How Do We Ensure Adherence In Patients With Diabetes For A Better Quality Of Life?

David G. Armstrong DPM MD PhD

Given the mounting evidence that patients with diabetes have a lower quality of life if they do not adhere to their foot care regimens, how can physicians drive home the importance of adherence?

A recently published study outlined the dangers of non-adherence.1 The authors focused on 500 patients with type 2 diabetes who had been diagnosed for at least a year. Using a chi-squared test, the study authors found a significant association between non-adherence to foot care and problems with mobility, self-care and usual activities, as well as a significant association between non-adherence and exercise and poor mobility, self-care, usual activities, pain and anxiety. In addition, non-adherence to diet was associated with poor mobility. The authors found that about 50.4 percent of patients had problems in mobility, 28.2 percent had problems with self-care, 47.6 percent had difficulties with usual activities, 72.8 percent had pain/discomfort and 73.6 percent had anxiety/depression.

The issue here is something that we have been working on for much of my career. It is both complex and simple. The complex aspect of this involves the fact that our patients have lost what one of my mentors, Paul Brand, MD, called "the gift of pain." Literally, when something doesn't hurt, the perception is that it isn't broken.

This has profound implications on how we behave and the choices we make whether we are doctors or patients. As doctors, we tend to have less of a sense of urgency around someone who is not writhing in pain (it is just human nature). As patients, the lack of that feedback fundamentally changes what is important. Even when we instinctively understand what can happen, the hole in our foot becomes 11th on the 10 most important things to do.

I think we have to strike a balance with what the marketers and political class might call messaging. If we as clinicians stay on message and keep that message short and impactful — and if we keep repeating it until it rings in ours and our patients' ears — then our therapeutic partner might best work to meet us halfway.

Also, we are working hard to develop inexpensive technologies that can serve as an "early warning system" around the house (smart monitors/bathmats) and on the patient (Smart Sox). I foresee a day when our patients or our patients' families might "subscribe" to these tools just as they do to their mobile phone or their cable/Netflix.


1. Saleh F, Mumu SJ, Ara F, et al. Non-adherence to self-care practices & medication and health related quality of life among patients with type 2 diabetes: a cross-sectional study. BMC Public Health. 2014 May 7;14:431.

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