Research and Evidence Based Practice critique

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RESEARCH ARTICLE Open Access

“I’ve made this my lifestyle now”: a
prospective qualitative study of motivation
for lifestyle change among people with
newly diagnosed type two diabetes
mellitus
Simon J. Sebire1*, Zoi Toumpakari1, Katrina M. Turner2,3, Ashley R. Cooper1,4, Angie S. Page1,4, Alice Malpass5

and Robert C. Andrews6

  • Abstract
  • Background
  • : Diagnosis with Type 2 Diabetes is an opportunity for individuals to change their physical activity and
    dietary behaviours. Diabetes treatment guidelines recommend theory-based, patient-centred care and advocate the
    provision of support for patient motivation but the motivational experiences of people newly diagnosed with
    diabetes have not been well studied. Framed in self-determination theory, this study aimed to qualitatively explore
    how this patient group articulate and experience different types of motivation when attempting lifestyle change.

  • Methods
  • : A secondary analysis of semi-structured interview data collected with 30 (n female = 18, n male = 12)
    adults who had been newly diagnosed with type two diabetes and were participants in the Early ACTID trial was
    undertaken. Deductive directed content analysis was performed using NVivo V10 and researcher triangulation to
    identify and describe patient experiences and narratives that reflected the motivation types outlined in self-
    determination theory and if/how these changed over time.

  • Results
  • : The findings revealed the diversity in motivation quality both between and within individuals over
    time and that patients with newly-diagnosed diabetes have multifaceted often competing motivations for
    lifestyle behaviour change. Applying self-determination theory, we identified that many participants reported
    relatively dominant controlled motivation to comply with lifestyle recommendations, avoid their non-compliance
    being “found out” or supress guilt following lapses in behaviour change attempts. Such narratives were accompanied
    by experiences of frustrating slow behaviour change progress. More autonomous motivation was expressed as
    something often achieved over time and reflected goals to improve health, quality of life or family time.
    Motivational internalisation was evident and some participants had integrated their behaviour change to a
    new way of life which they found resilient to common barriers.

  • Conclusions
  • : Motivation for lifestyle change following diagnosis with type two diabetes is complex and can
    be relatively low in self-determination. To achieve the patient empowerment aspirations of current national
    health care plans, intervention developers, and clinicians would do well to consider the quality not just quantity of their
    patients’ motivation.

    Trial registration: ISRCTN ISRCTN92162869. Retrospectively registered

    Keywords: Type 2 diabetes, Motivation, Behaviour change, Intervention, Qualitative

    * Correspondence: simon.sebire@bristol.ac.uk
    1Centre for Exercise, Nutrition & Health Sciences, School for Policy Studies,
    University of Bristol, 8 Priory Road, Bristol BS8 1TZ, UK
    Full list of author information is available at the end of the article

    © The Author(s). 2018 Open Access This article is distributed under the terms of the Creative Commons Attribution 4.0
    International License (http://creativecommons.org/licenses/by/4.0/), which permits unrestricted use, distribution, and
    reproduction in any medium, provided you give appropriate credit to the original author(s) and the source, provide a link to
    the Creative Commons license, and indicate if changes were made. The Creative Commons Public Domain Dedication waiver
    (http://creativecommons.org/publicdomain/zero/1.0/) applies to the data made available in this article, unless otherwise stated.

    Sebire et al. BMC Public Health (2018) 18:204
    DOI 10.1186/s12889-018-5114-5

    http://crossmark.crossref.org/dialog/?doi=10.1186/s12889-018-5114-5&domain=pdf

    http://www.isrctn.com/ISRCTN92162869

    mailto:simon.sebire@bristol.ac.uk

    http://creativecommons.org/licenses/by/4.0/

    http://creativecommons.org/publicdomain/zero/1.0/

    Background
    Patient empowerment is a cornerstone of contemporary
    medicine and is central to national health care plans [1].
    Individuals are increasingly encouraged, with support
    from professionals, to manage their own health. For this
    approach to be effective, a detailed understanding of
    how patients experience regulating their behaviour when
    they initiate and attempt to sustain health behaviour
    change is needed.
    Approximately 6% of the adult population in England

    have diabetes, 90% are cases of Type 2 Diabetes Mellitus
    (T2DM) and the prevalence of T2DM is rising [2]. The
    burden of T2DM on individuals’ health (i.e., increased
    risk of cardiovascular disease, amputation, kidney dis-
    ease, retinopathy and depression) and the economy are
    well documented and preventing, managing and treating
    diabetes are public health priorities [2].
    The point of diagnosis with T2DM is an opportunity

    for clinicians to help patients initiate changes in lifestyle
    behaviours such as physical activity and diet [3]. Guide-
    lines for the care of adults with T2DM build on a foun-
    dation of patient-centred care, and advocate the
    provision of theory-based patient education at, or soon
    after diagnosis to create personalised management plans,
    combining advice on diet, increasing physical activity
    and losing weight [3]. It is also suggested that patients
    try to improve their diet and increase their physical
    activity for 3 months before starting medication [4]. Re-
    lated guidance (e.g., National Institute for Health and
    Care Excellence) on changing lifestyle behaviours such
    as physical activity suggests a range of techniques to mo-
    tivate and support individual-level change including
    helping patients understand the consequences of their
    health-related behaviour, goal setting, and devising cop-
    ing strategies to prevent relapse [5]. However, despite
    this potentially complementary dual focus on patient
    self-regulation and motivation, current guidelines do not
    consider the degree to which patients’ motivation for
    lifestyle change itself is or is not self-regulated.
    Recently Fisher et al. [6] have stated that the efficacy

    of diabetes-directed interventions “is often dependent
    upon on how well a clinician is able to support personal
    engagement and motivation of the person with diabetes
    to use these new tools and knowledge consistently, and
    as directed”. Self-determination theory (SDT) [7] is a
    psychological framework of motivational self-regulation
    that has been extensively applied to physical activity [8],
    diet [9], medication adherence [10] and diabetes control
    interventions [11–13]. Rather than considering only the
    quantity of people’s motivation (i.e., motivated vs. not
    motivated) as in previous work with patients with
    T2DM [14], within SDT, the quality of motivation is
    considered based on the extent to which it is self-
    regulated [15].

    Within SDT (Table 1), the most self-determined form
    of motivation is intrinsic motivation, where behaviour is
    driven by interest, enjoyment or the satisfaction that it
    brings. Types of motivation that are not intrinsic but
    based on tangible consequences or outcomes can vary in
    their level of autonomy/self-regulation. The most
    autonomous form (integrated motivation) is where
    motivation is derived from an alignment of the out-
    comes of a given behaviour (e.g., healthy eating) with a
    person’s broader sense of self, values or goals. Less self-
    determined, but still considered autonomous, is identi-
    fied motivation which is based on personally important
    or valued benefits of an activity (e.g., valued health or
    social benefits of being active). Introjected motivation is
    a form of controlled motivation where self-imposed
    sanctions such as avoiding guilt or gaining contingent
    self-esteem drive behaviour whereas external motivation
    represents motivation based on a desire to comply with
    external demands or requests, avoid punishments or to
    gain rewards. Finally, amotivation represents an absence
    of motivation or intention to act. The dynamic process
    (although not necessarily linear) through which individ-
    uals’ progress from less to more self-regulation/autono-
    mous motivation is called internalisation [15].
    Research amongst people with T2DM has shown that

    autonomous motivation is positively associated with life-
    style behaviours such as physical activity [16], dietary
    self-care [17, 18], medication adherence [13], key media-
    tors of behaviour change (e.g., action planning) [18] and
    sustained improvement in physical health including dia-
    betes control [12]. There is also some evidence that con-
    trolled motivation (e.g., pressure to comply with advice
    or change ones behaviour to please others or to suppress
    feelings of guilt) is associated with improved dietary self-
    care amongst people with newly-diagnosed T2DM [19].
    Together, this evidence highlights the beneficial out-
    comes associated with autonomous motivation but also
    that controlled motivation may play a role in the lifestyle
    changes of people with newly diagnosed diabetes. This is
    not surprising given that upon diagnosis, patients com-
    monly receive information (e.g., identifying previous life-
    style behaviours that may have contributed to diabetes,
    possible future health complications, the lifestyle change
    needed to manage their symptoms, and weight and
    blood glucose targets to meet); interactions that have the
    potential to trigger either autonomous (e.g., identifying
    personally important reasons for change) or controlled
    (e.g., feeling guilty or pressured) motivation for change.
    The majority of previous research has studied motiv-

    ation amongst people with T2DM using quantitative
    questionnaires and existing qualitative research has only
    identified motivational factors such as weight manage-
    ment and physical and mental well-being as motivating
    physical activity among people at risk of diabetes [20].

    Sebire et al. BMC Public Health (2018) 18:204 Page 2 of 10

    Despite calls from researchers [21], the quality of the
    motivation of people who are in early phases of initiating
    behaviour change following a diagnosis of diabetes has
    not been studied from the patients’ perspective. It is im-
    portant to address this gap because understanding peo-
    ple’s motivational experiences at critical times of
    behaviour change can inform the design of patient-
    centred lifestyle interventions or care.
    The present study aimed to: (1) qualitatively explore

    how people newly diagnosed with T2DM articulate and
    experience motivation for lifestyle change as proposed in
    SDT, and (2) to examine qualitative evidence for pa-
    tients’ motivational internalisation over time (i.e., transi-
    tion from controlled to autonomous motivation).

    Methods
    Study design
    A secondary analysis of interview data collected with in-
    dividuals who had been newly diagnosed with T2DM
    and were participants in the Early ACTID (Early ACTiv-
    ity In Diabetes) trial.

    The early ACTID trial
    Early ACTID was a lifestyle RCT, conducted between
    December 2005 and September 2009, at three sites in
    South West England, involving 593 adults aged between
    30 and 80 years old who had received a diagnosis of
    T2DM within the previous 6 months [22]. Patients were
    recruited through GP practices and randomised to three
    arms; usual care (UC), intensive dietary advice (ID), or
    an intensive dietary advice and physical activity interven-
    tion (DPAI). Usual care comprised the provision of
    standard advice from a dietician at a baseline appoint-
    ment, followed by two visits to a doctor blinded to treat-
    ment allocation at 6 and 12 months post-randomisation.
    The ID arm comprised UC plus 15 20-min appoint-
    ments with a nurse or dietician for 12 months following
    randomisation where patients were encouraged to
    achieve a daily intake reduction of 500 Kcal and 5 to
    10% loss of initial weight over 12-months. In addition to
    receiving UC and the ID intervention, patients in the

    DPAI arm were encouraged to increase their physical ac-
    tivity to at least 30 min of brisk walking on 5 days/week.
    The ID and DPAI interventions were not based on SDT
    or other psychological theory, however behaviour change
    techniques included; information provision, setting and
    negotiating achievable physical activity and/or eating
    behaviour and weight loss goals, weighing at appoint-
    ments, barrier identification and assistance to overcome
    them, encouragement to self-monitor weight, comple-
    tion of food and or/physical activity diaries and wearing
    a pedometer.

    Interviewee recruitment
    At their baseline appointment, each participant was
    given information about the qualitative study and asked
    to consent to being approached to take part in an inter-
    view. Consenting individuals were purposefully sampled
    to ensure interviews were held with participants in each
    trial arm, with men and women of varying ages, and
    from the different trial sites. No relationship was estab-
    lished with participants before interview.

    Data collection
    The aim of the original ACTID qualitative study was to
    explore how patients recently diagnosed with T2DM ex-
    perience and manage their condition as well as monitor-
    ing implementation and identifying improvements to the
    intervention. Thirty patients (n female = 18) were inter-
    viewed, comprising 6 from the UC arm (n female = 3),
    12 from the ID arm (n female = 8) and 12 (n female = 7)
    from the DPAI arm. Participants were aged between 40
    and 72 years. Semi-structured interviews were con-
    ducted (by AM) at 6-months (face-to-face interview)
    and 9-months (telephone interview) post-randomisation.
    The 6-month interview was timed so as not to influence
    participants’ experience of the initial intervention stages.
    By 9-months participants had received the majority of
    intervention and sufficient time to make lifestyle
    changes following diagnosis and inclusion in the trial.
    The 6 month interview covered topics including re-

    sponse to diagnosis, use of the information, behavioural

    Table 1 Types of motivation along the Self-determination Theory continuum and diet/physical activity examples

    Amotivation Extrinsic Motivation Intrinsic motivation

    Controlled regulations Autonomous regulation

    Non-regulation External Regulation Introjected Regulation Identified
    Regulation

    Integrated
    Regulation

    Intrinsic
    Regulation

    Motivation type
    description

    Lack of motivation
    or intention to act

    Lifestyle behaviour
    change is to avoid
    punishment or gain
    a reward

    Lifestyle change aims
    at avoiding guilt or
    enhancing self-worth

    Lifestyle changes
    are personally
    important or
    valued

    Lifestyle behaviours
    are in harmony with
    other personal values
    and goals

    Lifestyle behaviours
    are enjoyable
    or inherently
    satisfying to do

    Diet / physical
    activity example

    Not changing one’s
    lifestyle behaviours
    or passively going
    through the motions

    Eating less
    confectionary to
    avoid being told
    off by a dietician

    Exercising because
    one feels they should,
    and will feel guilty if
    one doesn’t

    Maintaining one’s
    physical fitness is
    a personally
    important goal

    Eating a healthily is
    consistent with one’s
    goals to be physically
    active

    Trying out new
    healthy recipes is
    satisfying and fun

    Sebire et al. BMC Public Health (2018) 18:204 Page 3 of 10

    changes and relationship with the clinical team [23]. The
    9 month interview covered topics including diet and/or
    exercise changes, maintaining change, barriers, coping
    with reduce appointment frequency and the trial ending.
    Neither the interview guide nor the interviews them-
    selves were based on SDT, although the topic of motiv-
    ation for change was discussed in depth. Within the
    original data collection team, KM and AM discussed
    themes and data saturation pertaining to the research
    questions. At the time, this was felt to have been
    reached. The 6 month (n = 30) and 9 month (n = 29,
    one participant did not participate in a 9 month inter-
    view) interviews were, on average, 90 and 15 min in dur-
    ation respectively. Interview audio recordings were
    transcribed verbatim. Ethical approval was given by the
    Bath Research Ethics Committee (05/Q2001/5).

    Data analysis
    The analysis combined both supra (i.e., by answering a
    new theoretical question) and supplementary (i.e., a
    more in depth investigation of motivation themes which
    were not addressed fully in the primary study) secondary
    qualitative analysis [24]. Initial analysis involving three
    of the authors indicated that there were sufficient ac-
    counts to explore the quality of participants’ motivation.
    All available data were analysed using directed content
    analysis which is appropriate where an existing theory
    can guide research questions and initial theory-based
    themes and can be supported, challenged or extended
    [25]. Analysis was primarily deductive and sought to
    identify patient experiences and narratives that reflected
    the motivation types outlined in Table 1. Further, a
    within-participant analysis probed for evidence of motiv-
    ational internalisation between the 6 and 9 month inter-
    views. Alongside the deductive analysis, coding was
    flexible to allow participants’ narratives and personal
    context to guide the complexity of themes and new
    themes to emerge.
    Transcripts were loaded to NVivo software (QSR

    International Pty Ltd. Version 10, 2012) to enable coding
    of the data and to facilitate the organisation of codes
    into themes and subthemes. Coding was undertaken by
    two researchers (ZT & SJS) who had experience of
    studying SDT. Both began by coding the same three
    transcripts, discussing their initial interpretations/codes
    and then refining the initial coding frame (i.e., new codes
    being added and existing codes being deleted/refined).
    The coding frame was then applied to another five
    transcripts, further refined and agreed and then applied
    to the remaining 52 transcripts which were divided
    equally between ZT and SJS. Researcher triangulation
    was undertaken via independent coding of transcripts
    and regular meetings to discuss code refinements and

    emergent themes. The researchers agreed that the
    quotes presented were representative of the themes.

    Results
    The results are presented as six themes reflecting the
    motivation types in SDT (See Table 1) with narratives
    reflecting internalisation (or the lack of) integrated
    alongside each motivation type. Participant gender,
    trial arm allocation (ID: Intensive Dietary Advice,
    DPAI: Intensive Dietary Advice & Physical Activity, &
    UC: Usual Care) and interview time point are shown
    for each quote.

    Amotivation
    Some participants were reluctant to change and articu-
    lated a passivity towards any changes they reported. Ig-
    noring one’s diabetes, feeling helpless, not able to
    change or resigned to one’s current way of life and not
    believing the health benefits of recommended treatments
    were also common:

    … the other tablets I take is all in the morning, this
    one is at night, then one night I forget, then the next
    night I forget and I can’t be bothered taking these
    because I don’t think – I can’t believe tablets would
    do [me any good] – you know? (Mo, male, DPAI, 6
    months)

    Some participants felt helpless: “At 66 I’m hardly …
    going to change very much” (Ronny, male, ID, 6 months)
    and others reported acting against advice that was not in
    line with a “good life”, deceiving their health practi-
    tioners to appear compliant:

    Well they don’t know I’m not doing anything, I’m
    living a good life and being a good boy. [laughs] I don’t
    tell ‘em, I’m back on scones, they just say “how’s your
    diet?” And I say “okay”. (James, male, UC, 6 months)

    Three months later, James had not changed his motiv-
    ation or diet:

    Well I never hardly made any [diet changes], only cut
    out me scones and Rich Tea biscuits, that’s all I’ve
    done, but that’s gone by the board [been abandoned]
    the last few months, mind. (James, male, UC, 9 months)

    External motivation
    The majority of the participants referred to their motiv-
    ation being controlled by external sources when first
    changing behaviour post-diagnosis. Participants felt re-
    stricted in what they were “allowed to eat” (Frank, male,
    UC, 6 months) or the exercise that they “have to” do

    Sebire et al. BMC Public Health (2018) 18:204 Page 4 of 10

    (Nina, female, DPAI, 6 months), found the changes
    unenjoyable, and a threat to their quality of life. Ex-
    ternal motivation was commonly interpreted from
    narratives about patient compliance with the Early
    ACTID health practitioners’ recommendations or
    goals to avoid negative outcomes (such as increasing
    medication).

    I can use those [books] for reference for restricting
    carbohydrate intake, which I’m trying to do at the
    moment. It’s the latest aim of my – or goal of my
    dietician. And that way I can hopefully reduce these
    glucose levels a bit more … I don’t want to get a third
    tablet a day, that’s what I’m trying to avoid. (Stuart,
    Male, ID, 6 months)

    Some participants’ behaviours were motivated
    by wanting to demonstrate that they had been
    “behaving” between appointments, completing be-
    haviour change activities such as diet diaries, and
    a fear that non-compliance would be identified by
    measurements:

    Knowing that I’m going to see [practitioner] every so
    often … part of me says “well you’ve got to behave
    yourself girl because you’re going to be going and
    seeing them, and they’ll know if you haven’t been
    behaving yourself, your weight and your levels and
    everything else” (Wendy, Female, ID, 9 months)

    Narratives rich in external motivation coincided with
    reports of challenges to behaviour change and disap-
    pointment when effort was not rewarded with the de-
    sired outcomes such as weight loss:

    So we’re there cutting, cutting, cutting, and doing
    everything they say and the weight doesn’t come off, ‘oh
    you’ve got to get your output up’, so my output is now
    up, the weight is not coming off, you know? (Hugh,
    Male, DPAI, 6 months)

    The majority of participants who articulated exter-
    nal motivation at 6 months, appeared to remain con-
    trolled by external sources 3 months later. During
    their second interview their low enjoyment of lifestyle
    changes persisted, and they reported challenges, lapses
    and slow progress towards change that they did not
    feel in control of:

    Things have just gone on like a slow train without any
    stations. (Rose, Female, DPAI, 9 months)

    Participants (in all trial arms) were commonly con-
    cerned about losing the professional support when the

    intervention ended that provided them with motivation
    they needed to sustain change.

    Through not seeing [practitioner] so much,
    no one is on top of me, keeping … I am like
    a little boy really, I suppose, I need somebody
    to give me a kick up the backside … and I
    know it’s coming to an end now as well, so I’m
    getting a little bit lax I think. (Mo, male, DPAI,
    9 months)

    Introjected motivation
    Motivation based on personal pressures such as
    avoiding guilt were commonly rooted in partially-
    internalised lifestyle advice. Participants’ understood
    the reasons for lifestyle change but appeared relatively
    controlled by these reasons rather than describing
    them as personally valued. Participants commonly re-
    ported introjected exercise motivation to burn calories
    consumed during dietary lapses:

    Admittedly if I’ve eaten something that I know I
    shouldn’t have and I haven’t yet exercised, I’m more
    determined to go and exercise then, because … I’ve got
    to get rid of that, I’ve got to burn it off. (Wendy,
    Female, ID, 9 months)

    Similarly, introjected motivation was common where
    participants had hung their self-worth on successful be-
    haviour change but not achieved it. They judged their
    behaviour as “wrong” versus right and themselves as
    “naughty”, “stupid” or at “fault”.

    I’m going to be good and go back on my diet, it’s
    entirely my fault because I know the rights and the
    wrongs and the dos and the don’t dos … it was also
    summer and barbeques and I just think I’d been very
    naughty and stupid and allowed this to happen, but
    I do see the dietician on Thursday, so it is entirely my
    own fault. (Diana, female, DPAI, 9 months)

    Showing the interplay between external and intro-
    jected motivation over time, at 6 months Clive (Male,
    DPAI) was motivated by the reward of preventing a
    worsening of his diabetes but viewed certain dietary
    changes as punishment:

    I’m very motivated by rewards if you like, and I
    consider the reward for not doing that is my
    diabetes not getting any worse, and if I can hold it
    at that, then I’ll punish myself with other things,
    such as giving up sugars and sweets (Clive, Male,
    DPAI, 6 months)

    Sebire et al. BMC Public Health (2018) 18:204 Page 5 of 10

    Three months later, Clive’s diabetes had worsened, he
    had been prescribed medication to improve his blood
    sugar control and felt guilty for not having made
    changes sooner. He now felt internal pressure to adopt
    the lifestyle advice “more seriously”.

    I was cursing myself for not giving it [unhealthy
    food] all up and trying to keep on the diet rather
    than have to go onto tablets … I’ve still left myself
    subject to eat some sweet things a week, and had
    I known that it would take me out of the diet
    side onto tablets I would have made even more
    effort I think … So yeah, I really must settle down
    with these tablets – and take it a little bit more
    seriously than I have done. (Clive, Male, DPAI, 9
    months)

    Identified motivation
    At diagnosis, all participants had been informed of the
    potential health implications of diabetes and the benefits
    of lifestyle changes for glucose control. It was therefore
    unsurprising that many referred to valuing the experi-
    enced or anticipated health benefits of diet or physical
    activity changes including feeling fitter, healthier, im-
    proved quality of life and well-being. Others identified
    with maintaining their health in order to spend time
    with family and/or fulfil caring responsibilities:

    (I) don’t want to go blind, I don’t want my legs chopped
    off and I’d like to live a bit longer. [laughs] And I’ve got
    a family to look after. It’s all that sort of stuff. So I want
    to stay as healthy as I can for as long as I can,
    preferably with as little medication as I can. (Pete,
    Male, DPAI, 6 months)

    Like Pete, many participants reported identified motiv-
    ation based on the importance they placed on avoiding
    deleterious health consequences of diabetes. While this
    form of motivation was initially an external motivation,
    and accompanied for some by fear of the consequences
    of not changing, many participants had internalised the
    health threat to become a personally valued outcome of
    change. Commonly, these motivations were based on
    participants wanting to avoid the ill health experienced
    by their relatives or friends:

    Knowing how my mother went with her diabetes and
    the fact that before she died she could only just about
    see, I thought “well I don’t want that happening to
    me”. (Monica, female, UC, 6 months)

    Further, the personal importance placed on avoiding ill
    health was accompanied by participants taking responsibility

    for change, following advice and wanting to avoid future
    feelings of shame associated with not changing:

    I don’t want it [heart problems] to happen to me
    because I’m not following recommended lines. If it
    happened to me for any other reason then that’s
    something that I probably can’t control, but if there
    is something that I can contribute to stop it happening
    then I will do so. (Robert, male, UC, 6 months)

    For some participants, their diagnosis with diabetes
    provided “a stronger motivation that is bigger than the
    other motivations for not doing it” (Alice, Female, ID,
    6 months). This was in contrast to their previous, less
    effective appearance-based motivations for dieting:

    That’s what I was like with my diets, I [would] not-
    stick to them, because – well you don’t think there’s
    any health reason why you should stick to this thing
    apart from vanity with slimming. But as soon as
    you’re told you’re diabetic, it’s in your best interests to
    get that weight off and stick to a healthy diet. So I
    suppose in a roundabout way that complication helps
    you another way, and then I feel much better now for
    that. (Mary, female, DPAI, 6 months)

    Participants carried their identified motivation from 6
    to 9 months but also expressed their need for continued
    collaborative professional or social support to help them
    monitor their diabetes and/or support their motivation:

    I am frightened of it [Early ACTID] ending. I
    would like to be monitored by experts, but I
    don’t think they are experts at my surgery … if
    I was monitored regularly like I am now, I would
    know that it was the diabetes that I allowed to
    get out of control and I’ll do something about it.
    Without knowing I’m very worried. (Frank, Male,
    UC, 9 months)

    Integrated motivation
    Some participants described how over time their lifestyle
    behaviours had become motivated by forming a new pat-
    tern, routine, or a way of life. Many of these statements
    were articulated at the 6 month interviews suggesting
    that some participants had internalised the motivation
    for lifestyle change relatively quickly after diagnosis:

    I think I’ve entered now into a pattern and a way of
    life (Jill, female, DPAI, 6 months).

    Many narratives like this reflected an internalisation
    process whereby participants’ motivation was initially

    Sebire et al. BMC Public Health (2018) 18:204 Page 6 of 10

    controlled but over time aligned lifestyle recommenda-
    tions with their perception of a good quality of life:

    Obviously it’s becoming a way of life now, what I’m
    doing, it’s becoming a way of life, and I don’t think
    about it so much. The first few months I did, I thought
    “I mustn’t do this, I mustn’t do that”, and [practitioner]
    said “I think you’re being a bit hard on yourself here,
    you’re being a bit too strict and you won’t keep it up”.
    But now I’m settled into a very comfortable way of life
    with it. (Nora, female, ID, 6 months)

  • References
  • to behavioural habits, viewing exercise or
    healthy eating as a personal characteristic, and flexible
    resilience to challenges such as dietary lapses or bad
    weather were common alongside integrated motivation:

    I’ve made this my lifestyle now, my exercise, it’s just
    such a routine now that I get up, I have my breakfast
    and I go out, and I just do it really. If it’s raining I go,
    if it’s absolutely lashing I might wait and say “I’ll go
    this afternoon”, but very rarely do I miss. (Penny,
    Female, ID, 9 months)

    Personal characteristics that supported internalisation
    of lifestyle changes included listening to advice from
    practitioners, taking responsibility for change, being
    positive, and persistent. Participants also referred to
    making gradual changes, perceiving that the time was
    right for change and balancing their new and more
    established lifestyle components (e.g., social life)

    Systematically [it] becomes part of your life … I try in
    life not to make a hard life any harder, just try and
    make it easy by getting to grips with this, listening to
    what you’re told and being positive about this. (Nora,
    female, ID, 6 months)

    Intrinsic motivation
    Several participants reported enjoying their new way of
    eating or the relaxation and satisfaction brought about
    by exercise:

    The exercise now has become so much a part of my life
    that I don’t think about it as the fact that I must do it as a
    chore, I do it because I enjoy it, I go out, the hour walking
    sorts the brain out for the day, its relaxing, sometimes I’m
    out and I’m back before I’ve gone, before I realise [laughs].
    Yes, I enjoy it. (Penny, Female, ID, 6 months)

    Intrinsic motivation was sometimes supported by
    identified and introjected motivations at the moment of
    deciding to exercise:

    Some days I have to make myself do it, but I always
    feel better when I come back. I always feel I’ve got
    more energy, and more get up and go when I’ve been.
    It sounds daft don’t it- it’s almost like somebody strikes
    match and you do it and then you come back. (Sylvia,
    female, DPAI, 6 months)

    Robert demonstrated internalisation where his motiv-
    ation transitioned from eating to follow recommenda-
    tions to a combination of integrated (his eating “style
    has changed”) and intrinsic motivation (he now enjoys
    different foods). He thought that it was important to be
    motivated by enjoyment rather than pressure.

    When you see somebody alongside you with a
    meal that you like but you can’t have, I don’t find
    it envious anymore that they are eating something
    I would like to have eaten, my style has changed,
    I now enjoy a different type of food, but the
    important thing is I enjoy it, it’s not simply because
    I know that that’s what I’ve got to eat. (Robert,
    male, UC, 6 months)

  • Discussion
  • This study is the first qualitative examination of the
    types of motivation for lifestyle change articulated in
    SDT amongst people newly diagnosed with T2DM. As
    the participants were involved in a lifestyle intervention,
    it could be argued that almost all had some motivation
    to change, but despite this, the findings highlight the di-
    versity in motivation quality both between and within
    participants. The prospective data facilitated an analysis
    of motivation transitions.
    Diagnosis with T2DM provokes a range of emotional

    responses [26], close scrutiny of patients’ lifestyle, threats
    to people’s social and personal identity and the need to
    construct a new identity representations [27]. It is not
    surprising therefore that many participants’ motivation
    for change was controlled, or not self-regulated. External
    motivation for diet or physical activity change was expe-
    rienced as participants complying with what they per-
    ceived to be restrictive dietary advice and through fear
    of non-compliance (i.e., “lapses”) being identified in ap-
    pointments or assessments. On the SDT continuum
    (Table 1) external and introjected motivation are located
    adjacently and in the theory, motivation is viewed as dy-
    namic rather than static [15]. This was supported in our
    findings as participants often experienced these motiva-
    tions concurrently, by complying with recommendations
    and labelling themselves as “good” or “naughty” and
    their behaviour as “right” or “wrong” based on the extent
    to which their behaviour change was successful. Consist-
    ent with previous research with exercisers pursuing

    Sebire et al. BMC Public Health (2018) 18:204 Page 7 of 10

    extrinsic (relatively controlling) goals [28], participants
    whose motivation was relatively controlled experienced
    frustrating slow progress towards rigidly defined end
    point goals (e.g., weight loss). These experiences of con-
    trolled motivation amongst people with newly diagnosed
    T2DM are a source of internal conflict and potential
    barriers to their development of self-regulation.
    Previous work has shown that autonomous motivation

    is associated with physical activity and healthy eating [8,
    9]. Identified motivation (i.e., personally important valu-
    ing of a behaviour) mainly stemmed from the value par-
    ticipants placed on health, quality of life and family
    responsibilities which they understood to be compro-
    mised by uncontrolled diabetes. Improved health is an
    intrinsic goal [29] which, relative to extrinsic goals, such
    as improved appearance, is associated with autonomous
    motivation and physical activity behaviour [30, 31]. The
    results add experiential support to this finding as for
    some participants health-based reasons for change,
    prompted by their T2DM diagnosis, were more motivat-
    ing than their previous extrinsic appearance-based
    weight loss goals. Diabetes diagnosis may offer an oppor-
    tunity to help individuals identify meaningful intrinsic
    goals (e.g., health or family time) which will likely under-
    pin autonomous motivation.
    Despite the participants being relatively newly diagnosed

    with T2DM some reported integrated motivation (i.e., phys-
    ical activity or healthy eating being part of their identity),
    which plays an important role in motivating diet [9] and
    physical activity [32]. Having internalised early controlled
    motivations (i.e., moved from controlled to autonomous
    motivation), participants’ new lifestyle had become a pat-
    tern or a way of life which was robust to challenges. Inte-
    grated motivation developed over time and internalisation
    was supported by personal factors such as a positive atti-
    tude, resilience to barriers (e.g., bad weather), persistence
    and practitioners who encouraged gradual change.
    Intrinsic motivation (i.e., being motivated by enjoy-

    ment, interest and satisfaction) was articulated least fre-
    quently, although some participants enjoyed their
    exercise and diet changes and this was commonly sup-
    ported by integrated motivation. It is to be expected that
    new physical activity and eating behaviours may not yet
    be intrinsically motivated in a sample such as ours, and
    it is possible that for some patients, or for some behav-
    iours (e.g., cutting down on high sugar foods) which pa-
    tients find enjoyable, identified motivation for change
    (i.e., identifying a health-based value) may be a more
    realistic and adequate motivational target. Indeed it is
    suggested that maintenance of lifestyle behaviours, such
    as exercise, is most likely when a person has a combin-
    ation of intrinsic, identified and integrated motivation
    types [33]. Collectively, the findings suggest that if
    T2DM patients can be supported to internalise their

    motivation to the point of identifying a personal benefit,
    or integrate changes as part of an enjoyable way of life,
    such changes may be more sustainable and resilient to
    common challenges to behaviour change (e.g., lack of
    time, periods of holiday, & changes in routine).
    Recent quantitative research using SDT has sought to

    identify how different types of motivation for physical
    activity commonly cluster within individuals [21, 32, 34].
    Amongst adults with T2DM, Gourlan et al. [21] identi-
    fied a “self-determined” profile (high scores on autono-
    mous motivation types), a “moderate” profile (all
    motivation types moderately endorsed), and a “high
    combined” profile (all motivation types strongly en-
    dorsed plus moderate amotivation). Our findings add
    further experiential evidence to support the existence of
    these multifaceted motivation profiles which commonly
    include both autonomous and controlled motivation.
    For example, amongst patients who reported largely
    identified and intrinsic motivation, low-level controlled
    motivation (often introjected) supported their mainten-
    ance of behaviour change at times. Together, the find-
    ings support calls for future research to take a theory-
    driven person- rather than variable-centred approach to
    understanding motivation [35] and indicate that mixed-
    methods approaches may be particularly illuminating.
    Largely regardless of their dominant motivation, par-

    ticipants articulated a need for structure in their care,
    commonly through provision of expert guidance and
    support. However, the nature of the structure sought dif-
    fered depending on participants’ motivation. Specifically,
    participants mainly motivated by autonomous reasons
    sought support for their ongoing self-regulation (with
    particular interest in ongoing assessment of health out-
    comes), whereas participants mainly motivated by con-
    trolled reasons sought more continuous provision of
    motivation (i.e., being pushed or prompted) by a practi-
    tioner, family member or friend with references to pater-
    nalistic perspectives (e.g., “like a little boy”). The
    provision of structure is a cornerstone of autonomy-
    supportive clinical/interpersonal interactions, which aim
    to facilitate patients’ autonomous motivation and com-
    petence [36]. This study highlights the importance of
    considering the long term provision of support/structure
    for people newly diagnosed with T2DM for two reasons;
    first, the transition from controlled to autonomous mo-
    tivation can take time, and ongoing continuity in expert
    support can create a space to facilitate patients’ internal-
    isation, and second, it is clear that even participants who
    were relatively self-regulated did not want to be left on
    their own, rather they wanted professional support to
    “keep on track”. Our findings therefore support the dis-
    tinction drawn in SDT between the provision of
    autonomy-support (i.e., support for self-regulation) and
    independence (i.e., being left to fend for oneself).

    Sebire et al. BMC Public Health (2018) 18:204 Page 8 of 10

    The findings of this study suggest that to achieve the
    patient empowerment aspirations of current national
    health care plans [1], clinicians would do well to con-
    sider the quality not just quantity of their patients’ mo-
    tivation. Research suggests that physicians may not
    know whether their T2DM patients are motivated to
    change or not and recommend the regular measurement
    of patient motivation [14]. While our findings support a
    greater focus on patient motivation, we would argue that
    considering the quality of motivation is of primary im-
    portance. Our findings complement a recent framework
    for supporting engagement and motivation for behaviour
    change in people with diabetes which draws on multiple
    patient-centred approaches including SDT [6]. This
    framework provides clinicians with a pragmatic, three-
    step approach to building a supportive clinician-patient
    relationship. Our findings support this work by document-
    ing patient motivational experiences in line with the
    framework’s underpinning theory that clinicians will likely
    experience in conversations with patients about behaviour
    change. Previous work has identified how concepts from
    SDT could be integrated into medical training [37] which
    would help clinicians become attuned to patients’ motiv-
    ation quality and support patients’ motivational needs.

    Strengths and limitations
    The qualitative data provided a rich person-centred re-
    source with which we were able to extend previous
    variable-centred quantitative literature. The sample size
    was relatively large and the initial interviews were exten-
    sive. The repeated interviews helped us hear personal
    experiences of the dynamic nature of behaviour change
    and motivation. Despite these strengths, the follow-up
    interviews were shorter (although the transcripts sug-
    gested that discussions were detailed) and although there
    can be strength in not basing interviews on theory, more
    theory-driven follow up interviews would have allowed a
    more in-depth analysis of motivation change. Finally,
    while we have reported our secondary analysis methods
    transparently and used researcher triangulation to agree
    our interpretations, due to the lapse between data collec-
    tion and the analysis, it was not possible to use other
    strategies, such as member checking.

    Conclusions
    Understanding T2DM patients’ motivation for lifestyle be-
    haviour change is considered central to successful patient-
    centred care [6]. Combining qualitative methods with
    SDT, we have identified the diverse motivational experi-
    ences of people newly diagnosed with T2DM. Participants
    who reported relatively dominant controlled motivation
    experienced initial behaviour change but this was often
    accompanied by internal conflict, frustration and a need
    for continual external prompting. Participants’ reporting

    more autonomous motivation approached behaviour
    change with more flexibility had integrated it in to a new
    way of life and wanted ongoing support for their self-
    regulation. The findings highlight the importance of un-
    derstanding the quality of motivation in this group and
    carefully considering the types of motivation that are tar-
    geted in lifestyle interventions for people with T2DM.

  • Abbreviations
  • DPAI: Dietary advice and physical activity; HbA1c: Glycated haemoglobin
    (A1c); ID: Intensive dietary advice; SDT: Self-determination theory;
    T2DM: Type 2 diabetes mellitus; UC: Usual care

    Acknowledgements
    Not applicable.

  • Ethical approval and consent to participate
  • Ethical approval for the Early-ACTID study was given by the Bath Research
    Ethics Committee (05/Q2001/5) and all participants provided consent to the
    Early-ACTID study and additionally to be interviewed.

  • Funding
  • This study was supported by the NIHR Biomedical Research Centre at the
    University Hospitals Bristol NHS Foundation Trust and the University of
    Bristol. The views expressed in this publication are those of the author (s)
    and not necessarily those of the NHS, the National Institute for Health
    Research or the Department of Health. The Early ACTID study was funded
    by Diabetes UK and the UK Department of Health. The funders were not
    involved in the design of the study, the collection, analysis or interpretation
    of the data nor the writing of the manuscript.

  • Availability of data and materials
  • The datasets generated and/or analysed during the current study are not
    publicly available due to the level of personal information that is contained
    in the qualitative transcripts.

  • Authors’ contributions
  • SJS, ASP and ARC conceived of the study and sought funding to undertake
    the secondary data analysis. KMT and AM designed and conducted the
    interviews. SJS, ZT & KMT designed the analytical approach, SS & ZT undertook
    the secondary data analysis and all authors provided critical input into the
    interpretation of the findings. SS wrote the first draft of the paper and
    coordinated contributions from the co-authors. All authors made critical
    comments on the drafts of the paper and approved the final submission.

  • Consent for publication
  • Not applicable.

  • Competing interests
  • The authors declare that they have no competing interests.

  • Publisher’s Note
  • Springer Nature remains neutral with regard to jurisdictional claims in published
    maps and institutional affiliations.

  • Author details
  • 1Centre for Exercise, Nutrition & Health Sciences, School for Policy Studies,
    University of Bristol, 8 Priory Road, Bristol BS8 1TZ, UK. 2Department of
    Population Health Sciences, Bristol Medical School, University of Bristol,
    Bristol, UK. 3The National Institute for Health Research Collaboration for
    Leadership in Applied Health Research and Care West (NIHR CLAHRC West)
    at University Hospitals Bristol NHS Foundation Trust, Bristol, UK. 4National
    Institute for Health Research Bristol Biomedical Research Centre, University
    Hospitals Bristol NHS Foundation Trust and University of Bristol, Bristol, UK.
    5Centre for Academic Primary Care, Bristol Medical School, University of
    Bristol, Bristol, UK. 6Institute of Biomedical and Clinical Sciences, University of
    Exeter Medical School, Medical Research, RILD Level 3, Barrack Road, Exeter,
    Devon EX2 5DW, UK.

    Sebire et al. BMC Public Health (2018) 18:204 Page 9 of 10

    Received: 11 May 2017 Accepted: 23 January 2018

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    http://dx.doi.org/10.1080/1612197X.2016.1155637

      Abstract
      Background
      Methods
      Results
      Conclusions
      Trial registration
      Background
      Methods
      Study design
      The early ACTID trial
      Interviewee recruitment
      Data collection
      Data analysis
      Results
      Amotivation
      External motivation
      Introjected motivation
      Identified motivation
      Integrated motivation
      Intrinsic motivation
      Discussion
      Strengths and limitations
      Conclusions
      Abbreviations
      Ethical approval and consent to participate
      Funding
      Availability of data and materials
      Authors’ contributions
      Consent for publication
      Competing interests
      Publisher’s Note
      Author details
      References

    Oncotarget14516www.impactjournals.com/oncotarget

    www.impactjournals.com/oncotarget/ Oncotarget, 2017, Vol. 8, (No. 9), pp: 14516-14524

    Impact of diabetes on the risk of bedsore in patients undergoing
    surgery: an updated quantitative analysis of cohort studies

    Mining Liang1,*, Qiongni Chen2,*, Yang Zhang3, Li He1, Jianjian Wang1, Yiwen Cai1,
    Lezhi Li2
    1Department of Psychiatry, The Second Xiangya Hospital, Central South University, Changsha, Hunan Province, China
    2Department of Nursing, The Second Xiangya Hospital, Central South University, Hunan Province, Changsha, China
    3Nursing Teaching and Research Institute, Medical College of Guangxi University of Science and Technology, Liuzhou, Guangxi
    Province, China

    *These authors contributed equally to this work

    Correspondence to: Lezhi Li, email: llz6511@126.com

    Keywords: diabetes, bedsore, surgery, meta-analysis

    Received: November 26, 2016 Accepted: December 21, 2016 Published: December 27, 2016

    ABSTRACT
    Diabetes is a major cause of morbidity for patients undergoing surgery and can

    increase the incidence of some postoperative complications such as bedsores. We
    conducted a meta-analysis of observational studies to examine whether patients with
    diabetes undergoing surgery had high risk of bedsore. We performed a systematic
    literature search in Pubmed, Embase and the Cochrane Library Central Register of
    Controlled Trials database from inception to November 2016. Studies were selected
    if they reported estimates of the relative risk (RR) for bedsore risk in postoperative
    diabetic patients compared with that of in non-diabetic patients. Random-effects
    meta-analysis was conducted to pool the estimates. A total of 16 studies with 24,112
    individuals were included in our meta-analysis. The pooled RR of bedsore development
    for patients with diatetes was 1.77 (95% CI 1.45 to 2.16). The results of subgroup
    analyses were consistent when stratified by surgery type, study design, research
    region, sample size, inclusion period, analysis method and study quality. There was
    evidence of publication bias among studies and a sensitivity analysis using the Duval
    and Tweedie “trim-and-fill” method did not significantly alter the pooled results
    (adjusted RR 1.17, 95% CI 1.02 to 1.36).This meta-analysis provides indications
    that diabetic patients undergoing surgery could have a higher risk of developing
    bedsores. Further large-scale prospective trials should be implemented to comfirm
    the association.

    INTRODUCTION

    Bedsore, also known as pressure ulcer, is a common
    cause of prolonging length of hospital stay for patients
    with surgery. It has been reported that the length of
    hospital stay of surgical patients could increase by 3.5 to
    5 days on average when a bedsore occurs [1, 2]. For some
    severe cases, the length of stay for bedsores could even be
    longer than 15 days [3], which adds tremendous financial
    burden on the patient and healthcare facility.

    Several risk factors and aetiologies have been
    reported to contribute to the development of bedsores

    during perioperative period. Traditionally, it is considered
    that patients with advanced age, malnutrition (lower levels
    of hematocrit or albumin), poor circulation or smoking
    may have a higher risk of bedsores [4–7]. Moreover,
    for patients with surgery, some other factors such as
    anesthesia and surgery type, length of surgery, patient
    position during the surgery, warming or moisture devices
    used,and padding type the patients used [8–11] could also
    affect the development of bedsores.

    Numerous studies have explored the role of patients
    with preexisting diabetes on the development of bedsore.
    Despite the fact that some studies have reported significant

    Research Paper

    Oncotarget14517www.impactjournals.com/oncotarget

    association between diabetes and risk of surgery-related
    bedsore, some others have reported varying results on this
    association. It was noted in several studies that surgical
    patients with diabetes had higher risk of bedsore than
    those without diabetes [12–18], while still others showed
    null association [19–23]. Although two previous meta-
    analyses have explored this topic and found significant
    association between diabetes and surgery-related bedsore
    [24, 25], limited sample size and significant heterogeneity
    which was not sufficiently examined made the results less
    reliable. Therefore, there is an urgent need to update the
    evidence of association between preexisting diabetes and
    surgery-related bedsore.

    RESULTS

    Search and selection of studies

    The initial literature search yielded 1046 abstracts of
    which 31 were considered potentially relevant for full-text
    review. Totally, 16 studies including 24,112 participants
    met our eligibility criteria and were involved in the meta-

    analysis [12–23, 26–29]. Figure 1 gives the detailed
    process for study selection of this meta-analysis.

    Study characteristics

    Table 1 presents the baseline characteristics of the
    16 included studies. In summary, the included studies
    were published between 1994 and 2013 with a sample
    size ranging from 102 to 9400. Nine of the studies
    were conducted in the USA and six in Europe. For case
    ascertainment, 11 studies had a prospective study design,
    and 5 had a retrospective study design. Four types of
    surgical procedures including general surgery, hip surgery,
    cardiac surgery and lower extremity amputations were
    involved. Seven studies investigated patients more than
    70 years in age, and 9 less than 70 years in age. Ten studies
    applied univariate analysis and 6 studies used multivariate
    analysis as statistical method. The NOS scores for the
    assessment of methodological quality for cohort studies
    ranged from 5 to 8, with scores ≥ 6 in 14 studies and
    scores < 6 in 2 studies. The NOS score for the included studies were summarized in Table 3.

    Figure 1: Flow diagram of the study selection.

    Oncotarget14518www.impactjournals.com/oncotarget

    Relationship between diabetes and risk of bedsore

    Sixteeen cohort studies investigating the relationship
    between diabetes and risk of bedsore in surgical patients
    were included in our meta-analysis. The pooled RR was
    1.77 (95% CI, 1.45 to 2.16) and there was statistical inter-
    study heterogeneity (I2 = 62.7%; P < 0.001) (Figure 2).

    Methodological quality of the studies

    Table 2 presented the summary RRs for bedsore
    risk and diabetes from 14 high quality studies (≥ 6) and
    two low quality studies (< 6). In terms of methodological quality of studies, the summary RRs of bedsore risk were 1.72 (95% CI 1.40 to 2.10) in high quality studies and 2.07 (95% CI 1.04 to 4.14) in low quality studies, respectively,

    in comparison between surgical patients with diabetes
    and without diabetes. There was statistically significant
    difference for inter-study heterogeneity (P = 0.009).

    Type of surgery

    Four types of sugery were involved in the
    studies, with 6 of general surgery, 4 of hip surgery, 4 of
    cardiac surgery and 2 of lower extremity amputations,
    respectively. The summary RRs estimated for bedsore
    incidence were 1.71 (95% CI 1.40 to 2.09) for general
    surgery, 1.78 (95% CI 1.14 to 2.78 ) for hip surgery,
    1.98 (95% CI 1.41 to 2.79) for cardiac surgery and 1.44
    (95% CI 0.93 to 2.24) for lower extremity amputations,
    respectively. No statistically significant difference for
    inter-study heterogeneity (P = 0.238) was noted.

    Table 1: Characteristics of the included studies on the risk of bedsore in diabetic patients undergoing
    surgery

    Oncotarget14519www.impactjournals.com/oncotarget

    Study design

    As demonstrated in Table 2, the pooled RRs
    evaluated for bedsore risk were 1.96 (95% CI 1.52 to 2.52)
    for prospective studies and 1.31 (95% CI 1.07 to 1.59)
    for retrospective studies, respectively, with no significant
    difference for inter-study heterogeneity (P = 0.017).

    Sample size

    The summarised RRs for bedsore risk stratified by
    sample size were 1.66 (95% CI 1.21 to 2.29) for studies
    with large sample size (≥ 1000) and 1.93 (95% CI 1.57
    to 2.38) for studies with small sample size (< 1000). We found statistically significant difference for inter-study heterogeneity (P = 0.019).

    Research region

    Six and 9 studies were conducted in Europe and
    USA, respectively. The summary RRs for bedsore risk
    were 1.94 (95% CI 1.26 to 2.99) for studies conducted
    in Europe and 1.62 (95% CI 1.33 to 1.97) for studies
    conducted in USA. No statistically significant difference
    for inter-study heterogeneity was found (P = 0.523).

    Inclusion period

    Four studies included participants before year 2000
    and the pooled RR was 1.38 (95% CI 1.09 to 1.76); and
    4 included participants after year 2000 with the pooled RR
    of 1.61 (95% CI 1.30 to 2.00). We did not find statistically
    significant difference for inter-study heterogeneity
    (P = 0.089).

    Age

    The summarised RRs for bedsore risk stratified
    by patient age were 1.66 (95% CI 1.19 to 2.32) for
    studies with patients having older age (≥ 70 years) and
    1.77 (95% CI 1.48 to 2.11) for studies with patients having
    less older age (< 70). There was no statistically significant difference for inter-study heterogeneity (P = 0.078).

    Statistical analysis method

    Ten studies applied univariate analysis to analyze the
    risk estimates and 6 studies applied multivariate analysis.
    The results showed that the pooled RRs for bedsore risk
    were 2.08 (95% CI 1.73 to 2.50) for studies with univariate
    analysis and 1.44 (95% CI 1.11 to 1.88) for studies with

    Figure 2: Association between diabetes and the risk of bedsore in patients undergoing surgery.

    Oncotarget14520www.impactjournals.com/oncotarget

    multivariate analysis. Statistically significant difference for
    inter-study heterogeneity (P < 0.001) was found.

    Publication bias and sensitivity analyses

    The shape of the funnel plot for the studies on the
    diabetes and bedsore risk seemed asymmetrical. In addition,
    Egger’s adjusted rank correlation test showed potential
    evidence of publication bias (P = 0.002). We further test
    whether publication bias significantly influenced the
    pooled risk estimates by using trim and filled method and
    the adjusted RR indicated the same trend with the result
    of the primary analysis (RR 1.17 95% CI 1.02 to 1.36).

    A sensitivity analysis was carried out by excluding one
    study at each time and then recalculating the pooled RRs
    for the remaining ones to test the effect of each study on
    the overall estimates. We did not find the alteration of in
    the direction of the estimate when any one of the included
    study was excluded. This analysis confirmed the robustness
    of the positive association between diabetes and bedsore
    risk in surgical patients.

    DISCUSSION

    Our systematic review and meta-analysis
    summarizing the results of 16 observational studies,

    Table 2: Subgroup analyses of the associations between diabetes and the risk of bedsore in patients
    undergoing surgery

    Variables RR 95% CI
    Degree of

    heterogeneity
    (I2 statistics; %)

    P
    No. of

    included
    Studies

    Pa

    Total 1.77 1.45 to 2.16 62.7 < 0.001 16 Study quality 0.009

    Score ≥ 6 1.72 1.40 to 2.10 58.1 0.002 14
    < 6 2.07 1.04 to 4.14 65.4 0.089 2

    Surgery type 0.238
    General surgery 1.71 1.40 to 2.09 0 0.496 6
    Hip surgery 1.78 1.14 to 2.78 88.4 < 0.001 4 Cardiac surgery 1.98 1.41 to 2.79 0 0.859 4 LEAs 1.44 0.93 to 2.24 0 0.414 2

    Study design 0.017
    Prospective 1.96 1.52 to 2.52 68.3 < 0.001 11 Retrospective 1.31 1.07 to 1.59 2.9 0.398 5

    Sample size 0.019
    ≥ 1000 1.66 1.21 to 2.29 82.6 < 0.001 6 < 1000 1.93 1.57 to 2.38 0 0.856 10

    Research region 0.523
    Europe 1.94 1.26 to 2.99 80.8 < 0.001 6 USA 1.62 1.33 to 1.97 30.8 0.162 9

    Inclusion period 0.089
    Before year 2000 1.38 1.09 to 1.76 16.8 0.308 4
    After year 2000 1.61 1.30 to 2.00 0 0.575 4

    Age 0.078
    ≥ 70 1.66 1.19 to 2.32 78.3 < 0.001 7 < 70 1.77 1.48 to 2.11 0 0.695 9

    Analysis method < 0.001 Univariate 2.08 1.73 to 2.50 10.6 0.342 10 Multivariate 1.44 1.11 to 1.88 64.8 0.014 6

    Abbreviations: CI, confidence interval; LEA, Lower Extremity Amputations; RR, relative risk.
    Pa: P values from the test of homogeneity between strata.

    Oncotarget14521www.impactjournals.com/oncotarget

    which comprised a total of 24,112 participants on the
    association between diabetes and risk of bedsore support
    the evidence that the risk of developing bedsore among
    surgical patients exposed to diabetes was 1.77 times that
    of the non-exposed patients. Analyses stratified by surgical
    site suggest a greater risk increase for cardiac surgery than
    for other three investigated surgeries (general surgery,
    hip surgery or lower extremity amputations), though no
    statistical significance is found among different surgery
    types in this meta-analysis.

    This updated meta-analysis further confirms and
    extends the preliminary findings of the two previous
    published meta-analyses [24, 25]. The first one performed
    by Liu et al. [25], reported a 115% (OR, 2.15; 95% CI
    1.62 to 2.84) higher risk of surgery-related bedsore in
    diabetic patients compared with that of in non-diabetic
    patients. The other one conducted by Kang et al. found
    similar result (surgery related bedsore risk: diabates
    vs. non-diabetes OR, 1.74; 95% CI 1.40 to 2.15) [24].
    Our findings are consistent with the results of previous
    systematic reviews. We also explored the effect of
    different surgery types and other potential variables
    more thoroughly on the combined estimates than the
    previous ones. Compared with the study by Kang et al.,
    our meta-analysis has added more statistical power to
    test the surgery type subgroup and examined some other
    variables which could explain the potential heterogeneity.
    This study found that diabetic patients having general
    surgery, hip surgery and cardiac surgery all had significant

    higher bedsore risk than non-diabetic patients. However,
    we did not find that association for patients having lower
    extremity amputations.

    Multiple mechanisms can contribute to the
    deveopment and severity of bedsores, which may result
    from capillary occlusion by external pressure, leading to
    the shut off of blood supply, cell death, necrosis removal
    and ulceration. The severity of the bedsore is determined
    by the length of time pressure is applied to the local
    region. Moreover, for a patient receiving surgery, the
    incidence rate of bedsores is mainly determined by the
    duration and intensity of the shearing force given upon the
    tissue during surgery. For the impact of different surgery
    types on the risk of bedsore development, we noted that
    patients with cardiact surgery had the higher risk (RR 1.98,
    95% CI 1.41 to 2.79) than patients with general surgery
    or hip surgery, while patients with lower extremity
    amputations had the lowest risk (RR 1.44, 95% CI 0.93
    to 2.24). We propose that the trauma severity of surgery
    to the body could be a major influential factor determining
    the risk of developing bedsore.

    We noted moderate inter-study heterogeneity in our
    meta-analysis (I2 = 62.7%, Pheterogeneity < 0.001). Sensitivity analyses indicated that exclusion of any one of the study did not significantly alter the summary estimate. The trim- and-fill model and multiple subgroup analyses stratified by some main clinical variables were in agreement with the initial findings, indicating that the result of this meta- analysis was robust and not affected by publication bias.

    Table 3: Quality assessment of the included studies
    Selection Comparability Outcome

    Study ID

    Represent
    ativeness

    of the

    exposed
    cohort

    Selection
    of the
    non

    exposed
    cohort

    Ascertain
    ment of

    exposure

    Demonstration
    that outcome

    of interest
    was not

    present at
    start of study

    Comparability
    of cohorts on

    the basis of the
    design or
    analysis

    Assessment
    of outcome

    Was follow-up
    long enough for

    outcomes to
    occur

    Adequacy
    of follow

    up of
    cohorts

    Quality
    score

    1 Zambonato 2013      5
    2 Ekström 2013        8
    3 Tschannen 2012        8
    4 Bulfone 2012       6
    5 Norris-DOI 2011       6
    6 Slowikowski 2010        8
    7 Aragón-Sánchez 2010       6
    8 Haleem 2008      5
    9 Frankel 2007       7
    10 Pokorny 2003       6
    11 Baumgarten 2003        8
    12 Spittle 2001       6
    13 Schultz 1999        8
    14 Stordeur 1998       6
    15 Lewicki-

    preoperative
    1997      

    6
    16 Papantonio 1994        7

    Newcastle-Ottawa Scale for assessing the quality of studies in meta-analysis.
    Note: A study can be awarded a maximum of one star for each numbered item within the Selection and Outcome categories. A maximum of two stars can be given for
    Comparability.

    Oncotarget14522www.impactjournals.com/oncotarget

    Nevertheless, we should interpret the results with caution
    due to the common occurance of publication bias [30] and
    statistical tests to detect publication bias are incomplete.

    Despite the previous published studies investigating
    the association between diabetes and risk of surgery-related
    bedsore, the statistical power was quite limited for the small
    sample sizes of these studies (ranging from 67 to 616).
    To the best of our knowledge, our study is the most
    comprehensive one with the largest sample size to evaluate
    this association. Furthermore, exhaustive search strategies
    were developed to garantee the inclusion of almost all of
    the eligible studies, generating 16 studies and data from
    24,112 individuals. Such a large sample size could provide
    us a precise and important risk estimates. Moreover, based
    on the subgroup analyses, our study also showed that

    bedsore risk increased among different types of
    surgery although statistical significance was not noted
    for lower extremity amputations probably due to limited
    sample size. Lastly, consistent and stable sensitivity
    analyses and result of trim and filled method made the
    results more strengthened.

    Several limitations in our study should be
    acknowledged. First, variations of treatment or nursing
    procedures for different types of surgery, may result
    in variations in risk estimates. Secondly, in order to
    assess the effect of different blood glucose levels or
    patient body mass index on the different risk of bedsore,
    related subgroup analyses should ideally be performed.
    However, due to the nature of study-level data instead
    of patient-level data, the available data did not allow us
    to conduct such assessment. Thirdly, 10 of 16 studies
    used univariate analysis instead of multivariate analysis
    to obtain the risk estimates as they did not adjust for
    some potential influential confounders, such as gender,
    patient age, diabetes duration and type, which could
    lead to inaccurately generating the pooled estimates. In
    addition, for the studies using multivariate analysis, the
    adjustment variables varied considerably. Moreover,
    the data sources from observational studies restricted
    the power to fully explore the influence of unmeasured
    confounding variables and observational studies could
    not establish a causal relationship between exposure
    factor of diabetes and risk of bedsore. Finally, some of the
    study authors could not be contacted for retrieving some
    necessary data. Despite the limitations of the current study,
    the major clinical implication lies in that for some types of
    surgery, clinicians should take more care of patients with
    diabetes to mininize the development of surgery-related
    bedsore and improve the quality of patient life during
    hospitalization.

    In conclusion, our systematic review and meta-
    analysis provide evidence that diabetic patients having
    surgery could have a higher risk of developing bedsore.
    This association is almost independent of surgery type and
    other study characteristics. However, further large-scale
    prospective studies should be implemented to further test
    the association.

    MATERIALS AND METHODS

    Search strategy

    We systematically searched Pubmed, EMBASE,
    and the Cochrane Library without language restriction
    through November 2016 for related peer-reviewed studies
    that examined an association between diabetes and risk
    of bedsore in patients undergoing surgery. We performed
    this systematic review and meta-analysis based on the
    Preferred Reporting Items for Systematic Reviews and
    Meta-Analyses (PRISMA) (Supplementary Table S4) [31].
    Two authors (M.L. and Q.C.) independently conducted
    the literature search using the terms: (surgery OR surgical
    OR operation OR operative) AND (diabetes mellitus OR
    diabetes) AND (pressure sore* OR pressure ulcer* OR
    bedsore* OR decubitus). Manual searches of reference
    lists of relevant studies obtained from the initial searches
    were also conducted for some missing citations. Detailed
    search strategies of each database are provided in
    Supplementary Appendix.

    Study selection

    Two reviewers (M.L. and Q.C.) independently
    assessed all records through reading the titles and/or
    abstracts for potentially eligible studies. In case there were
    different opinions, a senior reviewer (L.L ) would join to
    discuss and resolve the disagreement. We included studies
    in this meta-analysis if they satisfied the following criteria:
    (i) observational studies including cohort or case–control
    studies; (ii) investigating diabetes and risk of bedsore in
    patients undergoing surgery; (iii) providing odds ratios
    (ORs)/relative risks (RRs) along with 95% confidence
    intervals (95% CIs) or sufficient information to calculate
    them, for bedsore risk stratified by diabetes in patients
    having operation. We included patients with history or
    diagnosis of diabetes, irrespective of diabetes type (1 or 2),
    disease severity, duration or anti-diabetic drug use due to
    unavailability of those data.

    Data extraction and quality assessment

    Data were extracted independently according to a
    predesigned form by two reviewers (Y.Z. and L.H.) and the
    results were crosschecked. A third reviewer(L.L.) would
    reevaluated the extracted data if any disagreements occurred.
    The following data were extracted from each study:
    first author, publication year, study region, study design,
    inclusion period, opertion site, number of participants, sex,
    mean/median age,body mass index, treatment regimen,
    analysis method, follow up period, adjustment variables,
    and risk estimates for association between bedsore risk and
    diabetes in patients having operation.

    Two reviewers (M.L. and L.H.) independently
    assessed the methodological quality of each included
    study using Newcastle-Ottawa quality assessment

    Oncotarget14523www.impactjournals.com/oncotarget

    scale (NOS) for cohort studies, which included
    3 domains (4 points for selection, 2 points for comparability
    and 3 points for exposure/outcome) totaling 9 points
    (Table 3). We categoried score less than 6 as low quality
    and score of 6 or more than 6 as high quality. Discrepancies
    were resolved by consensus with a senior reviewer (L.L.).

    Statistical analyses

    We quantified the relationship between diabetes and
    risk of bedsore using an inverse variance method using
    DerSimonian and Laird random-effects models [32]. All
    statistical analyses were carried out with Stata Statistical
    Software (version 12.0; StataCorp LP, College Station, TX,
    USA) by two reviewers (M.L. and L.H.). Between-study
    heterogeneity was assessed using the chi-square statistic and
    quantified by I², with an I2 statistic more than 50% defining
    significant heterogeneity [33, 34]. We further investigated
    potential sources of between-study heterogeneity by
    subgroup analyses based on some baseline variables
    (study quality, surgery type, study design, sample size,
    research region, inclusion period, patient age and analysis
    method). Egger’s regression model was quantified to assess
    publication bias [35]. If publication bias existed, we used
    the trim-and-fill method to adjust the pooled estimates
    of the potential unpublished studies in the meta-analysis,
    which were compared with the original pooled RRs [36].
    Sensitivity analysis was also conducted to investigate the
    influence of each study on the separate analyses of cohort
    studies [26]. All statistical analyses were two-sided with a
    P value less than 0.05 indicating significant difference.

    CONFLICTS OF INTEREST

    The authors declare no potential conflicts of interest.

    FINANCIAL SUPPORT

    None.

    Authors ̕contributions

    Study concept and design (ML LL); acquisition of
    data (ML QC); analysis and interpretation of data (ML
    QC YZ LH LL); drafting of the manuscript (ML QC
    LL); critical revision of the manuscript for important
    intellectual content (ML QC YZ LH JW YC LL); study
    supervision.

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    Areas of Expertise

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    Trusted Partner of 9650+ Students for Writing

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    Our Services

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    Check Out Our Sample Work

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    The Value of a Nursing Degree
    Undergrad. (yrs 3-4)
    Nursing
    2
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    We Handle Your Writing Tasks to Ensure Excellent Grades

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