Flourish and Nourish – the story of my PhD journey

Credits: Sven Menschel (menschel applied photographic art)

ONCE UPON A TIME….

Six years ago, there was a young researcher who had the opportunity to develop a salutogenic programme for people with type 2 diabetes. And so she did. That salutogenic programme was named the 'SALUD programme'. This opportunity was made possible by a good fairy: the late WUR researcher Johanna Edema. It was Ms Edema's last wish to use her legacy to inspire a new generation of researchers with her line of research that focused on the question 'why do people eat what they eat'.

ON A MISSION

You may wonder why it is necessary to develop a salutogenic diabetes programme at all. Well, this is needed because there are about 1.2 million people with diabetes in the Netherlands, about 90% of whom have type 2 diabetes. Type 2 diabetes is a disease in which the body no longer responds properly to insulin, leaving too much sugar in the blood. Over time, this can damage nerves and heart and blood vessels. More and more people with type 2 diabetes are being diagnosed. This is because an unhealthy lifestyle and obesity are major risk factors for developing this disease.

Previous research has shown that that the progression of type 2 diabetes can be influenced by lifestyle modifications such as exercise and healthy diet. In fact, healthy diet can be just as effective as diabetes medication; some people can even be completely cured by a strict diet. These are impressive findings, but unfortunately it turns out that in everyday life, people with diabetes find dietary adjustments the most difficult part of diabetes self-care. In addition, we know from systematic reviews and meta-analyses that diets usually don't work for more than a year; after that, people relapse. In other words, the optimal way to support people with diabetes has not yet been discovered. Therefore, the young researcher made it her mission to find out whether an alternative health perspective could help optimise diabetes care.

A NEW PERSPECTIVE

That alternative health perspective is the salutogenic model of health, developed by medical sociologist Antonovsky in the 1970s. The word salutogenesis translates to 'the origin of health'. What is innovative about the salutogenic model is that it focuses on the factors that create and promote health. A salutogenic mode considers a person as a whole, by probing into deeper motivations underlying a (health) behaviour and how this relates to what someone wants to get out of life. Hence, the salutogenic model stimulates behavioural change through an introspective learning process to mobilise a set of health enhancing resources necessary for coping with challenges for healthy eating. Within this model, health is seen as the ability to adapt and take control in the face of life's challenges.

So, the researcher used the salutogenic model of health used as the starting point for the development of the salutogenic diabetes programme called SALUD. The development of SALUD consisted of 3 main steps: a literature review of other diabetes programmes, extensive interviews with people with type 2 diabetes and a large questionnaire survey on the links about mental health and lifestyle. It is important to note that both quantitative and qualitative methods were used in the SALUD development process. The great advantage of combining different research methods is that it helps to better contextualise findings: the different methods enrich each other.

THE PROTAGONISTS

One step of this developmental process deserves to be highlighted: the life course interviews with people with type 2 diabetes. Prior to these interviews, people with type 2 diabetes outlined a timeline of their lives, indicating how their eating behaviour changed over time. During such an interview, the researcher and participant the timeline together. Analysis of these interviews showed that the eating behaviour of people with type 2 diabetes is strongly intertwined with the level of stress and social support a person experiences. It also showed that introspection and reflecting on eating habits are important to engage in healthier eating. Therefore, the main pillars in the SALUD programme became social support from peers and guidance on self-reflection. The emphasis on self-reflection and social support is something that sets SALUD apart from previous diabetes programmes. It is important to stress that salutogenic theory has thus been used as a source of inspiration, but not as a prescription for the interpretation of the SALUD programme. The content and form of SALUD largely determined by the people it really concerns: people with type 2 diabetes. The people with type 2 diabetes are the main protagonists in the thesis.

THE SALUD PROGRAMME

The researcher combined the life stories with the other types of research in the development process. From this, the SALUD programme was born. The SALUD programme consists of 12 weekly group session under supervision on a certified lifestyle coach. During the 12 weeks, SALUD participants set their own health goal and they set to work with small steps that fitted into their daily lives. The approach of the SALUD programme was mainly practical tips on nutrition skills, rather than knowledge transfer. An example of one such assignment was for participants to compile their own cookbook of healthy recipes. The co-creation did not stop after the development process. Even during the programme, participants had a large degree of influence on content of the SALUD programme. This high degree of flexibility in the programme is another point that distinguishes SALUD from previous diabetes programmes.

THE HEALTH EFFECTS

So, the first part of the research journey was co-creating a salutogenic programme. The second part involved determining the health effects of the SALUD programme. And that is quite an ordeal, for which the researcher had to brave the medical ethics committee. Fortunately, this succeeded and with that, the researcher had permission to evaluate SALUD through a randomised controlled trial. This involved dividing a group of people with type 2 diabetes into two subgroups of about 23 people per group. One group followed the SALUD programme and the other group was the control group following normal diabetes care. Both groups were measured at three points in time: baseline, directly after completing the SALUD programme (12 weeks) and three months after finishing the SALUD programma (24 weeks). To get a good overall picture, the researcher also looked qualitatively at the effects of the SALUD programme through focus groups/group discussions.

First the quantitative effect. The results show a positive pattern: the SALUD group consistently outperforms the control group in regards of resilience, food literacy, dietary intake and body weight. The statistical analysis shows that SALUD is statistically significantly better at improving individual resilience. This is an important result because we know from previous research that high resilience is associated with healthy eating and health. The statistical analysis does not reveal whether the positive effects of the other outcomes are actually caused by SALUD. Interestingly, the control group also did very well. That is, the control group also improved in health over the duration of the study: this is not is what you expect. It seems that a kind of placebo effect took place in the control group.

Then, the qualitative effect: the focus groups with SALUD participants showed that all participants found SALUD to be an enjoyable programme. The peer-support from and listening to other participants was the component that participants found the most valuable to start to eat healthier. SALUD was described as a positive and meaningful learning process in which participants discovered new ways to start eating healthier. Participants indicated also that they felt healthier. Several participants emphasised that the programme led to experiencing more control on their health and life.

SALUD: A HAPPY ENDING AFTER ALL?

And then we have come to the end of the research journey. Is it a happy ending after all? On the one hand, yes: The young researcher has succeeded in developing, implementing and evaluating a salutogenic programme for people with type 2 diabetes. Yet, of course, the burning question is now: is SALUD now the redeeming answer for all people with diabetes? No, unfortunately I cannot say that: a longer and larger study is needed to better determine the health effects of SALUD and its long-term effects. At the same time, my PhD thesis also shows how difficult it is to properly evaluate a programme in everyday life.

That being said, these first results of the SALUD do make me very happy: all participants were healthier at the end of the study and very satisfied with the SALUD programme. And that without putting people on a diet. I therefore concluded a number of important issues regarding diabetes care: the importance of making diabetes clients feel seen and heard, a holistic approach to health and well-being, and the importance of social support from peers. It is therefore worth exploring opportunities where salutogenic thinking can be used to further improve current diabetes care.

If you are interested in the more scientific narrative of this research trajectory, you can find my PhD thesis here: Flourish and nourish: Development and evaluation of a salutogenic healthy eating programme for people with type 2 diabetes mellitus — Research@WUR

Kristel Polhuis is a researcher and lecturer at the chair group Health and Society. Her research applies a salutogenic perspective to enable healthful eating among people with Type 2 Diabetes Mellitus. Kristel holds a MSc in Nutrition and Health, obtained at Wageningen University.