limited nutrition care received by individuals after a prediabetes diagnosis The diet quality of individuals who were previously diagnosed with prediabetes did not differ from individuals who were not previously diagnosed. Both groups eventually developed T2D, suggesting the nutrition support currently provided for prediabetes is ineffective in delaying the onset of T2D Aim 2. To explore the past experiences of receiving nutrition care for prediabetes among a population of people with newly diagnosed T2D PD versus no-PD diagnosis group had higher satisfaction with a dietitian interaction (P = 0.031) after being diagnosed with T2D Theme 2: Limited nutrition care received by individuals after a prediabetes diagnosis Individuals report wishing they had received more, individualized nutrition support during prediabetes and only four were referred to a dietitian at that time Participants previously diagnosed with prediabetes who visit a dietitian after T2D may feel they receive more individualized nutrition care and may build upon the general knowledge received during prediabetes, resulting in greater satisfaction with the health care interaction Theme 3: Comparing prediabetes to T2D diagnosis experiences Open in new tab Results Surveys Among the 225 3D study participants, 120 (53.3%) were not diagnosed with prediabetes (no-PD) and 100 (44.4%) were previously diagnosed (PD). Five individuals (2.2%) were unsure. The 3D sample included slightly more males (n = 126; 56%) than females (n = 99; 44%), and this proportion remained similar amongst the PD and no-PD groups (Table 3). Table 3. Demographic and lifestyle characteristics comparing prediabetes diagnosed versus non-diagnosed groups from 2018 data Variables PD (n = 100) N (%) No-PD (n = 120) N (%) Difference Test P-value Age (years)  Median (IQR) 61.0 (14) 58.5 (17) 5268.0b 0.119 Gender  Male 56 (56) 67 (55.8) 0.001a 0.980  Female 44 (44) 53 (44.2) Physical Activity  Low 34 (34.0) 40 (33.3)  Moderate 57 (57.0) 64 (53.3) 1.042a 0.594  High 9 (9.0) 16 (13.3) Body Mass Index (kg/m2)  Median (IQR) 30.46 (9) 31.05 (9) 5927.0b 0.961  Normal 11 (11.0) 18 (15.3)  Overweight 34 (34.0) 27 (22.9) 3.562a 0.168  Obese 55 (55.0) 73 (61.9) Weight (kg)  Median (IQR) 61.0 (14) 58.5 (17) 5268.0b 0.119 Waist circumference (cm)  Median (IQR) 108.0 (19) 106.7 (21) 4817.5b 0.764 Smoking Status  Yes 6 (6.0) 19 (15.8) 5.236a 0.022  No 94 (94.0) 101 (84.2) Income  <$30 000 14 (16.5) 11 (10.6) 2.906a 0.406  $30–50 000 22 (25.9) 21 (20.2)  $50–100 000 23 (27.1) 35 (33.7)  >$100 000 26 (30.6) 37 (35.6) ARIA  Major city 59 (59.6) 82 (68.3) 1.838a 0.399  Inner regional 25 (25.3) 23 (19.2)  Outer reg./remote 15 (15.2) 15 (12.5) SEIFA  Quintile 1 21 (21.4) 24 (20.0) 3.786a 0.436  Quintile 2 21 (21.4) 26 (21.7)  Quintile 3 22 (22.4) 18 (15.0)  Quintile 4 19 (19.4) 23 (19.2)  Quintile 5 15 (15.3) 29 (24.2) Variables PD (n = 100) N (%) No-PD (n = 120) N (%) Difference Test P-value Age (years)  Median (IQR) 61.0 (14) 58.5 (17) 5268.0b 0.119 Gender  Male 56 (56) 67 (55.8) 0.001a 0.980  Female 44 (44) 53 (44.2) Physical Activity  Low 34 (34.0) 40 (33.3)  Moderate 57 (57.0) 64 (53.3) 1.042a 0.594  High 9 (9.0) 16 (13.3) Body Mass Index (kg/m2)  Median (IQR) 30.46 (9) 31.05 (9) 5927.0b 0.961  Normal 11 (11.0) 18 (15.3)  Overweight 34 (34.0) 27 (22.9) 3.562a 0.168  Obese 55 (55.0) 73 (61.9) Weight (kg)  Median (IQR) 61.0 (14) 58.5 (17) 5268.0b 0.119 Waist circumference (cm)  Median (IQR) 108.0 (19) 106.7 (21) 4817.5b 0.764 Smoking Status  Yes 6 (6.0) 19 (15.8) 5.236a 0.022  No 94 (94.0) 101 (84.2) Income  <$30 000 14 (16.5) 11 (10.6) 2.906a 0.406  $30–50 000 22 (25.9) 21 (20.2)  $50–100 000 23 (27.1) 35 (33.7)  >$100 000 26 (30.6) 37 (35.6) ARIA  Major city 59 (59.6) 82 (68.3) 1.838a 0.399  Inner regional 25 (25.3) 23 (19.2)  Outer reg./remote 15 (15.2) 15 (12.5) SEIFA  Quintile 1 21 (21.4) 24 (20.0) 3.786a 0.436  Quintile 2 21 (21.4) 26 (21.7)  Quintile 3 22 (22.4) 18 (15.0)  Quintile 4 19 (19.4) 23 (19.2)  Quintile 5 15 (15.3) 29 (24.2) IQR, inter-quartile range; ARIA, Accessibility/Remoteness Index of Australia; SEIFA, socio-economic indexes for areas; Quintile 1, Lowest SEIFA; Quintile 2, Mid-lower SEIFA; Quintile 3, Middle SEIFA; Quintile 4, Upper middle SEIFA; Quintile 5, Highest SEIFA; PD, prediabetes diagnosis; no-PD, no prediabetes diagnosis. aChi-square test. bMann–Whitney U test. Open in new tab Table 3. Demographic and lifestyle characteristics comparing prediabetes diagnosed versus non-diagnosed groups from 2018 data Variables PD (n = 100) N (%) No-PD (n = 120) N (%) Difference Test P-value Age (years)  Median (IQR) 61.0 (14) 58.5 (17) 5268.0b 0.119 Gender  Male 56 (56) 67 (55.8) 0.001a 0.980  Female 44 (44) 53 (44.2) Physical Activity  Low 34 (34.0) 40 (33.3)  Moderate 57 (57.0) 64 (53.3) 1.042a 0.594  High 9 (9.0) 16 (13.3) Body Mass Index (kg/m2)  Median (IQR) 30.46 (9) 31.05 (9) 5927.0b 0.961  Normal 11 (11.0) 18 (15.3)  Overweight 34 (34.0) 27 (22.9) 3.562a 0.168  Obese 55 (55.0) 73 (61.9) Weight (kg)  Median (IQR) 61.0 (14) 58.5 (17) 5268.0b 0.119 Waist circumference (cm)  Median (IQR) 108.0 (19) 106.7 (21) 4817.5b 0.764 Smoking Status  Yes 6 (6.0) 19 (15.8) 5.236a 0.022  No 94 (94.0) 101 (84.2) Income  <$30 000 14 (16.5) 11 (10.6) 2.906a 0.406  $30–50 000 22 (25.9) 21 (20.2)  $50–100 000 23 (27.1) 35 (33.7)  >$100 000 26 (30.6) 37 (35.6) ARIA  Major city 59 (59.6) 82 (68.3) 1.838a 0.399  Inner regional 25 (25.3) 23 (19.2)  Outer reg./remote 15 (15.2) 15 (12.5) SEIFA  Quintile 1 21 (21.4) 24 (20.0) 3.786a 0.436  Quintile 2 21 (21.4) 26 (21.7)  Quintile 3 22 (22.4) 18 (15.0)  Quintile 4 19 (19.4) 23 (19.2)  Quintile 5 15 (15.3) 29 (24.2) Variables PD (n = 100) N (%) No-PD (n = 120) N (%) Difference Test P-value Age (years)  Median (IQR) 61.0 (14) 58.5 (17) 5268.0b 0.119 Gender  Male 56 (56) 67 (55.8) 0.001a 0.980  Female 44 (44) 53 (44.2) Physical Activity  Low 34 (34.0) 40 (33.3)  Moderate 57 (57.0) 64 (53.3) 1.042a 0.594  High 9 (9.0) 16 (13.3) Body Mass Index (kg/m2)  Median (IQR) 30.46 (9) 31.05 (9) 5927.0b 0.961  Normal 11 (11.0) 18 (15.3)  Overweight 34 (34.0) 27 (22.9) 3.562a 0.168  Obese 55 (55.0) 73 (61.9) Weight (kg)  Median (IQR) 61.0 (14) 58.5 (17) 5268.0b 0.119 Waist circumference (cm)  Median (IQR) 108.0 (19) 106.7 (21) 4817.5b 0.764 Smoking Status  Yes 6 (6.0) 19 (15.8) 5.236a 0.022  No 94 (94.0) 101 (84.2) Income  <$30 000 14 (16.5) 11 (10.6) 2.906a 0.406  $30–50 000 22 (25.9) 21 (20.2)  $50–100 000 23 (27.1) 35 (33.7)  >$100 000 26 (30.6) 37 (35.6) ARIA  Major city 59 (59.6) 82 (68.3) 1.838a 0.399  Inner regional 25 (25.3) 23 (19.2)  Outer reg./remote 15 (15.2) 15 (12.5) SEIFA  Quintile 1 21 (21.4) 24 (20.0) 3.786a 0.436  Quintile 2 21 (21.4) 26 (21.7)  Quintile 3 22 (22.4) 18 (15.0)  Quintile 4 19 (19.4) 23 (19.2)  Quintile 5 15 (15.3) 29 (24.2) IQR, inter-quartile range; ARIA, Accessibility/Remoteness Index of Australia; SEIFA, socio-economic indexes for areas; Quintile 1, Lowest SEIFA; Quintile 2, Mid-lower SEIFA; Quintile 3, Middle SEIFA; Quintile 4, Upper middle SEIFA; Quintile 5, Highest SEIFA; PD, prediabetes diagnosis; no-PD, no prediabetes diagnosis. aChi-square test. bMann–Whitney U test. Open in new tab Characteristics of PD versus no-PD groups are shown in Table 3. There were neither statistically significant differences for age, education level, ARIA, SEIFA or household income between the two groups nor were there differences between the groups for physical activity level, weight, BMI or waist circumference. A difference was noted between groups for smoking status, with significantly more smokers in the no-PD group (P = 0.022). This was the only health behaviour difference; with no differences in individual food groups or DASH score (Table 4). Table 4. Diet quality by DASH score and food group serves comparing prediabetes diagnosed versus non-diagnosed groups from 2018 data Variables PD (n = 100) Median (IQR) No-PD (n = 120) Median (IQR) Difference Test P-value DASH score  Mean (SD) 24.22 (4.89) 24.56 (4.50) −0.538b 0.591 DASH quartiles 2.073a 0.557  Quartile 1 24 (24.0) 38 (31.7)  Quartile 2 28 (28.0) 26 (21.7)  Quartile 3 23 (23.0) 26 (21.7)  Quartile 4 25 (25.0) 30 (25.0) Fruit  Serves/day 0.55 (1.10) 0.40 (1.20) 5908.0c 0.842 Vegetables  Serves/day 3.05 (3.0) 3.45 (4.07) 5350.5c 0.167 Whole grains  Serves/day 2.15 (3.65) 1.60 (2.70) 5549.0c 0.334 Variables PD (n = 100) Median (IQR) No-PD (n = 120) Median (IQR) Difference Test P-value DASH score  Mean (SD) 24.22 (4.89) 24.56 (4.50) −0.538b 0.591 DASH quartiles 2.073a 0.557  Quartile 1 24 (24.0) 38 (31.7)  Quartile 2 28 (28.0) 26 (21.7)  Quartile 3 23 (23.0) 26 (21.7)  Quartile 4 25 (25.0) 30 (25.0) Fruit  Serves/day 0.55 (1.10) 0.40 (1.20) 5908.0c 0.842 Vegetables  Serves/day 3.05 (3.0) 3.45 (4.07) 5350.5c 0.167 Whole grains  Serves/day 2.15 (3.65) 1.60 (2.70) 5549.0c 0.334 IQR, inter-quartile range; DASH, dietary approaches to stop hypertension; PD, prediabetes diagnosis; no-PD, no prediabetes diagnosis; DASH Quartile 1, score 0–21; Quartile 2, score 22–24; Quartile 3, score 25–27; Quartile 4, score 28–37. aChi-square test. bt-test. cMann–Whitney U test. Open in new tab Table 4. Diet quality by DASH score and food group serves comparing prediabetes diagnosed versus non-diagnosed groups from 2018 data Variables PD (n = 100) Median (IQR) No-PD (n = 120) Median (IQR) Difference Test P-value DASH score  Mean (SD) 24.22 (4.89) 24.56 (4.50) −0.538b 0.591 DASH quartiles 2.073a 0.557  Quartile 1 24 (24.0) 38 (31.7)  Quartile 2 28 (28.0) 26 (21.7)  Quartile 3 23 (23.0) 26 (21.7)  Quartile 4 25 (25.0) 30 (25.0) Fruit  Serves/day 0.55 (1.10) 0.40 (1.20) 5908.0c 0.842 Vegetables  Serves/day 3.05 (3.0) 3.45 (4.07) 5350.5c 0.167 Whole grains  Serves/day 2.15 (3.65) 1.60 (2.70) 5549.0c 0.334 Variables PD (n = 100) Median (IQR) No-PD (n = 120) Median (IQR) Difference Test P-value DASH score  Mean (SD) 24.22 (4.89) 24.56 (4.50) −0.538b 0.591 DASH quartiles 2.073a 0.557  Quartile 1 24 (24.0) 38 (31.7)  Quartile 2 28 (28.0) 26 (21.7)  Quartile 3 23 (23.0) 26 (21.7)  Quartile 4 25 (25.0) 30 (25.0) Fruit  Serves/day 0.55 (1.10) 0.40 (1.20) 5908.0c 0.842 Vegetables  Serves/day 3.05 (3.0) 3.45 (4.07) 5350.5c 0.167 Whole grains  Serves/day 2.15 (3.65) 1.60 (2.70) 5549.0c 0.334 IQR, inter-quartile range; DASH, dietary approaches to stop hypertension; PD, prediabetes diagnosis; no-PD, no prediabetes diagnosis; DASH Quartile 1, score 0–21; Quartile 2, score 22–24; Quartile 3, score 25–27; Quartile 4, score 28–37. aChi-square test. bt-test. cMann–Whitney U test. Open in new tab Comparison of HCP interaction and satisfaction level is found in Table 5. No differences existed between the two groups for number of visits to GPs or dietitians since being diagnosed with T2D. The likelihood of discussing diet with any HCPs did not differ between the groups. Neither group reported higher satisfaction with seeing a GP since being diagnosed with T2D, but individuals in the PD group reported higher satisfaction with seeing a dietitian compared to the no-PD group since a T2D diagnosis (P = 0.031) (Table 5). Table 5. Health care provider interaction and satisfaction since type 2 diabetes comparing those previously diagnosed with prediabetes versus those non-diagnosed from 2018 data Variables PD (n = 100) N (%) No-PD (n = 120) N (%) Difference Test P-value Number of individuals who interacted with a HCP since T2D diagnosis  GP Yes 43 (43.0) 59 (49.2) 0.834a 0.361 No 57 (57.0) 61 (50.8)  Dietitian Yes 46 (46.0) 68 (56.7) 2.486a 0.115 No 54 (54.0) 52 (43.3) Patient satisfaction with HCP during health care interaction  GP Not at all/neutral 17 (39.5) 23 (39.0) 0.003a 0.955 Very/extremely 26 (60.5) 36 (61.0)  Dietitian Not at all/neutral 10 (21.7) 28 (41.2) 4.665a 0.031 Very/extremely 36 (78.3) 40 (58.8) Number of HCPs that talked about diet with participants since T2D diagnosis No HCPs 21 (24.7) 21 (22.3) 1.351a 0.509 1 HCP 46 (54.1) 46 (48.9) ≥ 2 HCP 18 (21.2) 27 (28.7) Variables PD (n = 100) N (%) No-PD (n = 120) N (%) Difference Test P-value Number of individuals who interacted with a HCP since T2D diagnosis  GP Yes 43 (43.0) 59 (49.2) 0.834a 0.361 No 57 (57.0) 61 (50.8)  Dietitian Yes 46 (46.0) 68 (56.7) 2.486a 0.115 No 54 (54.0) 52 (43.3) Patient satisfaction with HCP during health care interaction  GP Not at all/neutral 17 (39.5) 23 (39.0) 0.003a 0.955 Very/extremely 26 (60.5) 36 (61.0)  Dietitian Not at all/neutral 10 (21.7) 28 (41.2) 4.665a 0.031 Very/extremely 36 (78.3) 40 (58.8) Number of HCPs that talked about diet with participants since T2D diagnosis No HCPs 21 (24.7) 21 (22.3) 1.351a 0.509 1 HCP 46 (54.1) 46 (48.9) ≥ 2 HCP 18 (21.2) 27 (28.7) HCP, health care provider; GP, general practitioner; PD, prediabetes diagnosis; no-PD, no prediabetes diagnosis; T2D, type 2 diabetes. aChi-square test. Open in new tab Table 5. Health care provider interaction and satisfaction since type 2 diabetes comparing those previously diagnosed with prediabetes versus those non-diagnosed from 2018 data Variables PD (n = 100) N (%) No-PD (n = 120) N (%) Difference Test P-value Number of individuals who interacted with a HCP since T2D diagnosis  GP Yes 43 (43.0) 59 (49.2) 0.834a 0.361 No 57 (57.0) 61 (50.8)  Dietitian Yes 46 (46.0) 68 (56.7) 2.486a 0.115 No 54 (54.0) 52 (43.3) Patient satisfaction with HCP during health care interaction  GP Not at all/neutral 17 (39.5) 23 (39.0) 0.003a 0.955 Very/extremely 26 (60.5) 36 (61.0)  Dietitian Not at all/neutral 10 (21.7) 28 (41.2) 4.665a 0.031 Very/extremely 36 (78.3) 40 (58.8) Number of HCPs that talked about diet with participants since T2D diagnosis No HCPs 21 (24.7) 21 (22.3) 1.351a 0.509 1 HCP 46 (54.1) 46 (48.9) ≥ 2 HCP 18 (21.2) 27 (28.7) Variables PD (n = 100) N (%) No-PD (n = 120) N (%) Difference Test P-value Number of individuals who interacted with a HCP since T2D diagnosis  GP Yes 43 (43.0) 59 (49.2) 0.834a 0.361 No 57 (57.0) 61 (50.8)  Dietitian Yes 46 (46.0) 68 (56.7) 2.486a 0.115 No 54 (54.0) 52 (43.3) Patient satisfaction with HCP during health care interaction  GP Not at all/neutral 17 (39.5) 23 (39.0) 0.003a 0.955 Very/extremely 26 (60.5) 36 (61.0)  Dietitian Not at all/neutral 10 (21.7) 28 (41.2) 4.665a 0.031 Very/extremely 36 (78.3) 40 (58.8) Number of HCPs that talked about diet with participants since T2D diagnosis No HCPs 21 (24.7) 21 (22.3) 1.351a 0.509 1 HCP 46 (54.1) 46 (48.9) ≥ 2 HCP 18 (21.2) 27 (28.7) HCP, health care provider; GP, general practitioner; PD, prediabetes diagnosis; no-PD, no prediabetes diagnosis; T2D, type 2 diabetes. aChi-square test. Open in new tab Interviews Of the 3D participants previously diagnosed with prediabetes, 45 agreed to be interviewed. Twenty interviews (8 male and 12 female) were conducted prior to reaching data saturation. Participants were from four Australian states and ranged in age from 54 to 75 years. Thematic analysis revealed three main themes: (i) experiencing a prediabetes diagnosis; (ii) receiving nutrition care during prediabetes and (iii) reflecting on the experience of receiving care for prediabetes versus T2D. Experiencing a prediabetes diagnosis All participants received a prediabetes diagnosis, however, for most, this experience felt confusing and unclear. Eleven participants reported receiving a vague diagnosis of prediabetes, with a term other than prediabetes used to describe their condition. He said I was on the spectrum, that’s how he described it. (P09) Some participants were aware that prediabetes increased their risk of T2D, but the unclear diagnosis and minimal concern from HCPs led many to classify prediabetes as ‘not very serious’. And so my head kicked in and went right ‘crikey, I better take this serious(ly)’ [talking about T2D]. Up until then it was just like oh you know you’ve got the flu. (P10) Participants reported receiving little follow-up and support after a prediabetes diagnosis. Individuals were unsure about the implications of prediabetes, leaving them to investigate on their own or act indifferent. I wasn’t given an explanation at the time as to really what the implications of prediabetes were. (P20) The overall perception that prediabetes was not serious appeared to be a result of the minimal action taken by HCPs during routine care. Participants looked to HCPs to guide them with appropriate management of prediabetes. Receiving nutrition care during prediabetes All participants reported receiving nutrition advice from a HCP during prediabetes, however, this was limited. The nutrition information participants received was general and confusing, resulting in individuals seeking unreliable sources of nutrition information from friends, family or the internet. One participant was even encouraged to do this by their GP: He just said look it up online and that and you can see what you should be eating and what you shouldn’t be eating. (P16) The reported nutrition advice participants received from HCPs tended to focus on carbohydrates. Some individuals had discussions with HCPs about pasta and bread, while others only considered soft drinks and confectionary as containing carbohydrates. There was little mention of other dietary recommendations such as modifying fibre or fat intake. He just said to me stay off the baked biscuits and that was about it. (P20) The limited nutrition care led to misunderstandings around nutrition for some participants with many unable to distinguish between carbohydrates and sugar. I avoid fried food altogether only because of being told about the carbohydrates turning into sugar. (P18) In contrast, four individuals received referrals to a dietitian or diabetes educator. One of these participants felt although they eventually developed T2D, the nutrition support they received delayed their diagnosis and armed them with knowledge still valuable during T2D. There was a question of access for prediabetes services. One participant was angry she had to pay for dietetic services for prediabetes, yet received subsidized dietetic care upon developing T2D. The inconsistency in access and content of nutrition support led to participant confusion about food, and frustration in how to make appropriate dietary changes. I spent a lot of money because I wasn’t on any plan at that stage and it had cost me quite a lot to go to the exercise classes and dietitian and…I thought what else can I do. I was really, really angry when I finally got the T2D diagnosis. (P06) Reflecting on the experience of receiving care for prediabetes versus T2D Participants compared their prediabetes and T2D diagnoses. For many, the care received for T2D seemed straightforward, with a clear diagnosis and management plan. This contrasted participants’ prediabetes experience. Like once you are pre-diabetic, it doesn’t seem to me to be a lot of help until you are actually diagnosed [with T2D]. Well that’s how it was for me anyway. (P04) Several participants suggested prediabetes should be treated similarly to T2D, with access to relevant nutrition information and support. As a result of the level of support received during T2D, participants interpreted it to be a serious condition requiring immediate action. Well, it’s a bit of a wake-up call and you need to follow it straight away. If somebody’s told that like I was, I wasn’t worried about it until I was told I’m actually diabetic, type 2. (P17) This reinforced the seriousness of the disease influenced the level of action taken. Participants reported if the same significance and level of care was provided for prediabetes, they would have taken more action, sooner. Had I had the same sort of information given to me or suggested to me, I could have made those changes years earlier. (P02) In retrospect, I wish I had known about a lot of the support available for diabetes, had it been available during the prediabetes stage…that would have been much more helpful. (P20) The negative experience of being diagnosed with T2D was amplified when participants compared the experience to being diagnosed with prediabetes. The regret over a missed opportunity to take action during prediabetes was clearly expressed. Realizing this lack of support may have led to a subsequent T2D diagnosis was confronting. Well had I known to change my diet before, I wouldn’t have reached the diabetic level. (P17) Discussion This was the first study to comprehensively explore the experience of receiving nutrition care for prediabetes and determine whether individual characteristics are associated with this diagnosis in Australia. Among this sample of individuals with newly diagnosed T2D, less than half were previously diagnosed with prediabetes. This is significant because all individuals would have progressed through prediabetes before T2D, indicating many missed opportunities for early intervention. Evidence-based guidelines recommend all individuals with prediabetes receive lifestyle intervention to delay T2D (10–14), highlighting gaps in the current care provided to patients with prediabetes. Among individuals in this study who were diagnosed with prediabetes, their collective diagnosis experience was vague, inconsistent and implied that prediabetes was not serious. This is similar to findings from Troughton et al. where individuals with prediabetes expressed feelings of uncertainty about their condition (34). Without a clear diagnosis and follow-up, individuals with prediabetes are unable to make appropriate dietary changes, making a future T2D diagnosis inevitable. Despite undesirable rates of diagnosis, our recent review found individuals with prediabetes are highly motivated to change behaviour and identify a preference for lifestyle support (18). Participants in this study reported if they had the opportunity to take action during prediabetes, they would have attempted dietary changes. This is convincing considering the level of action participants reported taking after their T2D diagnosis, suggesting increased access to nutrition support services for prediabetes is needed. No differences in diet quality between the no-PD and PD groups suggest individuals with a prediabetes diagnosis did not make sufficient lifestyle changes to prevent T2D. This is reflected in participants’ reported experiences of receiving little nutrition support, inconsistent advice and non-evidence based recommendations during prediabetes. This further highlights the importance of receiving adequate nutrition care for prediabetes, and a diagnosis alone is insufficient to invoke change. Similarly, no differences in demographic or health characteristics between the two groups suggest HCP versus patient characteristics may be more predictive of prediabetes management behaviours. Associations between HCP characteristics and diagnosis behaviour have been reported previously (20), and this is clearly an area for further investigation in prediabetes research. Together, the qualitative and quantitative results of this study provided a comprehensive understanding of the research topic, making the mixed methods design a key strength. The 3D study, which provided the basis for these subanalyses, added further strength due to the use of validated tools and methodological rigour. A limitation of this study was all participants interviewed about their prediabetes diagnosis experience were living with T2D. The experiences of those who had not progressed to T2D may have differed. Conclusion Prediabetes is a serious condition, presenting increased cardio-metabolic risk. Early lifestyle intervention is necessary to delay T2D and should be the focus of prediabetes management. However, this study found individuals may neither receive adequate nutrition support following a prediabetes diagnosis, nor are all individuals who meet the prediabetes criteria being diagnosed in practice. This suggests HCP characteristics may be more predictive of the level of nutrition care provided for prediabetes. Therefore, future research should explore associations between HCPs and prediabetes management behaviours and to understand their views on providing nutrition care in practice. Further work is needed to equip HCPs with nutrition knowledge and skills to adequately support individuals with prediabetes and prevent future T2D diagnoses. Increased access and promotion of nutrition support services for prediabetes may be an effective management approach. This study adds to our current understanding of prediabetes management in Australian primary care settings from the patients’ perspective. This is important for future prediabetes management and patient care. Acknowledgments The research team would like to thank all participants involved in the 3D study for taking the time to provide valuable responses to survey questions over the past year. The authors would also like to thank Griffith University for providing financial support so that study participants could be reimbursed for their time. Declaration Funding: NHMRC Early Career Fellowship to LB. Conflict of interest: LB is an Associate Editor for Family Practice. References 1. International Diabetes Federation. IDF Diabetes Atlas: Eighth Edition . Brussels, Belgium: International Diabetes Federation, 2017 . WorldCat COPAC 2. Unwin N , Shaw J , Zimmet P , Alberti KG . Impaired glucose tolerance and impaired fasting glycaemia: the current status on definition and intervention . Diabet Med 2002 ; 19 : 708 – 23 . Google Scholar Crossref Search ADS PubMed WorldCat 3. Ali MK , Bullard KM , Saydah S , Imperatore G , Gregg EW . 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‘I could have made those changes years earlier’: experiences and characteristics associated with receiving a prediabetes diagnosis among individuals recently diagnosed with type 2 diabetes

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Oxford University Press
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© The Author(s) 2019. Published by Oxford University Press. All rights reserved.For permissions, please e-mail: journals.permissions@oup.com.
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0263-2136
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1460-2229
DOI
10.1093/fampra/cmz081
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Abstract

Abstract Background Prediabetes increases the risk of developing type 2 diabetes (T2D). Improving diet quality is key in preventing this progression, yet little is known about the characteristics of individuals with prediabetes or the nutrition care they receive. Objectives This study aims to identify characteristics and experiences associated with receiving a prediabetes diagnosis prior to developing T2D. Methods A mixed methods study encompassed a quantitative subanalysis of participants with newly diagnosed T2D from The 3D Study, and semi-structured telephone interviews with a subsample of participants who were previously diagnosed with prediabetes. Interviews were thematically analysed and survey data synthesized using SPSS statistical software. Results Of the 225 study participants, 100 individuals were previously diagnosed with prediabetes and 120 participants were not. Those with prediabetes were less likely to be smokers (P = 0.022) and more likely to be satisfied with seeing a dietitian (P = 0.031) than those without a previous prediabetes diagnosis. A total of 20 participants completed semi-structured interviews. Thematic analysis revealed three themes: (i) experiencing a prediabetes diagnosis; (ii) receiving nutrition care during prediabetes and (iii) reflecting on the experience of receiving care for prediabetes versus T2D. Conclusions There are gaps in the current management of prediabetes in Australia. Low rates of prediabetes diagnosis and an ambiguous experience of receiving this diagnosis suggest an area of health service improvement. With no difference in diet quality between individuals with and without a previous prediabetes diagnosis, the nutrition care during prediabetes may be more important than the diagnosis itself in delaying the onset of T2D. diabetes mellitus, diet, health personnel, patients, prediabetic state, primary health care, type 2 Key Messages Prediabetes presents a significant health risk but it is under diagnosed. Patient characteristics are not predictive of being diagnosed with prediabetes. In prediabetes, nutrition care is rarely provided and is limited in its content. Improved prediabetes management to delay type 2 diabetes is needed in Australian settings. Background Prediabetes presents a significant global health burden. Prediabetes is characterized by elevated blood glucose levels and increased cardio-metabolic risk (1–3) and 5–10% of individuals with prediabetes will develop type 2 diabetes (T2D) each year (4). The prevalence of both prediabetes and T2D is increasing globally, with over 350 million people living with prediabetes, and over $727 billion USD spent annually on all forms of diabetes (1). Despite this rising prevalence, effective treatment approaches are clear, with a review of randomized controlled trials finding weight loss, improved diet quality and physical activity to delay the progression from prediabetes to T2D in approximately 60% of individuals (5). These positive outcomes have been observed in diverse populations and replicated in real-world settings (6–9), forming the basis of national and international practice guidelines (10–14). Guideline recommendations have not been widely adopted into practice and rates of prediabetes diagnosis remains low (15,16), clearly representing a gap in care. Primary care is the optimal setting for implementing lifestyle interventions for prediabetes (10). Screening tools, such as AUSDRISK, may assist with early identification but there are limitations in using these tools exclusively to detect prediabetes (17). Furthermore, challenges to implementing practice guidelines remain. Our recent review found health care providers’ (HCPs) views about prediabetes vary, with nutrition care irregularly provided and dietary advice inconsistent in its content (18). Despite the evidence in support of early intervention, the risk of over medicalizing prediabetes has also been argued (19). The perceived inability by HCPs to provide lifestyle support in primary care may further limit their management behaviours (20). Clearly, HCP-led decisions impact the level of care that individuals with prediabetes receive. Patients want to receive nutrition care for prediabetes that is individualized, consistent and accessible, despite this not being standard practice (18). A national US study found that certain patient characteristics are associated with receiving a prediabetes diagnosis, such as being middle-aged, female and having a high body mass index (BMI) (21). However, the reasons why some at-risk individuals are not diagnosed and managed warrants further investigation. The aims of this study are to: (i) identify characteristics associated with receiving a prediabetes diagnosis in Australia and (ii) explore the past experiences of receiving nutrition care for prediabetes among a population of people with newly diagnosed T2D. The synthesized findings will provide data on current prediabetes management practices with the added insight of patient perspectives around receiving a prediabetes diagnosis. Methods Study design A mixed methods design (22,23) was used to understand the phenomenon of receiving a prediabetes diagnosis in a sample of Australian adults. Participants were from an existing case-series study, The 3D Study (changes to Diet with a Diagnosis of Diabetes) (24). Quantitative baseline measures from 225 study participants were analysed to compare the characteristics of those with and without a previous prediabetes diagnosis. Qualitative semi-structured interviews of a subsample of participants were completed in parallel. The 3D study was approved by the Griffith University Human Research Ethics Committee (Protocol Number: 2017/951) and was registered with the Australian New Zealand Clinical Trials Registry (ref: ACTRN12618000375257) (24). The Good Reporting of A Mixed Methods Study tool was used to guide this study (25). Surveys Sample and data collection. The 3D study recruited non-pregnant adults recently diagnosed with T2D (24). In May 2018, Diabetes Australia emailed individuals who had registered with the National Diabetes Services Scheme within the preceding 6 months. Those willing to participate contacted the research team to request a participant information and consent form. Telephone surveys were conducted by trained research assistants. Baseline demographic, lifestyle and dietary data were collected from June to September 2018 as described in the methodology protocol (24). Prediabetes status. Participants were asked whether they had ever been told by a HCP that they had prediabetes, based on the National Health and Nutrition Examination Survey (26). Individuals who responded affirmatively were classified as ‘previously diagnosed with prediabetes’ (PD) and individuals who said ‘no’ were classified as ‘never diagnosed with prediabetes’ (no-PD). Individuals who were unsure about receiving a diagnosis were labelled as ‘unsure’. Demographic and health characteristics. Participants’ self-reported age, gender, income, education level and socio-economic status were collected (24). Income was calculated using total household earnings and categorized into quartiles. Level of highest education was recorded in five categories and collapsed into three: (i) high school diploma or less, (ii) diploma or certificate and (iii) university or post-graduate degree. Socio-economic Indexes for Areas (SEIFA) (27) and Accessibility/Remoteness Index of Australia (ARIA) (28) scores were allocated based on postal code. SEIFA was analysed in quintiles and ARIA scores were collapsed into three categories: (i) major city, (ii) inner regional and (iii) outer regional and remote. Weight in kilograms, height and waist circumference in centimetres was collected, and BMI was calculated. Physical activity data were collected and scored using the International Physical Activity Questionnaire (29). Smoking status was also collected. Diet quality and HCP interaction data. Research assistants conducted 24-hour diet histories using the Australian version of the ASA-24 food history tool (30). Diet quality was assessed using the Dietary Approaches to Stop Hypertension (DASH) scoring system (31). Mean serves of fruit, vegetables and whole grains were also analysed. Data on frequency and type of care provided by HCPs were collected. Participants ranked HCP satisfaction using a five-point Likert scale which was collapsed into two categories. Data analysis. Survey data were analysed with SPSS Version 22 statistical software. Demographic, lifestyle, dietary and HCP interaction variables were compared for the PD versus no-PD groups. Continuous variables were analysed using independent t-tests. Non-normally distributed data were analysed using Mann–Whitney U tests and presented as median and inter-quartile range. Categorical data were analysed using chi-square tests. Differences were considered significant at a P-value <0.05. Interview substudy Recruitment. The 3D study participants classified as ‘PD’ were asked: ‘Would you be willing to be contacted for a future study looking at experiences of people with prediabetes?’ Participants who agreed were sent an information and consent form by email and contacted to arrange an interview. Participants provided recorded verbal consent before participating in a one-on-one, semi-structured telephone interview. A phenomenological approach was used to understand patients’ lived experiences of receiving nutrition care after a diagnosis of prediabetes. Interview protocol. A semi-structured interview protocol was developed after a review of the literature (32,33). Interview questions were pilot tested with three individuals who met the study criteria. One research team member with significant qualitative research experience (LTW), listened to the audio-recordings to ensure the protocol was effective in producing valuable responses and to ensure credibility of the interviewer. The protocol was refined after discussions and feedback from the research team and patient interviews were conducted using the finalized, validated protocol. Data collection. Data were collected between August and September 2018 by the first author (MS). Interviews lasted between 30 and 60 minutes and were audio-recorded. Field notes were taken during interviews to add rigour to the data collection process. Data collection and analysis was conducted simultaneously until data saturation occurred. Participants received a copy of their interview transcript and were asked to return the transcript with corrections and feedback to ensure that interviews reflected participants’ true attitudes and opinions. Alterations were incorporated into the final transcripts. After completing the interview, participants received a $20 gift voucher as a reimbursement for their time. Data analysis. Interviews were transcribed verbatim and thematic analysis conducted manually. To ensure reliability of the data, two researchers (EB and MS) independently coded the transcripts. Codes were arranged based on commonly recurring phrases and keywords. The researchers reviewed the independently identified codes and determined the main themes. The research team collaboratively determined the final list of themes and subthemes and reached agreement that data saturation had occurred (Table 1). Table 1. Themes and corresponding patient quotes related to receiving nutrition care upon a prediabetes diagnosis from 2018 data Theme Description Indicative quotes 1. Experiencing a prediabetes diagnosis Participants report receiving a vague diagnosis of prediabetes He said I was on the spectrum, that’s how he described it. (P09) He gave me a dirty look, waved his finger and said oh I was pre-diabetic but he didn’t give any number at that time and he just said to me just stay off the baked biscuits and that was about it. (P20) A vague diagnosis implies that prediabetes should not be taken seriously She said yeah you’re diabetic [type 2] and so my head kicked in and went crikey, I better take this serious. So up until then it was just like oh you know you’ve got the flu. (P09) But nothing was sort of taken any further so I didn’t really take it sort of as anything serious, so you know I just sort of brushed it off. (P10) 2. Receiving nutrition care during prediabetes Nutrition advice received is inconsistent, general and not evidence based [The GP said] Do away with the colour white. No white pasta, no white potatoes, no white bread…You’ve got to cut back on carbs, no salt and no sugar. (P13) We never really sat down and talked about what I should and shouldn’t eat (GP). A general conversation, he just sort of said ‘you’ve got to watch the sugar you eat’. (P15) Dietary focus on carbohydrates and sugar but no other foods or nutrients, leading to misinformation about diet The thing I should have been more careful about so not eating as much rice and bread and that type of thing, so not only the cutting down the sugar. (P01) And it sort of rang in my ears when she sort of said to me ‘bread and potatoes are your worst enemy’. (P04) I avoid fried foods altogether only because of being told about the carbohydrates turning into sugar. (P18) Limited dietary advice makes patients feel unsupported in their nutrition care I changed a few things but nothing major, I didn’t understand how the diet sort of stuff worked. (P02) I just googled prediabetes. When I was diagnosed with prediabetes, I got very little information. (P05) 3. Reflecting on the experience of receiving care for prediabetes versus T2D Being diagnosed with T2D highlights the seriousness of prediabetes and the lack of support that was received at that time Like once you are pre-diabetic, it doesn’t seem to me to be a lot of help until you are actually diagnosed [with T2D]. Well that’s how it was for me anyway. (P04) I think there should be more support at the prediabetes stage. (P05) It should be impressed upon people where this leads to and the consequences. You know the amputation and the circulation and the eyesight and all that stuff. (P10) Reflecting on the diabetes journey leads patients to suggest ways that prediabetes could have been better managed Well had I known to change my diet before, I wouldn’t have reached the diabetic level. (P17) I wish they had told me what to do then and I could have done something to stop it. If I had help 2.5 years ago, maybe I wouldn’t have got to the state of being diabetic. (P19) Theme Description Indicative quotes 1. Experiencing a prediabetes diagnosis Participants report receiving a vague diagnosis of prediabetes He said I was on the spectrum, that’s how he described it. (P09) He gave me a dirty look, waved his finger and said oh I was pre-diabetic but he didn’t give any number at that time and he just said to me just stay off the baked biscuits and that was about it. (P20) A vague diagnosis implies that prediabetes should not be taken seriously She said yeah you’re diabetic [type 2] and so my head kicked in and went crikey, I better take this serious. So up until then it was just like oh you know you’ve got the flu. (P09) But nothing was sort of taken any further so I didn’t really take it sort of as anything serious, so you know I just sort of brushed it off. (P10) 2. Receiving nutrition care during prediabetes Nutrition advice received is inconsistent, general and not evidence based [The GP said] Do away with the colour white. No white pasta, no white potatoes, no white bread…You’ve got to cut back on carbs, no salt and no sugar. (P13) We never really sat down and talked about what I should and shouldn’t eat (GP). A general conversation, he just sort of said ‘you’ve got to watch the sugar you eat’. (P15) Dietary focus on carbohydrates and sugar but no other foods or nutrients, leading to misinformation about diet The thing I should have been more careful about so not eating as much rice and bread and that type of thing, so not only the cutting down the sugar. (P01) And it sort of rang in my ears when she sort of said to me ‘bread and potatoes are your worst enemy’. (P04) I avoid fried foods altogether only because of being told about the carbohydrates turning into sugar. (P18) Limited dietary advice makes patients feel unsupported in their nutrition care I changed a few things but nothing major, I didn’t understand how the diet sort of stuff worked. (P02) I just googled prediabetes. When I was diagnosed with prediabetes, I got very little information. (P05) 3. Reflecting on the experience of receiving care for prediabetes versus T2D Being diagnosed with T2D highlights the seriousness of prediabetes and the lack of support that was received at that time Like once you are pre-diabetic, it doesn’t seem to me to be a lot of help until you are actually diagnosed [with T2D]. Well that’s how it was for me anyway. (P04) I think there should be more support at the prediabetes stage. (P05) It should be impressed upon people where this leads to and the consequences. You know the amputation and the circulation and the eyesight and all that stuff. (P10) Reflecting on the diabetes journey leads patients to suggest ways that prediabetes could have been better managed Well had I known to change my diet before, I wouldn’t have reached the diabetic level. (P17) I wish they had told me what to do then and I could have done something to stop it. If I had help 2.5 years ago, maybe I wouldn’t have got to the state of being diabetic. (P19) Open in new tab Table 1. Themes and corresponding patient quotes related to receiving nutrition care upon a prediabetes diagnosis from 2018 data Theme Description Indicative quotes 1. Experiencing a prediabetes diagnosis Participants report receiving a vague diagnosis of prediabetes He said I was on the spectrum, that’s how he described it. (P09) He gave me a dirty look, waved his finger and said oh I was pre-diabetic but he didn’t give any number at that time and he just said to me just stay off the baked biscuits and that was about it. (P20) A vague diagnosis implies that prediabetes should not be taken seriously She said yeah you’re diabetic [type 2] and so my head kicked in and went crikey, I better take this serious. So up until then it was just like oh you know you’ve got the flu. (P09) But nothing was sort of taken any further so I didn’t really take it sort of as anything serious, so you know I just sort of brushed it off. (P10) 2. Receiving nutrition care during prediabetes Nutrition advice received is inconsistent, general and not evidence based [The GP said] Do away with the colour white. No white pasta, no white potatoes, no white bread…You’ve got to cut back on carbs, no salt and no sugar. (P13) We never really sat down and talked about what I should and shouldn’t eat (GP). A general conversation, he just sort of said ‘you’ve got to watch the sugar you eat’. (P15) Dietary focus on carbohydrates and sugar but no other foods or nutrients, leading to misinformation about diet The thing I should have been more careful about so not eating as much rice and bread and that type of thing, so not only the cutting down the sugar. (P01) And it sort of rang in my ears when she sort of said to me ‘bread and potatoes are your worst enemy’. (P04) I avoid fried foods altogether only because of being told about the carbohydrates turning into sugar. (P18) Limited dietary advice makes patients feel unsupported in their nutrition care I changed a few things but nothing major, I didn’t understand how the diet sort of stuff worked. (P02) I just googled prediabetes. When I was diagnosed with prediabetes, I got very little information. (P05) 3. Reflecting on the experience of receiving care for prediabetes versus T2D Being diagnosed with T2D highlights the seriousness of prediabetes and the lack of support that was received at that time Like once you are pre-diabetic, it doesn’t seem to me to be a lot of help until you are actually diagnosed [with T2D]. Well that’s how it was for me anyway. (P04) I think there should be more support at the prediabetes stage. (P05) It should be impressed upon people where this leads to and the consequences. You know the amputation and the circulation and the eyesight and all that stuff. (P10) Reflecting on the diabetes journey leads patients to suggest ways that prediabetes could have been better managed Well had I known to change my diet before, I wouldn’t have reached the diabetic level. (P17) I wish they had told me what to do then and I could have done something to stop it. If I had help 2.5 years ago, maybe I wouldn’t have got to the state of being diabetic. (P19) Theme Description Indicative quotes 1. Experiencing a prediabetes diagnosis Participants report receiving a vague diagnosis of prediabetes He said I was on the spectrum, that’s how he described it. (P09) He gave me a dirty look, waved his finger and said oh I was pre-diabetic but he didn’t give any number at that time and he just said to me just stay off the baked biscuits and that was about it. (P20) A vague diagnosis implies that prediabetes should not be taken seriously She said yeah you’re diabetic [type 2] and so my head kicked in and went crikey, I better take this serious. So up until then it was just like oh you know you’ve got the flu. (P09) But nothing was sort of taken any further so I didn’t really take it sort of as anything serious, so you know I just sort of brushed it off. (P10) 2. Receiving nutrition care during prediabetes Nutrition advice received is inconsistent, general and not evidence based [The GP said] Do away with the colour white. No white pasta, no white potatoes, no white bread…You’ve got to cut back on carbs, no salt and no sugar. (P13) We never really sat down and talked about what I should and shouldn’t eat (GP). A general conversation, he just sort of said ‘you’ve got to watch the sugar you eat’. (P15) Dietary focus on carbohydrates and sugar but no other foods or nutrients, leading to misinformation about diet The thing I should have been more careful about so not eating as much rice and bread and that type of thing, so not only the cutting down the sugar. (P01) And it sort of rang in my ears when she sort of said to me ‘bread and potatoes are your worst enemy’. (P04) I avoid fried foods altogether only because of being told about the carbohydrates turning into sugar. (P18) Limited dietary advice makes patients feel unsupported in their nutrition care I changed a few things but nothing major, I didn’t understand how the diet sort of stuff worked. (P02) I just googled prediabetes. When I was diagnosed with prediabetes, I got very little information. (P05) 3. Reflecting on the experience of receiving care for prediabetes versus T2D Being diagnosed with T2D highlights the seriousness of prediabetes and the lack of support that was received at that time Like once you are pre-diabetic, it doesn’t seem to me to be a lot of help until you are actually diagnosed [with T2D]. Well that’s how it was for me anyway. (P04) I think there should be more support at the prediabetes stage. (P05) It should be impressed upon people where this leads to and the consequences. You know the amputation and the circulation and the eyesight and all that stuff. (P10) Reflecting on the diabetes journey leads patients to suggest ways that prediabetes could have been better managed Well had I known to change my diet before, I wouldn’t have reached the diabetic level. (P17) I wish they had told me what to do then and I could have done something to stop it. If I had help 2.5 years ago, maybe I wouldn’t have got to the state of being diabetic. (P19) Open in new tab Data synthesis Quantitative data were collected prior to qualitative but analysis occurred in parallel. Quantitative results descriptively compared the two diagnosis groups while qualitative data added patient perspectives to support the differences observed. Results were synthesized in a table according to study aims (Table 2). Table 2. Synthesized findings from qualitative and quantitative results comparing participants with type 2 diabetes who were previously diagnosed with prediabetes versus those undiagnosed from 2018 data Study aims Quantitative result/s Qualitative result/s Synthesized finding Aim 1. To identify characteristics associated with receiving a prediabetes diagnosis in Australia 100/225 (44.4%) of participants received a prediabetes diagnosis Theme 1: Prediabetes diagnosis experience is vague The majority of individuals with prediabetes are undiagnosed, and among those who do receive a diagnosis, the experience is vague which leads to little action being taken No patient characteristics are associated with receiving a prediabetes diagnosis No statistically significant differences in characteristics between groups except for smoking status (P = 0.022) Aim 2. To explore the past experiences of receiving nutrition care for prediabetes among a population of people with newly diagnosed T2D No significant difference found between PD versus no-PD diagnosis groups for DASH score or food group serves Theme 2: Limited nutrition care received by individuals after a prediabetes diagnosis The diet quality of individuals who were previously diagnosed with prediabetes did not differ from individuals who were not previously diagnosed. Both groups eventually developed T2D, suggesting the nutrition support currently provided for prediabetes is ineffective in delaying the onset of T2D Aim 2. To explore the past experiences of receiving nutrition care for prediabetes among a population of people with newly diagnosed T2D PD versus no-PD diagnosis group had higher satisfaction with a dietitian interaction (P = 0.031) after being diagnosed with T2D Theme 2: Limited nutrition care received by individuals after a prediabetes diagnosis Individuals report wishing they had received more, individualized nutrition support during prediabetes and only four were referred to a dietitian at that time Participants previously diagnosed with prediabetes who visit a dietitian after T2D may feel they receive more individualized nutrition care and may build upon the general knowledge received during prediabetes, resulting in greater satisfaction with the health care interaction Theme 3: Comparing prediabetes to T2D diagnosis experiences Study aims Quantitative result/s Qualitative result/s Synthesized finding Aim 1. To identify characteristics associated with receiving a prediabetes diagnosis in Australia 100/225 (44.4%) of participants received a prediabetes diagnosis Theme 1: Prediabetes diagnosis experience is vague The majority of individuals with prediabetes are undiagnosed, and among those who do receive a diagnosis, the experience is vague which leads to little action being taken No patient characteristics are associated with receiving a prediabetes diagnosis No statistically significant differences in characteristics between groups except for smoking status (P = 0.022) Aim 2. To explore the past experiences of receiving nutrition care for prediabetes among a population of people with newly diagnosed T2D No significant difference found between PD versus no-PD diagnosis groups for DASH score or food group serves Theme 2: Limited nutrition care received by individuals after a prediabetes diagnosis The diet quality of individuals who were previously diagnosed with prediabetes did not differ from individuals who were not previously diagnosed. Both groups eventually developed T2D, suggesting the nutrition support currently provided for prediabetes is ineffective in delaying the onset of T2D Aim 2. To explore the past experiences of receiving nutrition care for prediabetes among a population of people with newly diagnosed T2D PD versus no-PD diagnosis group had higher satisfaction with a dietitian interaction (P = 0.031) after being diagnosed with T2D Theme 2: Limited nutrition care received by individuals after a prediabetes diagnosis Individuals report wishing they had received more, individualized nutrition support during prediabetes and only four were referred to a dietitian at that time Participants previously diagnosed with prediabetes who visit a dietitian after T2D may feel they receive more individualized nutrition care and may build upon the general knowledge received during prediabetes, resulting in greater satisfaction with the health care interaction Theme 3: Comparing prediabetes to T2D diagnosis experiences Open in new tab Table 2. Synthesized findings from qualitative and quantitative results comparing participants with type 2 diabetes who were previously diagnosed with prediabetes versus those undiagnosed from 2018 data Study aims Quantitative result/s Qualitative result/s Synthesized finding Aim 1. To identify characteristics associated with receiving a prediabetes diagnosis in Australia 100/225 (44.4%) of participants received a prediabetes diagnosis Theme 1: Prediabetes diagnosis experience is vague The majority of individuals with prediabetes are undiagnosed, and among those who do receive a diagnosis, the experience is vague which leads to little action being taken No patient characteristics are associated with receiving a prediabetes diagnosis No statistically significant differences in characteristics between groups except for smoking status (P = 0.022) Aim 2. To explore the past experiences of receiving nutrition care for prediabetes among a population of people with newly diagnosed T2D No significant difference found between PD versus no-PD diagnosis groups for DASH score or food group serves Theme 2: Limited nutrition care received by individuals after a prediabetes diagnosis The diet quality of individuals who were previously diagnosed with prediabetes did not differ from individuals who were not previously diagnosed. Both groups eventually developed T2D, suggesting the nutrition support currently provided for prediabetes is ineffective in delaying the onset of T2D Aim 2. To explore the past experiences of receiving nutrition care for prediabetes among a population of people with newly diagnosed T2D PD versus no-PD diagnosis group had higher satisfaction with a dietitian interaction (P = 0.031) after being diagnosed with T2D Theme 2: Limited nutrition care received by individuals after a prediabetes diagnosis Individuals report wishing they had received more, individualized nutrition support during prediabetes and only four were referred to a dietitian at that time Participants previously diagnosed with prediabetes who visit a dietitian after T2D may feel they receive more individualized nutrition care and may build upon the general knowledge received during prediabetes, resulting in greater satisfaction with the health care interaction Theme 3: Comparing prediabetes to T2D diagnosis experiences Study aims Quantitative result/s Qualitative result/s Synthesized finding Aim 1. To identify characteristics associated with receiving a prediabetes diagnosis in Australia 100/225 (44.4%) of participants received a prediabetes diagnosis Theme 1: Prediabetes diagnosis experience is vague The majority of individuals with prediabetes are undiagnosed, and among those who do receive a diagnosis, the experience is vague which leads to little action being taken No patient characteristics are associated with receiving a prediabetes diagnosis No statistically significant differences in characteristics between groups except for smoking status (P = 0.022) Aim 2. To explore the past experiences of receiving nutrition care for prediabetes among a population of people with newly diagnosed T2D No significant difference found between PD versus no-PD diagnosis groups for DASH score or food group serves Theme 2: Limited nutrition care received by individuals after a prediabetes diagnosis The diet quality of individuals who were previously diagnosed with prediabetes did not differ from individuals who were not previously diagnosed. Both groups eventually developed T2D, suggesting the nutrition support currently provided for prediabetes is ineffective in delaying the onset of T2D Aim 2. To explore the past experiences of receiving nutrition care for prediabetes among a population of people with newly diagnosed T2D PD versus no-PD diagnosis group had higher satisfaction with a dietitian interaction (P = 0.031) after being diagnosed with T2D Theme 2: Limited nutrition care received by individuals after a prediabetes diagnosis Individuals report wishing they had received more, individualized nutrition support during prediabetes and only four were referred to a dietitian at that time Participants previously diagnosed with prediabetes who visit a dietitian after T2D may feel they receive more individualized nutrition care and may build upon the general knowledge received during prediabetes, resulting in greater satisfaction with the health care interaction Theme 3: Comparing prediabetes to T2D diagnosis experiences Open in new tab Results Surveys Among the 225 3D study participants, 120 (53.3%) were not diagnosed with prediabetes (no-PD) and 100 (44.4%) were previously diagnosed (PD). Five individuals (2.2%) were unsure. The 3D sample included slightly more males (n = 126; 56%) than females (n = 99; 44%), and this proportion remained similar amongst the PD and no-PD groups (Table 3). Table 3. Demographic and lifestyle characteristics comparing prediabetes diagnosed versus non-diagnosed groups from 2018 data Variables PD (n = 100) N (%) No-PD (n = 120) N (%) Difference Test P-value Age (years)  Median (IQR) 61.0 (14) 58.5 (17) 5268.0b 0.119 Gender  Male 56 (56) 67 (55.8) 0.001a 0.980  Female 44 (44) 53 (44.2) Physical Activity  Low 34 (34.0) 40 (33.3)  Moderate 57 (57.0) 64 (53.3) 1.042a 0.594  High 9 (9.0) 16 (13.3) Body Mass Index (kg/m2)  Median (IQR) 30.46 (9) 31.05 (9) 5927.0b 0.961  Normal 11 (11.0) 18 (15.3)  Overweight 34 (34.0) 27 (22.9) 3.562a 0.168  Obese 55 (55.0) 73 (61.9) Weight (kg)  Median (IQR) 61.0 (14) 58.5 (17) 5268.0b 0.119 Waist circumference (cm)  Median (IQR) 108.0 (19) 106.7 (21) 4817.5b 0.764 Smoking Status  Yes 6 (6.0) 19 (15.8) 5.236a 0.022  No 94 (94.0) 101 (84.2) Income  <$30 000 14 (16.5) 11 (10.6) 2.906a 0.406  $30–50 000 22 (25.9) 21 (20.2)  $50–100 000 23 (27.1) 35 (33.7)  >$100 000 26 (30.6) 37 (35.6) ARIA  Major city 59 (59.6) 82 (68.3) 1.838a 0.399  Inner regional 25 (25.3) 23 (19.2)  Outer reg./remote 15 (15.2) 15 (12.5) SEIFA  Quintile 1 21 (21.4) 24 (20.0) 3.786a 0.436  Quintile 2 21 (21.4) 26 (21.7)  Quintile 3 22 (22.4) 18 (15.0)  Quintile 4 19 (19.4) 23 (19.2)  Quintile 5 15 (15.3) 29 (24.2) Variables PD (n = 100) N (%) No-PD (n = 120) N (%) Difference Test P-value Age (years)  Median (IQR) 61.0 (14) 58.5 (17) 5268.0b 0.119 Gender  Male 56 (56) 67 (55.8) 0.001a 0.980  Female 44 (44) 53 (44.2) Physical Activity  Low 34 (34.0) 40 (33.3)  Moderate 57 (57.0) 64 (53.3) 1.042a 0.594  High 9 (9.0) 16 (13.3) Body Mass Index (kg/m2)  Median (IQR) 30.46 (9) 31.05 (9) 5927.0b 0.961  Normal 11 (11.0) 18 (15.3)  Overweight 34 (34.0) 27 (22.9) 3.562a 0.168  Obese 55 (55.0) 73 (61.9) Weight (kg)  Median (IQR) 61.0 (14) 58.5 (17) 5268.0b 0.119 Waist circumference (cm)  Median (IQR) 108.0 (19) 106.7 (21) 4817.5b 0.764 Smoking Status  Yes 6 (6.0) 19 (15.8) 5.236a 0.022  No 94 (94.0) 101 (84.2) Income  <$30 000 14 (16.5) 11 (10.6) 2.906a 0.406  $30–50 000 22 (25.9) 21 (20.2)  $50–100 000 23 (27.1) 35 (33.7)  >$100 000 26 (30.6) 37 (35.6) ARIA  Major city 59 (59.6) 82 (68.3) 1.838a 0.399  Inner regional 25 (25.3) 23 (19.2)  Outer reg./remote 15 (15.2) 15 (12.5) SEIFA  Quintile 1 21 (21.4) 24 (20.0) 3.786a 0.436  Quintile 2 21 (21.4) 26 (21.7)  Quintile 3 22 (22.4) 18 (15.0)  Quintile 4 19 (19.4) 23 (19.2)  Quintile 5 15 (15.3) 29 (24.2) IQR, inter-quartile range; ARIA, Accessibility/Remoteness Index of Australia; SEIFA, socio-economic indexes for areas; Quintile 1, Lowest SEIFA; Quintile 2, Mid-lower SEIFA; Quintile 3, Middle SEIFA; Quintile 4, Upper middle SEIFA; Quintile 5, Highest SEIFA; PD, prediabetes diagnosis; no-PD, no prediabetes diagnosis. aChi-square test. bMann–Whitney U test. Open in new tab Table 3. Demographic and lifestyle characteristics comparing prediabetes diagnosed versus non-diagnosed groups from 2018 data Variables PD (n = 100) N (%) No-PD (n = 120) N (%) Difference Test P-value Age (years)  Median (IQR) 61.0 (14) 58.5 (17) 5268.0b 0.119 Gender  Male 56 (56) 67 (55.8) 0.001a 0.980  Female 44 (44) 53 (44.2) Physical Activity  Low 34 (34.0) 40 (33.3)  Moderate 57 (57.0) 64 (53.3) 1.042a 0.594  High 9 (9.0) 16 (13.3) Body Mass Index (kg/m2)  Median (IQR) 30.46 (9) 31.05 (9) 5927.0b 0.961  Normal 11 (11.0) 18 (15.3)  Overweight 34 (34.0) 27 (22.9) 3.562a 0.168  Obese 55 (55.0) 73 (61.9) Weight (kg)  Median (IQR) 61.0 (14) 58.5 (17) 5268.0b 0.119 Waist circumference (cm)  Median (IQR) 108.0 (19) 106.7 (21) 4817.5b 0.764 Smoking Status  Yes 6 (6.0) 19 (15.8) 5.236a 0.022  No 94 (94.0) 101 (84.2) Income  <$30 000 14 (16.5) 11 (10.6) 2.906a 0.406  $30–50 000 22 (25.9) 21 (20.2)  $50–100 000 23 (27.1) 35 (33.7)  >$100 000 26 (30.6) 37 (35.6) ARIA  Major city 59 (59.6) 82 (68.3) 1.838a 0.399  Inner regional 25 (25.3) 23 (19.2)  Outer reg./remote 15 (15.2) 15 (12.5) SEIFA  Quintile 1 21 (21.4) 24 (20.0) 3.786a 0.436  Quintile 2 21 (21.4) 26 (21.7)  Quintile 3 22 (22.4) 18 (15.0)  Quintile 4 19 (19.4) 23 (19.2)  Quintile 5 15 (15.3) 29 (24.2) Variables PD (n = 100) N (%) No-PD (n = 120) N (%) Difference Test P-value Age (years)  Median (IQR) 61.0 (14) 58.5 (17) 5268.0b 0.119 Gender  Male 56 (56) 67 (55.8) 0.001a 0.980  Female 44 (44) 53 (44.2) Physical Activity  Low 34 (34.0) 40 (33.3)  Moderate 57 (57.0) 64 (53.3) 1.042a 0.594  High 9 (9.0) 16 (13.3) Body Mass Index (kg/m2)  Median (IQR) 30.46 (9) 31.05 (9) 5927.0b 0.961  Normal 11 (11.0) 18 (15.3)  Overweight 34 (34.0) 27 (22.9) 3.562a 0.168  Obese 55 (55.0) 73 (61.9) Weight (kg)  Median (IQR) 61.0 (14) 58.5 (17) 5268.0b 0.119 Waist circumference (cm)  Median (IQR) 108.0 (19) 106.7 (21) 4817.5b 0.764 Smoking Status  Yes 6 (6.0) 19 (15.8) 5.236a 0.022  No 94 (94.0) 101 (84.2) Income  <$30 000 14 (16.5) 11 (10.6) 2.906a 0.406  $30–50 000 22 (25.9) 21 (20.2)  $50–100 000 23 (27.1) 35 (33.7)  >$100 000 26 (30.6) 37 (35.6) ARIA  Major city 59 (59.6) 82 (68.3) 1.838a 0.399  Inner regional 25 (25.3) 23 (19.2)  Outer reg./remote 15 (15.2) 15 (12.5) SEIFA  Quintile 1 21 (21.4) 24 (20.0) 3.786a 0.436  Quintile 2 21 (21.4) 26 (21.7)  Quintile 3 22 (22.4) 18 (15.0)  Quintile 4 19 (19.4) 23 (19.2)  Quintile 5 15 (15.3) 29 (24.2) IQR, inter-quartile range; ARIA, Accessibility/Remoteness Index of Australia; SEIFA, socio-economic indexes for areas; Quintile 1, Lowest SEIFA; Quintile 2, Mid-lower SEIFA; Quintile 3, Middle SEIFA; Quintile 4, Upper middle SEIFA; Quintile 5, Highest SEIFA; PD, prediabetes diagnosis; no-PD, no prediabetes diagnosis. aChi-square test. bMann–Whitney U test. Open in new tab Characteristics of PD versus no-PD groups are shown in Table 3. There were neither statistically significant differences for age, education level, ARIA, SEIFA or household income between the two groups nor were there differences between the groups for physical activity level, weight, BMI or waist circumference. A difference was noted between groups for smoking status, with significantly more smokers in the no-PD group (P = 0.022). This was the only health behaviour difference; with no differences in individual food groups or DASH score (Table 4). Table 4. Diet quality by DASH score and food group serves comparing prediabetes diagnosed versus non-diagnosed groups from 2018 data Variables PD (n = 100) Median (IQR) No-PD (n = 120) Median (IQR) Difference Test P-value DASH score  Mean (SD) 24.22 (4.89) 24.56 (4.50) −0.538b 0.591 DASH quartiles 2.073a 0.557  Quartile 1 24 (24.0) 38 (31.7)  Quartile 2 28 (28.0) 26 (21.7)  Quartile 3 23 (23.0) 26 (21.7)  Quartile 4 25 (25.0) 30 (25.0) Fruit  Serves/day 0.55 (1.10) 0.40 (1.20) 5908.0c 0.842 Vegetables  Serves/day 3.05 (3.0) 3.45 (4.07) 5350.5c 0.167 Whole grains  Serves/day 2.15 (3.65) 1.60 (2.70) 5549.0c 0.334 Variables PD (n = 100) Median (IQR) No-PD (n = 120) Median (IQR) Difference Test P-value DASH score  Mean (SD) 24.22 (4.89) 24.56 (4.50) −0.538b 0.591 DASH quartiles 2.073a 0.557  Quartile 1 24 (24.0) 38 (31.7)  Quartile 2 28 (28.0) 26 (21.7)  Quartile 3 23 (23.0) 26 (21.7)  Quartile 4 25 (25.0) 30 (25.0) Fruit  Serves/day 0.55 (1.10) 0.40 (1.20) 5908.0c 0.842 Vegetables  Serves/day 3.05 (3.0) 3.45 (4.07) 5350.5c 0.167 Whole grains  Serves/day 2.15 (3.65) 1.60 (2.70) 5549.0c 0.334 IQR, inter-quartile range; DASH, dietary approaches to stop hypertension; PD, prediabetes diagnosis; no-PD, no prediabetes diagnosis; DASH Quartile 1, score 0–21; Quartile 2, score 22–24; Quartile 3, score 25–27; Quartile 4, score 28–37. aChi-square test. bt-test. cMann–Whitney U test. Open in new tab Table 4. Diet quality by DASH score and food group serves comparing prediabetes diagnosed versus non-diagnosed groups from 2018 data Variables PD (n = 100) Median (IQR) No-PD (n = 120) Median (IQR) Difference Test P-value DASH score  Mean (SD) 24.22 (4.89) 24.56 (4.50) −0.538b 0.591 DASH quartiles 2.073a 0.557  Quartile 1 24 (24.0) 38 (31.7)  Quartile 2 28 (28.0) 26 (21.7)  Quartile 3 23 (23.0) 26 (21.7)  Quartile 4 25 (25.0) 30 (25.0) Fruit  Serves/day 0.55 (1.10) 0.40 (1.20) 5908.0c 0.842 Vegetables  Serves/day 3.05 (3.0) 3.45 (4.07) 5350.5c 0.167 Whole grains  Serves/day 2.15 (3.65) 1.60 (2.70) 5549.0c 0.334 Variables PD (n = 100) Median (IQR) No-PD (n = 120) Median (IQR) Difference Test P-value DASH score  Mean (SD) 24.22 (4.89) 24.56 (4.50) −0.538b 0.591 DASH quartiles 2.073a 0.557  Quartile 1 24 (24.0) 38 (31.7)  Quartile 2 28 (28.0) 26 (21.7)  Quartile 3 23 (23.0) 26 (21.7)  Quartile 4 25 (25.0) 30 (25.0) Fruit  Serves/day 0.55 (1.10) 0.40 (1.20) 5908.0c 0.842 Vegetables  Serves/day 3.05 (3.0) 3.45 (4.07) 5350.5c 0.167 Whole grains  Serves/day 2.15 (3.65) 1.60 (2.70) 5549.0c 0.334 IQR, inter-quartile range; DASH, dietary approaches to stop hypertension; PD, prediabetes diagnosis; no-PD, no prediabetes diagnosis; DASH Quartile 1, score 0–21; Quartile 2, score 22–24; Quartile 3, score 25–27; Quartile 4, score 28–37. aChi-square test. bt-test. cMann–Whitney U test. Open in new tab Comparison of HCP interaction and satisfaction level is found in Table 5. No differences existed between the two groups for number of visits to GPs or dietitians since being diagnosed with T2D. The likelihood of discussing diet with any HCPs did not differ between the groups. Neither group reported higher satisfaction with seeing a GP since being diagnosed with T2D, but individuals in the PD group reported higher satisfaction with seeing a dietitian compared to the no-PD group since a T2D diagnosis (P = 0.031) (Table 5). Table 5. Health care provider interaction and satisfaction since type 2 diabetes comparing those previously diagnosed with prediabetes versus those non-diagnosed from 2018 data Variables PD (n = 100) N (%) No-PD (n = 120) N (%) Difference Test P-value Number of individuals who interacted with a HCP since T2D diagnosis  GP Yes 43 (43.0) 59 (49.2) 0.834a 0.361 No 57 (57.0) 61 (50.8)  Dietitian Yes 46 (46.0) 68 (56.7) 2.486a 0.115 No 54 (54.0) 52 (43.3) Patient satisfaction with HCP during health care interaction  GP Not at all/neutral 17 (39.5) 23 (39.0) 0.003a 0.955 Very/extremely 26 (60.5) 36 (61.0)  Dietitian Not at all/neutral 10 (21.7) 28 (41.2) 4.665a 0.031 Very/extremely 36 (78.3) 40 (58.8) Number of HCPs that talked about diet with participants since T2D diagnosis No HCPs 21 (24.7) 21 (22.3) 1.351a 0.509 1 HCP 46 (54.1) 46 (48.9) ≥ 2 HCP 18 (21.2) 27 (28.7) Variables PD (n = 100) N (%) No-PD (n = 120) N (%) Difference Test P-value Number of individuals who interacted with a HCP since T2D diagnosis  GP Yes 43 (43.0) 59 (49.2) 0.834a 0.361 No 57 (57.0) 61 (50.8)  Dietitian Yes 46 (46.0) 68 (56.7) 2.486a 0.115 No 54 (54.0) 52 (43.3) Patient satisfaction with HCP during health care interaction  GP Not at all/neutral 17 (39.5) 23 (39.0) 0.003a 0.955 Very/extremely 26 (60.5) 36 (61.0)  Dietitian Not at all/neutral 10 (21.7) 28 (41.2) 4.665a 0.031 Very/extremely 36 (78.3) 40 (58.8) Number of HCPs that talked about diet with participants since T2D diagnosis No HCPs 21 (24.7) 21 (22.3) 1.351a 0.509 1 HCP 46 (54.1) 46 (48.9) ≥ 2 HCP 18 (21.2) 27 (28.7) HCP, health care provider; GP, general practitioner; PD, prediabetes diagnosis; no-PD, no prediabetes diagnosis; T2D, type 2 diabetes. aChi-square test. Open in new tab Table 5. Health care provider interaction and satisfaction since type 2 diabetes comparing those previously diagnosed with prediabetes versus those non-diagnosed from 2018 data Variables PD (n = 100) N (%) No-PD (n = 120) N (%) Difference Test P-value Number of individuals who interacted with a HCP since T2D diagnosis  GP Yes 43 (43.0) 59 (49.2) 0.834a 0.361 No 57 (57.0) 61 (50.8)  Dietitian Yes 46 (46.0) 68 (56.7) 2.486a 0.115 No 54 (54.0) 52 (43.3) Patient satisfaction with HCP during health care interaction  GP Not at all/neutral 17 (39.5) 23 (39.0) 0.003a 0.955 Very/extremely 26 (60.5) 36 (61.0)  Dietitian Not at all/neutral 10 (21.7) 28 (41.2) 4.665a 0.031 Very/extremely 36 (78.3) 40 (58.8) Number of HCPs that talked about diet with participants since T2D diagnosis No HCPs 21 (24.7) 21 (22.3) 1.351a 0.509 1 HCP 46 (54.1) 46 (48.9) ≥ 2 HCP 18 (21.2) 27 (28.7) Variables PD (n = 100) N (%) No-PD (n = 120) N (%) Difference Test P-value Number of individuals who interacted with a HCP since T2D diagnosis  GP Yes 43 (43.0) 59 (49.2) 0.834a 0.361 No 57 (57.0) 61 (50.8)  Dietitian Yes 46 (46.0) 68 (56.7) 2.486a 0.115 No 54 (54.0) 52 (43.3) Patient satisfaction with HCP during health care interaction  GP Not at all/neutral 17 (39.5) 23 (39.0) 0.003a 0.955 Very/extremely 26 (60.5) 36 (61.0)  Dietitian Not at all/neutral 10 (21.7) 28 (41.2) 4.665a 0.031 Very/extremely 36 (78.3) 40 (58.8) Number of HCPs that talked about diet with participants since T2D diagnosis No HCPs 21 (24.7) 21 (22.3) 1.351a 0.509 1 HCP 46 (54.1) 46 (48.9) ≥ 2 HCP 18 (21.2) 27 (28.7) HCP, health care provider; GP, general practitioner; PD, prediabetes diagnosis; no-PD, no prediabetes diagnosis; T2D, type 2 diabetes. aChi-square test. Open in new tab Interviews Of the 3D participants previously diagnosed with prediabetes, 45 agreed to be interviewed. Twenty interviews (8 male and 12 female) were conducted prior to reaching data saturation. Participants were from four Australian states and ranged in age from 54 to 75 years. Thematic analysis revealed three main themes: (i) experiencing a prediabetes diagnosis; (ii) receiving nutrition care during prediabetes and (iii) reflecting on the experience of receiving care for prediabetes versus T2D. Experiencing a prediabetes diagnosis All participants received a prediabetes diagnosis, however, for most, this experience felt confusing and unclear. Eleven participants reported receiving a vague diagnosis of prediabetes, with a term other than prediabetes used to describe their condition. He said I was on the spectrum, that’s how he described it. (P09) Some participants were aware that prediabetes increased their risk of T2D, but the unclear diagnosis and minimal concern from HCPs led many to classify prediabetes as ‘not very serious’. And so my head kicked in and went right ‘crikey, I better take this serious(ly)’ [talking about T2D]. Up until then it was just like oh you know you’ve got the flu. (P10) Participants reported receiving little follow-up and support after a prediabetes diagnosis. Individuals were unsure about the implications of prediabetes, leaving them to investigate on their own or act indifferent. I wasn’t given an explanation at the time as to really what the implications of prediabetes were. (P20) The overall perception that prediabetes was not serious appeared to be a result of the minimal action taken by HCPs during routine care. Participants looked to HCPs to guide them with appropriate management of prediabetes. Receiving nutrition care during prediabetes All participants reported receiving nutrition advice from a HCP during prediabetes, however, this was limited. The nutrition information participants received was general and confusing, resulting in individuals seeking unreliable sources of nutrition information from friends, family or the internet. One participant was even encouraged to do this by their GP: He just said look it up online and that and you can see what you should be eating and what you shouldn’t be eating. (P16) The reported nutrition advice participants received from HCPs tended to focus on carbohydrates. Some individuals had discussions with HCPs about pasta and bread, while others only considered soft drinks and confectionary as containing carbohydrates. There was little mention of other dietary recommendations such as modifying fibre or fat intake. He just said to me stay off the baked biscuits and that was about it. (P20) The limited nutrition care led to misunderstandings around nutrition for some participants with many unable to distinguish between carbohydrates and sugar. I avoid fried food altogether only because of being told about the carbohydrates turning into sugar. (P18) In contrast, four individuals received referrals to a dietitian or diabetes educator. One of these participants felt although they eventually developed T2D, the nutrition support they received delayed their diagnosis and armed them with knowledge still valuable during T2D. There was a question of access for prediabetes services. One participant was angry she had to pay for dietetic services for prediabetes, yet received subsidized dietetic care upon developing T2D. The inconsistency in access and content of nutrition support led to participant confusion about food, and frustration in how to make appropriate dietary changes. I spent a lot of money because I wasn’t on any plan at that stage and it had cost me quite a lot to go to the exercise classes and dietitian and…I thought what else can I do. I was really, really angry when I finally got the T2D diagnosis. (P06) Reflecting on the experience of receiving care for prediabetes versus T2D Participants compared their prediabetes and T2D diagnoses. For many, the care received for T2D seemed straightforward, with a clear diagnosis and management plan. This contrasted participants’ prediabetes experience. Like once you are pre-diabetic, it doesn’t seem to me to be a lot of help until you are actually diagnosed [with T2D]. Well that’s how it was for me anyway. (P04) Several participants suggested prediabetes should be treated similarly to T2D, with access to relevant nutrition information and support. As a result of the level of support received during T2D, participants interpreted it to be a serious condition requiring immediate action. Well, it’s a bit of a wake-up call and you need to follow it straight away. If somebody’s told that like I was, I wasn’t worried about it until I was told I’m actually diabetic, type 2. (P17) This reinforced the seriousness of the disease influenced the level of action taken. Participants reported if the same significance and level of care was provided for prediabetes, they would have taken more action, sooner. Had I had the same sort of information given to me or suggested to me, I could have made those changes years earlier. (P02) In retrospect, I wish I had known about a lot of the support available for diabetes, had it been available during the prediabetes stage…that would have been much more helpful. (P20) The negative experience of being diagnosed with T2D was amplified when participants compared the experience to being diagnosed with prediabetes. The regret over a missed opportunity to take action during prediabetes was clearly expressed. Realizing this lack of support may have led to a subsequent T2D diagnosis was confronting. Well had I known to change my diet before, I wouldn’t have reached the diabetic level. (P17) Discussion This was the first study to comprehensively explore the experience of receiving nutrition care for prediabetes and determine whether individual characteristics are associated with this diagnosis in Australia. Among this sample of individuals with newly diagnosed T2D, less than half were previously diagnosed with prediabetes. This is significant because all individuals would have progressed through prediabetes before T2D, indicating many missed opportunities for early intervention. Evidence-based guidelines recommend all individuals with prediabetes receive lifestyle intervention to delay T2D (10–14), highlighting gaps in the current care provided to patients with prediabetes. Among individuals in this study who were diagnosed with prediabetes, their collective diagnosis experience was vague, inconsistent and implied that prediabetes was not serious. This is similar to findings from Troughton et al. where individuals with prediabetes expressed feelings of uncertainty about their condition (34). Without a clear diagnosis and follow-up, individuals with prediabetes are unable to make appropriate dietary changes, making a future T2D diagnosis inevitable. Despite undesirable rates of diagnosis, our recent review found individuals with prediabetes are highly motivated to change behaviour and identify a preference for lifestyle support (18). Participants in this study reported if they had the opportunity to take action during prediabetes, they would have attempted dietary changes. This is convincing considering the level of action participants reported taking after their T2D diagnosis, suggesting increased access to nutrition support services for prediabetes is needed. No differences in diet quality between the no-PD and PD groups suggest individuals with a prediabetes diagnosis did not make sufficient lifestyle changes to prevent T2D. This is reflected in participants’ reported experiences of receiving little nutrition support, inconsistent advice and non-evidence based recommendations during prediabetes. This further highlights the importance of receiving adequate nutrition care for prediabetes, and a diagnosis alone is insufficient to invoke change. Similarly, no differences in demographic or health characteristics between the two groups suggest HCP versus patient characteristics may be more predictive of prediabetes management behaviours. Associations between HCP characteristics and diagnosis behaviour have been reported previously (20), and this is clearly an area for further investigation in prediabetes research. Together, the qualitative and quantitative results of this study provided a comprehensive understanding of the research topic, making the mixed methods design a key strength. The 3D study, which provided the basis for these subanalyses, added further strength due to the use of validated tools and methodological rigour. A limitation of this study was all participants interviewed about their prediabetes diagnosis experience were living with T2D. The experiences of those who had not progressed to T2D may have differed. Conclusion Prediabetes is a serious condition, presenting increased cardio-metabolic risk. Early lifestyle intervention is necessary to delay T2D and should be the focus of prediabetes management. However, this study found individuals may neither receive adequate nutrition support following a prediabetes diagnosis, nor are all individuals who meet the prediabetes criteria being diagnosed in practice. This suggests HCP characteristics may be more predictive of the level of nutrition care provided for prediabetes. Therefore, future research should explore associations between HCPs and prediabetes management behaviours and to understand their views on providing nutrition care in practice. Further work is needed to equip HCPs with nutrition knowledge and skills to adequately support individuals with prediabetes and prevent future T2D diagnoses. Increased access and promotion of nutrition support services for prediabetes may be an effective management approach. This study adds to our current understanding of prediabetes management in Australian primary care settings from the patients’ perspective. This is important for future prediabetes management and patient care. 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Journal

Family PracticeOxford University Press

Published: Jul 1, 2009

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