Adherence to Treatment: The Key for Avoiding Long-Term Complications of Diabetes

doi:10.1016/j.arcmed.2004.12.001

Archives of Medical Research

Volume 36, Issue 3, May–June 2005, Pages 300-306

https://doi.org/10.1016/j.arcmed.2004.12.001 Get rights and content

Behavioral changes and adherence to pharmacological treatment are essential for improving the prognosis in chronic illness. Lack of adherence to treatment is a common problem in every practice and many patients drop out of care prematurely. The present article is a review of our knowledge regarding adherence to treatment in type 2 diabetic patients and the strategies we can implement to improve it. Diabetes regimens contain many aspects that make compliance difficult; it is a chronic disorder, lifestyle changes are required, and treatment may be complex, intrusive and inconvenient. Prevention, instead of symptom reduction or cure, is usually the main goal. Successful interventions to improve adherence are labor intensive but ultimately cost effective. Educating patients, keeping regimens as simple as possible, negotiating priorities, monitoring adherence and attendance at appointments and reinforcing the patient's efforts to adhere at each visit provide practical and effective help. Clinicians must understand that failure to achieve the therapeutic goals might be related to inadequate self-management. Instead of changing prescriptions, increasing drug dosage, or switching or adding medications, clinicians should consider counseling patients on how to improve adherence.

Section snippets

The Magnitude of the Problem

Rapid improvement in health and longevity are dramatically changing the burden of illness throughout the world. In developed countries, changes in lifestyle and improvements in the treatment of major causes of mortality have resulted in an aged population with a greater prevalence of chronic diseases. Many underdeveloped countries are proceeding through an epidemiological transition with a change in the pattern of health, from communicable diseases and premature deaths to an increase in chronic

How to Define and Measure Adherence to Treatment

Conceptual problems in defining and measuring adherence to treatment include the absence of explicit adherence standards against which the patient's behavior can be compared. Inadvertent non-compliance can be attributed to patient provider miscommunication and patient knowledge/skill deficits. The World Health Organization has promoted the term adherence for use in chronic disorders with the following definition: the extent to which a person's behavior in terms of taking medications, following

Adherence to Treatment in Diabetes

The prevalence of type 2 diabetes varies widely worldwide. Populations of developing countries as well as minority groups and disadvantaged communities in industrialized countries face the greatest risk 11, 12. Type 2 diabetes and its complications have a high prevalence in the Mexican population, with this increased risk probably related to genetic and environmental determinants. Substandard levels of care often add to this burden, leading to late diagnosis and inadequate follow-up.

Diabetes

Main Barriers for Diabetes Self-Care Management

Several investigators have applied the health belief model for predicting adherence to diabetes treatment guidelines. This model hypothesizes that adherence increases as a function of the patient's perception of greater susceptibility to the illness, greater disease severity, greater perceived benefits of adherence, fewer emotional, physical or financial barriers to adhere, more social support and greater self-efficacy 17, 18.

Data from the Hispanic Health and Nutrition Examination and Survey

Strategies to Improve Adherence to Treatment in the Type 2 Diabetic Patient

Diabetes is a lifelong disease, prolific in its complications and impact on quality of life (47). Ideally, we should facilitate optimal health care for as many people as possible rather than ideal health care for a few (most current research needs some translation in routine clinical practice).

Analysis of cost effectiveness in diabetes has shown that the lifetime improvement in quality of life and longevity derived from intensive management outweighs the increased costs of such treatment 9, 48.

Models of Care

Models of care of patients with chronic disease have emphasized the need for a collaborative relationship between patient and provider and the central role of the patient provider interaction in promoting behavioral changes 52, 53, 54, 55. Practice system changes that have shown the greatest promise of success integrate self-management support programs. They include guideline-based treatment plans, nurse case-management programs, group sessions with leaders trained in motivation strategies,

Conclusions

Health care providers need to understand that failure to achieve optimal control may be related to inadequate self-management. The implication is that clinicians should consider counseling patients on how to improve adherence to treatment. Although accurate methods for assessing low adherence are sparse, simple measures such as asking patients and watching for appointment non-attendance and treatment non-response should detect the problem. Successful interventions to improve adherence are labor

References (59)

I. Lerman et al.
Psychosocial factors associated with poor diabetes self-care management in a specialized Center in Mexico City
Biomed Pharmacother
(2004)
A.D. Morris et al.
Adherence to insulin treatment, glycemic control and ketoacidosis in insulin dependent diabetes mellitus
Lancet
(1997)
J.B. Brown et al.
Ten year follow up of antidiabetic drug use, non-adherence and mortality in a defined population with type 2 diabetes
Clin Ther
(1999)
M.I. Rosen et al.
Electronic monitoring and counseling to improve medication adherence
Behav Res Ther
(2004)
W.J. Katon
Clinical and health services relationships between major depression, depressive symptoms, and general medical illness
Biol Psychiatry
(2003)
A. Jiménez-Cruz et al.
The fattening burden of type 2 diabetes on Mexicans
Diabetes Care
(2004)
O. Velazquez-Monroy et al.
Prevalencia e interrelación de enfermedades crónicas no transmisibles y factores de riesgo cardiovascular en México
Arch Cardiol Mex
(2003)
W.T. Branch
The ethics of caring and medical education
Acad Med
(2000)
H.P. McDonald
Interventions to enhance patient adherence to medication prescriptions: scientific review
JAMA
(2002)
R.B. Hynes
Helping patients follow prescribed treatment: clinical implications
JAMA
(2002)

J.Z. Ayanina et al.

Undiagnosed hypertension and hypercholesterolemia among uninsured and insured adults in the Third National Health and Nutrition Examination Survey

Am J Public Health

(2003)

National Cholesterol Education Program (NCEP) Expert Panel on Detection, Evaluation, and Treatment of High Blood Cholesterol in Adults (Adult Treatment Panel III). Executive summary of the third report of the national cholesterol education program (NCEP) expert panel on detection, evaluation, and treatment of high blood cholesterol in adults (adult treatment III)

JAMA

(2001)

World Health Organization

Report on medication adherence

(2003)

T. Schwab et al.

Measuring attitudes and health beliefs among Mexican Americans with diabetes

Diabetes Educator

(1994)

S.B. Johnson

Methodological issues in diabetes research. Measuring adherence

Diabetes Care

(1992)

J.A. Davidson et al.

Diabetes in United States Latinos: more than a growing concern

Clin Diabetes

(1994)

H. King et al.

Global estimates for prevalence of diabetes mellitus and impaired glucose tolerance in adults

Diabetes Care

(1993)

R.R. Wing et al.

Behavioral science in diabetes

Diabetes Care

(2001)

R.B. Haynes

Introduction

K.A. Bloom-Cerkoney et al.

The relationship between the health belief model and compliance of persons with diabetes mellitus

Diabetes Care

(1980)

R.E. Glasgow et al.

In diabetes care, moving from compliance to adherence is not enough. Something entirely different is needed

Diabetes Care

(1999)

S.M. Kurtz

Adherence to diabetes regimens. Empirical status and clinical applications

Diabetes Educator

(1990)

R.E. Glasgow et al.

Psychosocial barriers to diabetes self management and quality of life

Diabetes Spectrum

(2001)

J.A. Cramer

A systematic review of adherence with medications for diabetes

Diabetes Care

(2004)

P.S. Chiechanowski et al.

Depression and diabetes

Arch Intern Med

(2000)

C.M. Dezn et al.

Effects of a once daily and twice daily dosing on adherence with prescribed glipizide oral therapy for type 2 diabetes

South Med J

(2002)

P.T. Donnan et al.

Adherence to prescribed oral hypoglycemic medication in a population of patients with type 2 diabetes, a retrospective cohort study

Diabet Med

(2002)

W.H. Polonsky et al.

Insulin omission in women with IDDM

Diabetes Care

(1994)

S.J. Boccuzzi et al.

Utilization of oral hypoglycemic agents in a drug insured U.S. population

Diabetes Care

(2001)

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Citation Excerpt :
Diabetes management is complex and requires ongoing monitoring and adjustment by patients and their clinicians. Elevated HbA1c increases the risk for complications and other adverse events.2,3 Convenient video telehealth access could support engagement with health care and self-management behaviors.
Video telehealth can offer people convenient, real-time access to clinicians without arranging transportation or time off work. Among people with diabetes, this study examines the association between video telehealth access and changes in HbA1c.
This longitudinal cohort study (2016–2019) used linear regression with person-level fixed effects, stratified by baseline HbA1c (last value in 2015), to examine the association between video visit access and changes in HbA1c. HbA1c values were categorized into 3 periods of video visit exposure: (1) before any video visit, (2) during video visit transition year (calendar year of the first video visit), and (3) after video visits. The model compared changes in HbA1c values collected before the patient had any video visits with those collected after the transition year. Analyses were conducted in September 2020.
Among 204,301 people with diabetes, video visit access was associated with a statistically significant reduction of 0.15 (95% CI= −0.19, −0.11) percentage points in HbA1c, with greater reductions among patients with an elevated baseline HbA1c value (−0.22 percentage points, 95% CI= −0.32, −0.11) and with no baseline HbA1c measurement (−0.39 percentage points, 95% CI= −0.71, −0.07).
Gaining access to video telehealth was associated with reductions in HbA1c among people with diabetes. Video telehealth offers people with chronic conditions a new, convenient way to access health care, is not associated with worsening HbA1c, and may support better disease management, particularly among patients with higher baseline HbA1c.
Gaps in achieving coverage of diabetes treatments in low-income and middle-income countries
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Baseline Diabetes Knowledge Assessment Amongst Adults With Type 1 and Type 2 Diabetes Receiving Eye Care at a Tertiary Ophthalmic Centre in Canada
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The aim of this work was to assess the current state of baseline knowledge of diabetes and diabetic retinopathy (DR) in new patients referred to a tertiary retina service from their primary eye care provider.
This single-centre, prospective, observational study included patients presenting to the retina clinic at the Hamilton Regional Eye Institute, a major tertiary referral centre, for their initial consultation for diabetes- or DR-associated complications. Upon recruitment into the study, patients were asked to complete a 35-item questionnaire regarding diabetes and associated complications. All data were coded and analyzed using statistical software.
A total of 98 patients participated in the study, which included 50 men and 48 women. Seventy-eight patients (79.6%) were Caucasian. We found that 56.1% (n=55) of the patients did not know the meaning of “HbA1C” (glycated hemoglobin) and only 26.5% of patients sampled were aware of their DR status. Bivariate analysis revealed that patients who had postsecondary education (p<0.001) or those who had education on complications of diabetes (p<0.05) were more likely to know their DR status. More importantly, it was found that 56.1% of patients expressed interest in a future diabetes seminar.
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Ces travaux visaient à évaluer l’état actuel des connaissances de base sur le diabète et la rétinopathie diabétique (RD) des nouveaux patients dirigés par leur prestataire de soins oculaires primaires à un service de soins tertiaires de la rétine.
La présente étude observationnelle, prospective et monocentrique portait sur des patients qui se présentaient à la clinique de la rétine du Hamilton Regional Eye Institute, un important centre d’aiguillage en soins tertiaires, pour leur consultation initiale pour des complications associées au diabète ou à la RD. Lors de leur recrutement au sein de l’étude, les patients étaient invités à remplir un questionnaire de 35 items sur le diabète et les complications qui y sont associées. Toutes les données étaient codées et analysées à l’aide d’un logiciel de statistiques.
Un total de 98 patients ont participé à l’étude, soit 50 hommes et 48 femmes. Soixante-dix-huit patients (79,6 %) étaient caucasiens. Nous avons observé que 56,1 % (n = 55) des patients ne connaissaient pas la signification de « HbA1c » (hémoglobine glyquée) et que seulement 26,5 % des patients de l’échantillon étaient au fait de leurs antécédents de RD. L’analyse bivariée a révélé que les patients qui avaient une formation postsecondaire (p < 0,001) ou ceux qui avaient reçu un enseignement sur les complications du diabète (p < 0,05) étaient plus susceptibles de connaître leurs antécédents de RD. Notamment, il a été observé que 56,1 % des patients avaient exprimé leur intérêt à participer à un prochain séminaire sur le diabète.
Il est évident qu’une proportion significative de patients ne possèdent pas des connaissances adéquates sur le diabète ou la RD. Ceci est lié à leur niveau de scolarité et à l’absence d’enseignement sur les complications du diabète. Nos conclusions peuvent orienter les initiatives de prévention des prestataires de soins oculaires primaires et favoriser une prise de conscience accrue sur le diabète et la RD dans la prévention des complications de la maladie, dont la cécité.
Bereavement, Grief and Adult Type 1 Diabetes: Living With Diabetes Today
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Citation Excerpt :
In turn, they are predicted to add to and intensify feelings of grief and bereavement. Furthermore, financial distress, which affects compliance with care in 57% of Canadians with diabetes (16), is a major risk factor in patient mental health, and alleviating some of this pressure by providing blood glucose testing supplies has improved glycemic control in people living with diabetes (27). Previous reports have also identified formal stages of grief among those living with T1D who have undergone limb loss (28).
Efficacy of dietary intervention or in combination with exercise on primary prevention of cardiovascular disease: A systematic review
2020, Nutrition, Metabolism and Cardiovascular Diseases
Lifestyle factors heavily influence the development of cardiovascular disease (CVD); therefore, interventions delivering adequate lifestyle changes may improve the prognosis among patients at cardiovascular (CV) risk. Recently published research on the effectiveness of dietary and exercise intervention programmes, alone or combined, on reducing risk factors associated with CVD as well as preventing CV events have been now assessed.
Using the Medline database via PubMed, we searched for prospective studies published between January 2000 and January 2020 assessing the efficacy of dietary interventions alone or in combination with exercise on reducing CV risk factors or events in human adults at risk. Study quality was assessed using the American Dietetic Association Quality Criteria Checklist.
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Patient Assessment of Family Function, Glycemic Control and Quality of Life in Adult Patients With Type 2 Diabetes and Incipient Complications
2019, Canadian Journal of Diabetes
Family affects the perception of diabetes self-management in patients with diabetes. Family-related questionnaires have been used to assess family function, but the Brief Family Assessment Measure (Brief FAM-III) has not been used previously in a diabetes population. We aimed to determine whether the family function is associated with glycated hemoglobin levels and quality of life as potential predictors of diabetes self-management.
An exploratory study of patients with type 2 diabetes and incipient complications and their relatives using the Brief FAM-III, a self-report questionnaire comprising 3 scales assessing family function according to different perspectives: a general score, a dyadic relationship score and a self-rating score.
We included 127 patients: 72.4% males, mean age 65.23 (SD=10.26) years; glycated hemoglobin levels, 6.9% (SD=0.9%); diabetes duration, 9.1 (SD=0.6) years; and body mass index, 30.8 (SD=0.5) kg/m². Mean FAM-III scores for the 3 scales were 41.7 (SD=1.0), 41.5 (SD=0.9) and 38.5 (SD=1.1), respectively. Correlation coefficients were −0.06 (p=0.37), −0.09 (p=0.18) and −0.12 (p=0.06), showing no significant correlation between scales and glycated hemoglobin levels levels in the 3 perspectives before and after adjustment for confounders. Family function correlated with burden of diabetes at 0.14 (p=0.02), 0.24 (p=0.0003) and 0.16 (p=0.01), respectively, and mental health at −0.21 (p=0.0007), −0.23 (p=0.0005) and −0.25 (p<0.0001), respectively.
The results of our study suggest that in patients with type 2 diabetes, family function does not predict the level of glycemic control. However, we found an association among healthy family function, low burden of diabetes and strong mental health, issues that are important for the patients' quality of life, compliance with lifestyle factors and diabetes self-management.
La famille a une influence sur la perception de la prise en charge autonome du diabète chez les patients diabétiques. Des questionnaires sur la famille ont été utilisés pour évaluer le fonctionnement familial, mais le questionnaire court du FAM-III (Brief Family Assessment Measure) n'a jamais été utilisé auprès d'une population de personnes diabétiques. Nous avions pour objectif de déterminer si le fonctionnement familial est associé aux concentrations de l'hémoglobine glyquée et s'il constitue un prédicteur potentiel de la prise en charge autonome du diabète.
Il s'agissait d'une étude exploratoire auprès de patients atteints du diabète de type 2 et de complications naissantes au moyen du questionnaire court FAM-III, un questionnaire d'auto-évaluation qui consiste en 3 échelles d'évaluation du fonctionnement familial selon différentes perspectives : un score général, un score de relation dyadique et un score d'auto-évaluation.
Les variables des 127 patients admissibles sont les suivantes : 72,4 % d'hommes, âge moyen de 65,23 ans (ÉT=10,26); concentrations de l'hémoglobine glyquée, 6,9% (ÉT=0,9 %); durée du diabète, 9,1 ans (ÉT=0,6); indice de masse corporelle, 30,8 kg/m² (ÉT=0,5). Les scores moyens aux 3 échelles du FAM-III étaient respectivement de 41,7 (ÉT=1,0), de 41,5 (ÉT=0,9) et de 38,5 (ÉT=1,1). Les coefficients de corrélation étaient de –0,06 (p=0,37), de −0,09 (p=0,18) et de −0,12 (p=0,06), et ne démontrent aucune corrélation significative entre les échelles et les concentrations de l'hémoglobine glyquée dans les 3 perspectives avant et après l'ajustement des variables confusionnelles. Le fonctionnement familial corrélait avec le fardeau du diabète à 0,14 (p=0,02), à 0,24 (p=0,0003) et à 0,16 (p=0,01), et ce, de façon respective, et avec la santé mentale à −0,21 (p=0,0007), à −0,23 (p=0,0005) et à −0,25 (p<0,0001), et ce, de façon respective.
Notre étude montre que chez les patients atteints du diabète de type 2, le fonctionnement familial n'est pas un prédicteur de la régulation de la glycémie. Toutefois, nous avons observé une association entre le fonctionnement familial sain, le faible fardeau de diabète et la bonne santé mentale, des aspects importants de la qualité de vie des patients, de l'adhésion aux facteurs liés au mode de vie et de la prise en charge autonome du diabète.

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Review articleAdherence to Treatment: The Key for Avoiding Long-Term Complications of Diabetes

Section snippets

The Magnitude of the Problem

How to Define and Measure Adherence to Treatment

Adherence to Treatment in Diabetes

Main Barriers for Diabetes Self-Care Management

Strategies to Improve Adherence to Treatment in the Type 2 Diabetic Patient

Models of Care

Conclusions

Biomed Pharmacother

Lancet

Clin Ther

Behav Res Ther

Biol Psychiatry

The fattening burden of type 2 diabetes on Mexicans

Diabetes Care

Prevalencia e interrelación de enfermedades crónicas no transmisibles y factores de riesgo cardiovascular en México

Arch Cardiol Mex

The ethics of caring and medical education

Acad Med

Interventions to enhance patient adherence to medication prescriptions: scientific review

JAMA

Helping patients follow prescribed treatment: clinical implications

JAMA

Undiagnosed hypertension and hypercholesterolemia among uninsured and insured adults in the Third National Health and Nutrition Examination Survey

Am J Public Health

JAMA

Report on medication adherence

Measuring attitudes and health beliefs among Mexican Americans with diabetes

Diabetes Educator

Methodological issues in diabetes research. Measuring adherence

Diabetes Care

Diabetes in United States Latinos: more than a growing concern

Clin Diabetes

Global estimates for prevalence of diabetes mellitus and impaired glucose tolerance in adults

Diabetes Care

Behavioral science in diabetes

Diabetes Care

Introduction

The relationship between the health belief model and compliance of persons with diabetes mellitus

Diabetes Care

In diabetes care, moving from compliance to adherence is not enough. Something entirely different is needed

Diabetes Care

Adherence to diabetes regimens. Empirical status and clinical applications

Diabetes Educator

Psychosocial barriers to diabetes self management and quality of life

Diabetes Spectrum

A systematic review of adherence with medications for diabetes

Diabetes Care

Depression and diabetes

Arch Intern Med

Effects of a once daily and twice daily dosing on adherence with prescribed glipizide oral therapy for type 2 diabetes

South Med J

Adherence to prescribed oral hypoglycemic medication in a population of patients with type 2 diabetes, a retrospective cohort study

Diabet Med

Insulin omission in women with IDDM

Diabetes Care

Utilization of oral hypoglycemic agents in a drug insured U.S. population

Diabetes Care

Review article
Adherence to Treatment: The Key for Avoiding Long-Term Complications of Diabetes