Education And Debate

Management of diabetes: are doctors framing the benefits from the wrong perspective?

BMJ 2001; 323 doi: (Published 27 October 2001) Cite this as: BMJ 2001;323:994
  1. Howard A Wolpert, senior physiciana (,
  2. Barbara J Anderson, research investigatorb
  1. a Section of Adult Diabetes, Joslin Diabetes Center, One Joslin Place, Boston, MA 02215, USA
  2. b Behavioral and Mental Health Research Unit, Joslin Diabetes Center
  1. Correspondence to: H A Wolpert
  • Accepted 5 September 2001

Several large intervention studies have shown that intensive glucose management in diabetic patients can prevent microvascular complications. 1 2 Furthermore, analysis of cost effectiveness in these studies indicates that the lifetime improvement in quality of life and longevity derived from intensive management would outweigh the increased costs of such treatment. 3 4 Nevertheless, tight glycaemic control has proved difficult to achieve in clinical practice. Even patients who have received comprehensive diabetes education and are skilled in self management have difficulty maintaining optimal glycaemic control in the long term. During the four years after completion of the diabetes control and complications trial, the median glycated haemoglobin concentrations of the intensive treatment cohort rose to 7.9% (up from a median value of 7.0-7.2% during the trial).5 Other studies have shown that education on self management of diabetes without interventions to reinforce behavioural change does not lead to sustained improvements in glucose control.6

Many factors can directly and indirectly influence disease management behaviour and metabolic control of people with diabetes. In addition to individual variables (biological and psychological factors), patient behaviour is influenced by transactions within the family system, the broader social and cultural community, and socioeconomic and healthcare system factors.7 In this article we focus on the influence from within the healthcare system—that is, the healthcare provider's message about the benefits of optimal glycaemic control—and argue that the message needs to be framed from the perspective of the patient.

Summary points

Because diabetes is a self managed condition, successful models of care must focus on strategies that promote and maintain improved selfcare behaviour

New treatment frameworks are needed to enhance the effectiveness of clinicians in promoting behavioural change

The message about the benefits of tight glycaemic control needs to be refocused from the perspective of the patient

The benefits of intensive …

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