Health coaching in diabetes

Issue: June 2012

ByEdward C. Chao, DO

Edward C. Chao, DO
Edward C. Chao

All of our advances in diabetes medications means little if patients aren’t taking these agents. I’m sure you’ve heard about the increasing presence and use of health coaches. These individuals have increasingly been called upon to assist patients with self-management support for diabetes, as well as other chronic diseases. These coaches were even highlighted in an article in The New Yorker by Dr. Atul Gawande.

Gawande spoke with a couple, Vibha and Bharat Gandhi. Vibha is 57 years old, with a history of multiple medical problems, including type 2 diabetes and chronic heart failure; she had just been discharged from the hospital after her third myocardial infarction.

Gawande asked the couple why she was adhering to her physician’s recommendations this time, which she had not been doing before.

“Jayshree,” Vibha said, naming the “health coach” from Dunkin’ Donuts, who also speaks Gujarati. “Jayshree pushes her, and she listens to her only and not to me,” Bharat said.

“Why do you listen to Jayshree?” Gawande asked Vibha.

“Because she talks like my mother,” she said.

You may ask what the literature has revealed about this. A study by Heisler and colleagues compared peer support with nurse case managers. The primary endpoint of HbA1c change at 6 months decreased by 0.29% in the peer support group vs. an increase of 0.29% in the nurse case-manager group. Additionally, two of 17 randomized clinical trials in the Cochrane Review revealed HbA1c reductions but no statistically significant difference between intervention and control groups.

A recent study published in the Annals of Internal Medicine compared peer mentors with financial incentives in improving glycemic control in 118 black veterans. These individuals had at least two HbA1c measurements in the last 3 years that were more than 8%. Participants were randomly assigned to one of three groups: peer mentoring, financial incentives or usual care. Study personnel were masked, except for one research assistant. Peer mentors were black patients with HbA1c levels less than 7.5% within 3 months of enrollment who had poor HbA1c in the past (,8% in the past 3 years). The peer mentors were trained for 1 hour on motivational interviewing techniques and were called once per month to provide reinforcement. Mentors interacted by phone at least once per week. Patients randomly assigned to the financial incentive cohort could earn $100 at 6 months if their HbA1c declined by 1% and $200 if the reduction was 2% or the HbA1c was 6.5%. The primary endpoint was change in HbA1c. The mean change at 6 months, compared with the control group, was –1.07% (95% CI, –1.84 to –0.31) in the peer mentor group and –0.4% (95% CI, –1.23 to 0.32) in the financial incentive group.

Researchers at UCSF published a protocol for examining 400 patients from six primary health centers that serve mainly low-income individuals. Study participants were randomly assigned to coaching or usual care during a period of 6 months. Coaching is provided by peers who underwent training as peer coaches. The primary outcome measure is change in HbA1c; secondary endpoints include changes in LDL cholesterol, quality of life, systolic blood pressure, BMI, self-management of diabetes and depression. These outcomes will be assessed at baseline and at 6 months for both patients and peer coaches; the latter will also be evaluated at 12 months.

Health coaching appears to continue to grow in popularity. Having a peer coach undoubtedly can be more motivating because the person can readily relate to another patient with, for instance, diabetes. While we can see some of the results anecdotally in our practices, more studies are needed and are being done to further assess its impact not only on outcomes, such as HbA1c, but also on patients’ quality of life.

References:

de Weerdt I. Diabet Med. 1991;8:338-345.
Gawande A. The hot spotters. The New Yorker. Jan. 24, 2011:41-51.
Ghorob A. BMC Public Health. 2011;11:208.
Heisler M. Ann Intern Med. 2010;153:507-515.
Holtrop JS. Am J Health Educ. 2002;33:161-166.
Long JA. Ann Intern Med. 2012;156:416-424.

For more information:

Edward C. Chao, DO, is assistant clinical professor of medicine at University of California, San Diego, and staff physician at VA Medical Center, San Diego.
Disclosure: Dr. Chao reports no relevant financial disclosures.