Diabetes self-management refers to the ongoing process in which individuals with diabetes actively participate in managing their condition through lifestyle choices, medication adherence, blood glucose monitoring, and education, aimed at maintaining optimal blood sugar levels and preventing complications.
Diabetes is a chronic disease affecting over 537 million adults worldwide in 2021 and predicted to reach 643 million people by 2030. [1] It is a global health burden and improving the health outcomes for people with diabetes is critical to reducing the economic and human burden of diabetes. [2] Self-management is the cornerstone for successful health outcomes in diabetes patients as there is a positive association between self-management behaviour and care outcomes. [3] [4] Self-management stresses the importance of the role of an individual and their responsibility in developing skilled behaviours to manage one's own illness. [5]
Healthcare organisations are increasingly focusing on providing diabetes self-management education and support programs to enable diabetes patients to effective self-management. [6] Diabetes patients face daily challenges due to the impact of their decisions on their health outcomes. Diabetes self-management helps diabetes patients to make better decisions and change their behaviour to achieve better outcomes. Diabetes self-management activities mainly consist of seven self-care behaviours. They are healthy eating, monitoring indicators of diabetes, physical activity, taking medication, healthy coping, and problem-solving. [7]
Diabetes patients with peripheral neuropathy and peripheral artery disease are at risk of developing foot ulcers and infection. [8] Poor knowledge about self-care increases the risk of amputation. [9] Adoption of suitable preventative measures and early treatment of diabetic foot problems are important components of diabetes foot care. [8] Good knowledge and practice regarding diabetes foot care can reduce the risk of foot complications and amputation. [10] Regular examination of the foot is one of the fundamental steps to modifying the foot risk factors thereby reducing the risk of ulceration and amputation. [9] Footwear tailored to the specific pathology of the patient can enable conservative management of the foot including debridement of the callus. Appropriate footwear can reduce abnormal pressure, reduce the rate of formation callus and ulcers and protect the foot from external trauma. [9]
Regular monitoring of blood glucose and optimal glucose control is a major part of diabetes self-management. Diabetes patients need to be capable of testing blood sugar at home at the recommended frequency. [6] Frequent self- monitoring of blood glucose and record keeping is key to identifying the possibility of hypoglycemia. [11] Diabetes patients should be able to know how to respond when blood sugar levels are too high or too low. [6]
Effective medication is the cornerstone of the proper treatment of diseases. [12] Many patients fail to take the medication as prescribed and many patients prematurely discontinue their medication. Poor medication adherence in patients with diabetes is a costly public health challenge in many healthcare systems. [12] Non-adherence to medication leads to poor treatment outcomes and the progression of diseases and complications. [13] The medication adherence of type 1 and type 2 diabetes patients assessed using self-report, pill counts, electronic monitoring devices and medication possession ratio found that the medication adherence rates ranged from 31% to 87%. [14] The medication adherence of diabetes patients is also measured by persistence which is defined by the proportion of patients who remained in treatment for a predetermined period and the mean number of days till discontinuation of treatment. [15] The persistence rates ranged from 16% to 63% at 12 months and ranged from 29% to 70%. [14]
Physical activity has a favourable influence on the health and well-being of diabetes patients as it achieves physiological changes, including improved overall glycemic control, liver insulin sensitivity, muscle glucose uptake and utilisation and overcomes the metabolic abnormalities related to type 2 diabetes. [16] [17] [18] Diabetes patients can undertake light to moderate physical activity. [11] The type of physical activity that can be performed by diabetes patients needs to be determined after consultations with health care providers. [19] The physical activities recommended for diabetes patients include brisk walking, recreational games and leisure time activities. [11] The most benefit of physical activity happens in the early progression of the disease. [20]
A healthy diet is one component of the management of diabetes. Dietary self-care behaviours include eating a low-saturated-fat diet making choices based on the glycemic index of food and controlling the amount of carbohydrates in food. [6] Sticking to the eating plan and following the diet plan when eating from a restaurant or when feeling stressed is a major challenge for diabetes patients. [6]
Understanding the levels (recommended practices) and patterns (specific behaviors) of primary daily diabetes self-management from a heterogeneous sample population is essential to devise suitable interventions to enhance the daily diabetes management of diabetes patients. Many of the diabetes self-management data involve only a small and highly selected sample, which does not represent the minorities and disadvantaged communities. The study conducted on a heterogeneous sample of population including minorities found that self-management levels increase with age. [5] The same study found that retired individuals and homemakers have better self-management than employed individuals.
Diabetes patients need to actively self-manage their diseases in everyday life for good diabetes outcomes. [21] However, there are certain barriers to the effective day-to-day management of the disease. This section identified the main barriers to the effective self-management of diabetes.
Financial constraints or poverty is a barrier to effective self-management as it prevents access to food, healthcare, medication and information. [4] The most significant impact of lack of financial resources is on the food consumption pattern, resulting in a vicious cycle of high carbohydrate consumption and hyperglycaemia. [4] Diabetes patients with limited financial resources often report that they find it difficult to purchase adequate food and it becomes impossible to buy different food for the family. [22] Financial difficulties cause diabetes care to become a problem of least importance as they have more pressing needs such as feeding the family and repaying loans. [23] When it comes to buying medicines for diabetes management, people from poor financial backgrounds choose food over medicine. To save costs, people from poor economic backgrounds alter the prescribed dosage of medication and medication is often taken with diabetes complications or the development of co-morbid illness. [23]
The attitude towards self-care behaviour is influenced by the local belief systems and social norms. [4] [24] Patients who attribute diabetes control to god are less likely to self-manage and control their sugar intake. [25] A study found that subjective norms attributed to 49% of the variance in the intent to perform diabetes-related self-management. [24]
An individual's and their family's beliefs about diabetes influence how they make sense of their disease and make efforts to manage their illness. [26] For example, individuals who are not adhering to the dietary intake shared the view that their decision to not follow the required dietary pattern is because they believe that their family, friends and peers would not approve of their diet. [27] Inadequate family support and cultural beliefs prevent diabetes patients from adhering to a diet with low-saturated fatty acids. [28] In Subsaharan Africa, diabetes patients face social stigma from family and community members from diabetes and diabetes-related self-management requirements which prevent diabetes-related self-care. [28] A study found that when there is diabetes that runs in the family, it becomes a family affair and participants normalise and downplay the seriousness of the disease. [26]
Gender-based family roles prevent adhering to the medication. In a study, woman responsible for house duties were found to have inadequate time to visit health facilities resulting in their ignoring their health care needs such as diabetes management. [23]
Diabetes knowledge has a significant influence on the self-care and glycemic control of a diabetes patient. [21] The lower knowledge about diabetes can affect diabetes management. Studies have found that patient's lack of knowledge and poor self-care practice is increasing the severity of diabetes every year. [29] [21] The level of education is a factor that has a positive correlation with self-care knowledge. [21]
Family support is highly beneficial for effective self-care. Diabetes-related stigma leads to a lack of family support and poor diabetes-related self-management behaviours. [4]
Diabetes patients expressed dissatisfaction with the attitude of healthcare professionals as they directly wrote prescription and directions without a proper conversation with the patients. [23] This prevents patients from asking lingering questions about their health conditions and management.
Inadequate coordination between the health care providers and diabetes patients is a major barrier to properly implementing the care guidelines. [30] Lack of collaboration and coordination leads to information conflict affecting the quality of self-management. [30] The diabetes patients who were identified to develop healthy diabetes management habits had a supportive patient-provider relationship. [31] People from economically disadvantaged backgrounds can have limited access to care which is one reason for inadequate coordination between healthcare providers and patients. [31]
Healthcare professionals play a crucial role in diabetes self-management. Diabetes patients rely on health care professionals to obtain information and support in developing an individualised self-management plan. [5] Self-management goals and recommendations given by health care professionals were identified to have a significant positive impact on the eating habits and physical activity of diabetes patients. Lack of proper emphasis on self-management may suggest to diabetes patients that self-management is either less important or even unimportant for diabetes management. [5]
Blood glucose monitoring is the use of a glucose meter for testing the concentration of glucose in the blood (glycemia). Particularly important in diabetes management, a blood glucose test is typically performed by piercing the skin to draw blood, then applying the blood to a chemically active disposable 'test-strip'. The other main option is continuous glucose monitoring (CGM). Different manufacturers use different technology, but most systems measure an electrical characteristic and use this to determine the glucose level in the blood. Skin-prick methods measure capillary blood glucose, whereas CGM correlates interstitial fluid glucose level to blood glucose level. Measurements may occur after fasting or at random nonfasting intervals, each of which informs diagnosis or monitoring in different ways.
Hyperglycemia or Hyperglycaemia is a condition in which an excessive amount of glucose (glucotoxicity) circulates in the blood plasma. This is generally a blood sugar level higher than 11.1 mmol/L (200 mg/dL), but symptoms may not start to become noticeable until even higher values such as 13.9–16.7 mmol/L (~250–300 mg/dL). A subject with a consistent fasting blood glucose range between ~5.6 and ~7 mmol/L is considered slightly hyperglycemic, and above 7 mmol/L is generally held to have diabetes. For diabetics, glucose levels that are considered to be too hyperglycemic can vary from person to person, mainly due to the person's renal threshold of glucose and overall glucose tolerance. On average, however, chronic levels above 10–12 mmol/L (180–216 mg/dL) can produce noticeable organ damage over time.
Type 2 diabetes (T2D), formerly known as adult-onset diabetes, is a form of diabetes mellitus that is characterized by high blood sugar, insulin resistance, and relative lack of insulin. Common symptoms include increased thirst, frequent urination, fatigue and unexplained weight loss. Symptoms may also include increased hunger, having a sensation of pins and needles, and sores (wounds) that do not heal. Often symptoms develop slowly. Long-term complications from high blood sugar include heart disease, stroke, diabetic retinopathy, which can result in blindness, kidney failure, and poor blood flow in the lower-limbs, which may lead to amputations. The sudden onset of hyperosmolar hyperglycemic state may occur; however, ketoacidosis is uncommon.
The Mediterranean diet is a concept first invented in 1975 by the American biologist Ancel Keys and chemist Margaret Keys. The diet took inspiration from the supposed eating habits and traditional food typical of southern Spain, southern Italy, and Crete, and formulated in the early 1960s. It is distinct from Mediterranean cuisine, which covers the actual cuisines of the Mediterranean countries, and from the Atlantic diet of northwestern Spain and Portugal. While inspired by a specific time and place, the "Mediterranean diet" was later refined based on the results of multiple scientific studies.
Diabetic nephropathy, also known as diabetic kidney disease, is the chronic loss of kidney function occurring in those with diabetes mellitus. Diabetic nephropathy is the leading causes of chronic kidney disease (CKD) and end-stage renal disease (ESRD) globally. The triad of protein leaking into the urine, rising blood pressure with hypertension and then falling renal function is common to many forms of CKD. Protein loss in the urine due to damage of the glomeruli may become massive, and cause a low serum albumin with resulting generalized body swelling (edema) so called nephrotic syndrome. Likewise, the estimated glomerular filtration rate (eGFR) may progressively fall from a normal of over 90 ml/min/1.73m2 to less than 15, at which point the patient is said to have end-stage renal disease. It usually is slowly progressive over years.
Microalbuminuria is a term to describe a moderate increase in the level of urine albumin. It occurs when the kidney leaks small amounts of albumin into the urine, in other words, when an abnormally high permeability for albumin in the glomerulus of the kidney occurs. Normally, the kidneys filter albumin, so if albumin is found in the urine, then it is a marker of kidney disease. The term microalbuminuria is now discouraged by Kidney Disease Improving Global Outcomes and has been replaced by moderately increased albuminuria.
The term diabetes includes several different metabolic disorders that all, if left untreated, result in abnormally high concentrations of a sugar called glucose in the blood. Diabetes mellitus type 1 results when the pancreas no longer produces significant amounts of the hormone insulin, usually owing to the autoimmune destruction of the insulin-producing beta cells of the pancreas. Diabetes mellitus type 2, in contrast, is now thought to result from autoimmune attacks on the pancreas and/or insulin resistance. The pancreas of a person with type 2 diabetes may be producing normal or even abnormally large amounts of insulin. Other forms of diabetes mellitus, such as the various forms of maturity-onset diabetes of the young, may represent some combination of insufficient insulin production and insulin resistance. Some degree of insulin resistance may also be present in a person with type 1 diabetes.
In medicine, patient compliance describes the degree to which a patient correctly follows medical advice. Most commonly, it refers to medication or drug compliance, but it can also apply to other situations such as medical device use, self care, self-directed exercises, or therapy sessions. Both patient and health-care provider affect compliance, and a positive physician-patient relationship is the most important factor in improving compliance. Access to care plays a role in patient adherence, whereby greater wait times to access care contributing to greater absenteeism. The cost of prescription medication also plays a major role.
A chronic condition is a health condition or disease that is persistent or otherwise long-lasting in its effects or a disease that comes with time. The term chronic is often applied when the course of the disease lasts for more than three months. Common chronic diseases include diabetes, functional gastrointestinal disorder, eczema, arthritis, asthma, chronic obstructive pulmonary disease, autoimmune diseases, genetic disorders and some viral diseases such as hepatitis C and acquired immunodeficiency syndrome. An illness which is lifelong because it ends in death is a terminal illness. It is possible and not unexpected for an illness to change in definition from terminal to chronic. Diabetes and HIV for example were once terminal yet are now considered chronic due to the availability of insulin for diabetics and daily drug treatment for individuals with HIV which allow these individuals to live while managing symptoms.
Pharmacotherapy, also known as pharmacological therapy or drug therapy, is defined as medical treatment that utilizes one or more pharmaceutical drugs to improve ongoing symptoms, treat the underlying condition, or act as a prevention for other diseases (prophylaxis).
Self-care has been defined as the process of establishing behaviors to ensure holistic well-being of oneself, to promote health, and actively manage illness when it occurs. Individuals engage in some form of self-care daily with food choices, exercise, sleep, and hygiene. Self-care is not only a solo activity, as the community—a group that supports the person performing self-care—overall plays a role in access to, implementation of, and success of self-care activities.
A diabetic diet is a diet that is used by people with diabetes mellitus or high blood sugar to minimize symptoms and dangerous complications of long-term elevations in blood sugar.
Patient education is a planned interactive learning process designed to support and enable expert patients to manage their life with a disease and/or optimise their health and well-being.
The dawn phenomenon, sometimes called the dawn effect, is an observed increase in blood sugar (glucose) levels that takes place in the early-morning, often between 2 a.m. and 8 a.m. First described by Schmidt in 1981 as an increase of blood glucose or insulin demand occurring at dawn, this naturally occurring phenomenon is frequently seen among the general population and is clinically relevant for patients with diabetes as it can affect their medical management. In contrast to Chronic Somogyi rebound, the dawn phenomenon is not associated with nocturnal hypoglycemia.
Telehomecare (THC) is a subfield within telehealth. It involves the delivery of healthcare services to patients at home through the use of telecommunications technologies, which enable the interaction of voice, video, and health-related data. The management of care is done from an external site by a healthcare professional.
The Patient Activation Measure (PAM) is a commercial product which assesses an individual's knowledge, skill, and confidence for managing one's health and healthcare. Individuals who measure high on this assessment typically understand the importance of taking a pro-active role in managing their health and have the skills and confidence to do so.
Diabetes mellitus, often known simply as diabetes, is a group of common endocrine diseases characterized by sustained high blood sugar levels. Diabetes is due to either the pancreas not producing enough insulin, or the cells of the body becoming unresponsive to the hormone's effects. Classic symptoms include thirst, polyuria, weight loss, and blurred vision. If left untreated, the disease can lead to various health complications, including disorders of the cardiovascular system, eye, kidney, and nerves. Diabetes accounts for approximately 4.2 million deaths every year, with an estimated 1.5 million caused by either untreated or poorly treated diabetes.
Rob Horne is Professor of Behavioural Medicine at the School of Pharmacy, University College London (UCL). In September 2006, he founded the Centre for Behavioural Medicine at UCL, which he continues to lead. Horne was designated a Fellow of the Royal College of Physicians Faculty of Pharmaceutical Medicine in 2013 and is a founding fellow of the Royal Pharmaceutical Society of Great Britain. He was appointed as a National Institute for Health Research (NIHR) Senior Investigator in 2011. He is an internationally recognised expert in self-management of chronic illness and adherence to medications.
Digital therapeutics, a subset of digital health, are evidence-based therapeutic interventions driven by high quality software programs to prevent, manage, or treat a medical disorder or disease. Digital therapeutic companies should publish trial results inclusive of clinically meaningful outcomes in peer-reviewed journals. The treatment relies on behavioral and lifestyle changes usually spurred by a collection of digital impetuses. Because of the digital nature of the methodology, data can be collected and analyzed as both a progress report and a preventative measure. Treatments are being developed for the prevention and management of a wide variety of diseases and conditions, including type 1 & type II diabetes, congestive heart failure, obesity, Alzheimer's disease, dementia, asthma, substance abuse, ADHD, hypertension, anxiety, depression, and several others. Digital therapeutics often employ strategies rooted in cognitive behavioral therapy.
The taxonomy of the burden of treatment is a visualization created for health care professionals to better comprehend the obstacles that interfere with a patient's health care plan. It was created as a result of a worldwide, qualitative-based study that asked adults with chronic conditions to list the personal, environmental, and financial barriers that burden a patient. The purpose of this visualization is to help health care providers develop personalized management strategies that the patient can follow through a narrative paradigm. The goal is to target interventions, achieve an interpersonal doctor-patient relationship, and improve health outcomes.