Behavioral Medicine: Empowering Diabetes Management
Behavioral Medicine: Empowering Diabetes Management
In the past decades, the sophistication of treatments for diabetes has increased dramatically, and evidence for effective interventions has proliferated. As a result, it is now possible to achieve excellent glucose control and reduce the risk of many of the complications associated with the disease. Despite these advances, however, many people with diabetes have less than optimal metabolic control and continue to suffer from preventable complications. The gap between optimal evidence-based medicine and actual practice can be great, dependent not only on the ability of the clinician to make changes in practice patterns but also on the central role of the patient in implementing optimal management plans in daily life. With recognition of the centrality of patients' actions to achieve optimal outcomes must come awareness that those actions reflect much more than simple "self-control." In addition to individual characteristics, the environment in which behaviors are enacted has great influence, from family eating patterns to the design of neighborhoods to workplace and national health policies. For patients and clinicians, these factors create the context or environment in which behaviors are enacted.
Diabetes provides a prime example of this fundamental interaction of individual characteristics with the ecological or contextual factors. For example, Pima Indians living in the U.S. have the highest prevalence of type 2 diabetes of any population in the world, yet Pimas living traditional lifestyles in Mexico have relatively low levels of diabetes. Ample evidence links genetics to diabetes within the Pima population, but exposure to an obesogenic environment is critical to expression of this very strong genetic propensity.
This interplay between the individual and the context in which he or she behaves is commonly cited in discussions of personal health choices and health and social policies. These perspectives have shifted in important ways over the past few decades. Previously, we thought that simply providing information would change health care and health behaviors. It was widely held that all that was necessary to change clinical practice was to inform doctors of the reasons or research behind recommendations and that changing individual health behavior was a simple matter of explaining the importance of performing specific actions. In the later decades of the twentieth century, this view of clinicians and patients as obedient adopters of facts and recommendations was replaced by two somewhat divergent viewpoints: those emphasizing characteristics of the individual versus those emphasizing the role of the broader contexts of economics, communities, organizations, cultures, and policies. This report will examine each of these in turn, before considering the synthesis of individual and context in a twenty-first century perspective of multilevel, multichannel influences. This consideration will include implications and lessons for clinical practice and development of improved approaches to promoting engagement in diabetes care, effective diabetes self-management, and quality of life among those with the disease.
Introduction
In the past decades, the sophistication of treatments for diabetes has increased dramatically, and evidence for effective interventions has proliferated. As a result, it is now possible to achieve excellent glucose control and reduce the risk of many of the complications associated with the disease. Despite these advances, however, many people with diabetes have less than optimal metabolic control and continue to suffer from preventable complications. The gap between optimal evidence-based medicine and actual practice can be great, dependent not only on the ability of the clinician to make changes in practice patterns but also on the central role of the patient in implementing optimal management plans in daily life. With recognition of the centrality of patients' actions to achieve optimal outcomes must come awareness that those actions reflect much more than simple "self-control." In addition to individual characteristics, the environment in which behaviors are enacted has great influence, from family eating patterns to the design of neighborhoods to workplace and national health policies. For patients and clinicians, these factors create the context or environment in which behaviors are enacted.
Diabetes provides a prime example of this fundamental interaction of individual characteristics with the ecological or contextual factors. For example, Pima Indians living in the U.S. have the highest prevalence of type 2 diabetes of any population in the world, yet Pimas living traditional lifestyles in Mexico have relatively low levels of diabetes. Ample evidence links genetics to diabetes within the Pima population, but exposure to an obesogenic environment is critical to expression of this very strong genetic propensity.
This interplay between the individual and the context in which he or she behaves is commonly cited in discussions of personal health choices and health and social policies. These perspectives have shifted in important ways over the past few decades. Previously, we thought that simply providing information would change health care and health behaviors. It was widely held that all that was necessary to change clinical practice was to inform doctors of the reasons or research behind recommendations and that changing individual health behavior was a simple matter of explaining the importance of performing specific actions. In the later decades of the twentieth century, this view of clinicians and patients as obedient adopters of facts and recommendations was replaced by two somewhat divergent viewpoints: those emphasizing characteristics of the individual versus those emphasizing the role of the broader contexts of economics, communities, organizations, cultures, and policies. This report will examine each of these in turn, before considering the synthesis of individual and context in a twenty-first century perspective of multilevel, multichannel influences. This consideration will include implications and lessons for clinical practice and development of improved approaches to promoting engagement in diabetes care, effective diabetes self-management, and quality of life among those with the disease.
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