Research has shown that taking medications and making lifestyle changes to manage diabetes can be challenging for patients. In general, diabetes self-management behaviors are multidimensional; for example, clinical studies indicate that adherence is better for medication use than it is for lifestyle changes, such as diet and exercise. At the same time, adherence to diabetes medications is still suboptimal. “Only about one-third of patients with diabetes are doing most of the things they need to do to manage their disease,” says Martha M. Funnell, MS, RN, CDE. “As health professionals, we have to move beyond blaming patients for being ‘nonadherent’ and learn how to work more effectively with them.”
Diabetes Self-Management Matters
The Diabetes Attitudes, Wishes, and Needs Study demonstrated that diabetes self-management is less than optimal and that psychosocial issues play a pivotal role in diabetes self-management. Identifying key factors and strategies associated with self-management practices is critical to improving outcomes in diabetes. These include demographic, psychological, and social factors as well as healthcare provider and system factors and disease- and treatment-related factors (Table 1).
“As health professionals, we have to move beyond blaming patients for being ‘non-adherent’ and learn how to work more effectively with them.”
“When working with patients, we should consider these factors during visits,” says Funnell. “Psychological and emotional factors are particularly important because they have a significant impact on diabetes management. Recognizing the potential risk factors allows us to better determine the optimal approaches to take with patients and helps lay the groundwork for patient-centered collaboration (Table 2).”
When assessing self-management, Funnell notes that providers cannot assume patients are taking their medications appropriately. “We need to understand that ‘taking medications as prescribed’ is often difficult and may not be possible for some patients. We need to ask patients—in a nonjudgmental manner—about how often they miss taking doses of medicine and about their actual medication-taking practices. They also need to be part of the decision-making process when new medicines are added.”
Enhance Adherence to Medications
On average, patients with diabetes take about nine medications per day, according to Funnell, and this represents a substantial burden to patients. “In addition to the pill burden and the fact that patients must remember what they’re taking, why they’re taking it, and how they’re supposed to take it, they’re also burdened with financial issues. Research shows that many patients do not fill all their prescriptions or take lower doses to save money. Providers need to consider financial issues and ask if patients have difficulty paying for their medications before prescribing them. Patients should then be asked again about these issues periodically thereafter.”
In the past several years, manufacturers have developed combination medications for treating diabetes. More of these drugs continue to emerge, and Funnell says that the benefits of using them are multifactorial. “In many cases, combination drugs can lead to cost savings in copays to patients. The reduced pill burden can increase medication-taking. Providers, however, need to check to see if these combination drugs will increase the patient’s out-of-pocket costs and if it makes sense to prescribe agents separately.”
Factor Lifestyle Into the Mix
Lifestyle behaviors contribute significantly to outcomes in diabetes, but are often challenging for patients and the source of frustration for clinicians. “Studies show that patients know they need to eat right, lose weight, exercise regularly, and quit smoking,” Funnell explains. “What they don’t know is how to get there. Simply telling patients what to do is rarely effective. Instead, collaborate with patients to identify reachable goals, and then create a stepwise approach to reach them. A step-by-step plan can help them sustain the behaviors they need to improve their diabetes-related outcomes and overall health. Providing effective self-management support requires collaboration and an understanding that the process will be ongoing.”
Helpful Diabetes Care Tools for Clinicians
Because most of diabetes care happens within the day-to-day lives of patients, they need resources and tools that address the totality of diabetes: the clinical, the behavioral, and the emotional. The American Diabetes Association (www.diabetes.org) and the National Diabetes Education Program (www.yourdiabetesinfo.org) are just two organizations that provide tools and resources to help clinicians and their patients manage diabetes more effectively and achieve treatment goals. “These free resources can be used to help patients learn more about how to manage their disease, set goals, and make behavioral changes in order to achieve recommended outcomes,” says Funnell. “We need to give our patients the message that self-management is hard work and isn’t always easy, but it is worth it.”
Readings & Resources (click to view)
Delamarter AM. Improving patient adherence. Clin Diabetes. 2006;24:71-77. Available at:http://clinical.diabetesjournals.org/content/24/2/71.full.
Lin EHB, Ciechanowski P. Working with patients to enhance medication adherence. Clin Diabetes. 2008;26:17-19. Available at: http://clinical.diabetesjournals.org/content/26/1/17.full.
Osterberg L, Blaschke T. Adherence to medication. N Engl J Med. 2005;353:487-497.
Praska JL, Kripalani S, Seright AL, Jacobsen TA. Identifying and assisting low-literacy patients with medication use: a survey of community pharmacies. Ann Pharmacother. 2005;39:1441-1445.