|Year : 2014 | Volume
| Issue : 1 | Page : 43-45
Counseling Strategies (Dr. Vinod Dhurandhar Oration at AIAAROCON-Pune on 9th February, 2013)
Hemraj B Chandalia1, Sonal Modi2
1 Diabetes Endocrine Nutrition Management and Research Centre; Jaslok Hospital and Research Centre, Mumbai, Maharashtra, India
2 Diabetes Endocrine Nutrition Management and Research Centre, Mumbai, Maharashtra, India
|Date of Submission||09-Aug-2013|
|Date of Acceptance||01-Nov-2013|
|Date of Web Publication||30-Dec-2013|
Hemraj B Chandalia
Director, Diabetes Endocrine Nutrition Management and Research Centre (DENMARC), Mumbai Endocrinologist and Diabetologist, Jaslok Hospital and Research Centre, Mumbai
Source of Support: None, Conflict of Interest: None
|How to cite this article:|
Chandalia HB, Modi S. Counseling Strategies (Dr. Vinod Dhurandhar Oration at AIAAROCON-Pune on 9th February, 2013). J Obes Metab Res 2014;1:43-5
|How to cite this URL:|
Chandalia HB, Modi S. Counseling Strategies (Dr. Vinod Dhurandhar Oration at AIAAROCON-Pune on 9th February, 2013). J Obes Metab Res [serial online] 2014 [cited 2020 Jul 7];1:43-5. Available from: http://www.jomrjournal.org/text.asp?2014/1/1/43/123903
| Importance of Counselling in LifeStyle Management (LSM)|| |
Diabetes, obesity and metabolic syndrome are extremely common diseases. They can be effectively managed by lifestyle changes. In United Kingdom Prospective Diabetes Study, only about 10% of subjects were controlled by lifestyle changes alone. However, LSM continued to be important aspect of treatment throughout the study. In diabetes prevention programme (DPP)  and similar prevention studies, LSM emerged as the most powerful tool. In DPP conversion of impaired glucose tolerance to type 2 diabetes mellitus was reduced by 58% in the LSM group. In contrast, metformin produced only a 31% reduction. In area of obesity, a multitude of drugs over the past 3 decades have been marketed and later on banned (e.g., Isomeride, Rimonabant, Sibutramine) Hence, LSM has come out as most important modality of treatment.
Counselling is the most important strategy capable of bringing about sustained lifestyle changes. Hence, it is important to look at various aspect of counselling strategies.
| Counsellor|| |
What makes the best counsellor? Obviously, he/she has to be well-trained and motivated, possessing an empathetic attitude towards the subject. If possible, he/she should serve as a role model for the patient. In a study on a group of physicians it was found that those undertaking regular aerobic exercises were more likely to counsel the patient on aerobic exercises.  Physicians can make good counsellors, but nutritional counselling is an important facet of counselling strategy and physicians are likely to have poor nutrition literacy.  As the medical curricula are extremely crowded, nutrition is only taught cursorily. Exercise therapist forms a good counsellor, but may not possess in-depth nutrition knowledge. This is the reason why we have evolved a cadre of personnel called diabetes educators, who are armed with full knowledge of the disease and superior counselling strategies.
Should a fellow sufferer serve as a counsellor? It is possible to occasionally seek assistance of a patient who is knowledgeable and possesses good communication skills. Such a person is often likely to exhibit great in depth understanding of certain aspects of the disease that he/she has experienced. However, the breadth of knowledge and balanced views are not likely to be expressed by this person. Hence, he/she should be used more in a supplementary role.
Spiritual leaders often have a close following and can enforce lifestyle changes. However, their knowledge about the disease is scanty. They too should be used only in a supplementary role. They can be very effective in introducing religious fasts and diet control. In India, political leaders often assume the role of counsellor, although they are ill-prepared and often dogmatic.
| Counselling Target|| |
Obviously, a diseased person or one with a family history of the disease or multiple risk factors for a given disease are the individual target. However, the whole community with high prevalence of a disease can be the target. This strategy can be implemented by using scarce resources. School children are an important target as prevalence of obesity is increasing in this group. However, in case of young children, the parents and teachers are the most fruitful targets. In schools, the availability of junk foods can be controlled by targeting the school authorities and food industry. In case of hospitality and airline industry, the counselling is targeted towards the managers.
| Individual, Group and Community Counselling|| |
An individual can receive very intensive and customised counselling. It is also possible to have good interaction in one-to-one session. Confidentiality is better maintained in this situation. However, cost of individual counselling is high. It is possible to identify problem areas in individual counselling and focus upon the same. Such counselling was employed in DPP study. The intensity of counselling was very high in this study.
Group counselling provides opportunity for interaction within the group, leading to more clarity and motivation. At the same time, if not supervised strongly by a qualified professional, a number of misunderstandings can be perpetuated.
Community counselling is highly cost-effective, but can only attain low intensity. The messages given have to be brief and unambiguous, more in the form of slogans. It is the least interactive strategy.
| Counselling Contents|| |
A good counselling strategy demands very careful design and accuracy of its contents. The contents can be in many different forms: Written, verbal or pictorial. In any case, they have to be lucid and well-illustrated. Important messages have to be emphasised and highlighted. The contents should be as brief as possible, as human attention span in general is limited. The contents should try to empower the patient to take full control of his life.
| Intensity and Methods|| |
Most intense methods of counselling have been utilised in research studies. This minimises the attrition or dropout of subjects to as low a rate as 15%. In real life situation it is difficult to apply such intense strategies. An argument often made against the LSM is that only a minimal to moderate intensity is feasible in real life situations. Interestingly, such moderate intensity of LSM was used in a university setting by using the existing resources. Yet the weight loss of 5.19 kg was achieved in a year's time when compared to a weight gain of 0.21 kg in the control group.  On the other hand, minimal education was found to produce similar improvement in glycaemic control in a study.  In this study, improved metabolic control was shown to correlate more closely with general school education and self-confidence level of the subjects.
At the time of induction of LSM, the intensity has to be high. Later on, a low to moderate intensity and reinforcement programme may be sufficient. In area of obesity, the maintenance and reinforcement programme is extremely important. In an obesity programme of Evaluation, Education and Empowerment at our centre, 13 subjects were followed for 3-6 months by regular counselling at 1-2 week intervals [Table 1]. At the end of 3-6 months, the average weight loss was 5.2 kg in the group. Not only did the subject lose weight but were able to maintain it for a 27-month period. These subjects further lost an average weight of 3.4 kg at 27 months. This shows that LSM had been adequately adopted by the study subjects. The success could be attributed to intensity and regular reinforcement strategy of the programme.
The frequency of counselling is also an important consideration. At the time of induction, a detailed counselling is important. Thereafter, the reinforcement can occur at 1-3 months intervals for 2-3 years. In a physical activity counselling programme on cardiovascular risk factors in type 2 diabetes, intensive counselling with reinforcement resulted in BMI of 28.9 kg/m¼ in the treatment group when compared to 30 ± 0.2 kg/m 2 in the control group. Most of the studies show that if weight loss is sustained for a 3 year period, the relapses become infrequent. It is expected that a 3-year period will result into a permanently altered behaviour leading to the success of programme.
Counselling should be in a language intelligible to the subject. It is possible to counsel semi literates or illiterates orally, as most subjects are intelligent enough even if illiterate. In one study on type 2 diabetics, who were illiterate or semiliterate, oral nutritional counselling was undertaken in small groups of 3-5 people. This resulted in improved nutritional knowledge and altered behaviour resulting into better glycaemic control. 
| Outcome Measures|| |
It is very important to measure the outcome of a counselling programme. Counsellors often assume that their efforts will be successful in improving knowledge and in turn, metabolic control of counselled group but this may not occur in real life situation. Hence, it is important to validate a counselling programme by testing systematically the knowledge and metabolic control before and after the counselling programme. For example, a few studies have shown that although the knowledge of those counselled improved, it did not translate into an improved metabolic control.  It is heartening to note that most of the studies have shown improvement in knowledge as well as metabolic control. ,,,,, Impact of education is particularly evident in case of foot complications in diabetes.  In another study, foot complications were more frequent in the uneducated group. 
Impact of counselling must be measured to recommend its wider use and make further improvements. Outcomes using the same strategy may produce variable results in different populations. Whenever the strategy is modified, re-testing and re-valuation is required. As a measurement of outcome, cost-benefit analyses need to be made and expressed as the number required to be counselled to save one's life or a vascular episode.
A massive study on 5145 subjects was conducted to compare intensive life-style interventions with standard diabetes support education.  Although the final outcomes are not yet reported, at 1 year intensive intervention group experienced a reduction in cardiovascular risk factor and reduced number of medications. At 4 years, weight loss was 6.15% of body weight in the intensive group and 0.88% of body weight in the controls.
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| Authors|| |