What’s So Tough about Diabetes Self-Management?
The Problem of “Perceived Treatment Efficacy”
June 23, 2010
William H Polonsky, PhD, CDE
It is an all-too-common and frustrating story: many of our patients with type 2 diabetes struggle with the day-to-day demands of the disease. Perhaps they are not taking medications as prescribed and/or not following diet or exercise recommendations. In any case, poor self-care over time is likely to contribute to grim, and often unnecessary, outcomes. We understand that our patients would prefer to live long and healthy lives, but that obstacles are common: depression, stress, poverty, poor social support, limited diabetes knowledge, poor diabetes self-efficacy and more. All of these can contribute to patient frustration and discouragement and, consequently, poor self-care. One additional contributor, simple but powerful, that is rarely considered is “perceived treatment efficacy” or PTE. Simply put, when the patient does not believe that the recommended treatment action — be it exercise, dietary changes, SMBG (self monitored blood glucose) or taking medications — is contributing to an observable, positive short-term impact on the patient’s own diabetes health (e.g., “no matter what I do, my blood sugars are still high”), the patient may lose motivation to continue to perform that action. Even worse, if they become convinced that prescribed treatments are directly contributing to poorer outcomes (e.g. “if I start insulin, my health is likely to worsen”), they will be reluctant to cooperate.
A considerable portion of what we typically refer to as “patient noncompliance” in diabetes may be due to impaired PTE. Patients are often unaware of the available tools, such as their own metabolic data (e.g. A1C, blood pressure and lipids), that can help them to determine whether their own actions are efficacious. For example, several studies have shown that patient knowledge regarding their own A1C values is limited. Also, many patients rarely check their blood glucose levels and, of those who do, many do not know how to interpret these data in order to accurately assess what is and isn’t working. Even worse, we see that blood glucose monitoring often serves, inadvertently, as a de-motivational agent. Patients may view individual BG (blood glucose) results as evidence of personal success or failure, which—given the common variability and often unpredictability of BG’s—can lead to significant discouragement and a sense that one’s own actions do not matter.
This presents us with a tremendous opportunity. A critical reason why some patients are able to stay motivated to manage the disease day after day, year after year, is due to their conviction that their actions are making a positive difference. And they and their health care team have found ways to highlight this impact in a tangible manner over time. For those who are struggling with diabetes self-management, we believe that self-care can be promoted in a proactive fashion by providing them with personalized feedback illustrating how these metabolic indicators may be influenced by self-care actions. Discuss your patients’ metabolic data with them. Make use of online risk calculators (e.g., see “My Diabetes Health Assessment” at www.heart.org) to help patients see how such behavior changes as smoking cessation, weight loss and/or taking medications appropriately can potentially influence metabolic parameters and, thereby, decrease complication risks. This can also help patients to recognize the benefits of the efforts they have already made, and where any new efforts might be best expended for maximum gain.
By assessing PTE and addressing it directly, healthcare provider’s have a powerful opportunity to help their patients feel more interested and engaged in ongoing diabetes self-care.
William H. Polonsky is the CEO and Founder of the Behavioral Diabetes Institute, Associate Clinical Professor in Psychiatry, University of California, San Diego.
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