Adults with diabetes who perceive family members’ behaviour as unsupportive are less adherent to their medication regimen
- Correspondence to: Richard W Grant
Division of Research, Kaiser Permanente Northern California, 2101 Webster, Oakland, CA 93452, USA;
Commentary on: Mayberry LS, Osborn CY. Family support, medication adherence, and glycemic control among adults with type 2 diabetes. Diabetes Care 2012;35:1239–45.
Implications for practice and research
Understanding the family dynamics is crucial to improve diabetes management.
Family members can both support and sabotage the patient's self-management efforts.
Adults with type 2 diabetes see their physician more often than most other patients. National survey data indicate that the typical patient with diabetes will have seven to nine appointments in a year with their primary provider and additional visits with specialists, nurses and educators.1 Added together over the course of a year clinical care interactions represent <1% of an individual's daily life. For the other 99% of the time, people must self-manage their disease within the context of their families, workplaces and communities. To truly change current levels of diabetes control, we must move beyond the patient–provider (or even patient-medical team) paradigm and increase our focus on the context outside of the medical system.
Individuals interact closely with their family and friends; live in communities that include local neighbourhoods, workplaces and other social networks; and experience the overall influence of a society's expectations and norms. Understanding and changing this larger context may be the key to ameliorating the unhealthy lifestyles that induce and perpetuate type 2 diabetes. The recent study by Mayberry and Osborn provides one small window into this larger world by focusing on the positive and negative impacts of family on adults with type 2 diabetes and their attempts to self-manage diabetes by maintaining healthy lifestyles and adhering to prescribed medicines. This study was a qualitative analysis of focus group discussions (n=45) nested within a quantitative analysis of survey responses (n=61).
Focus group transcripts featured frequent references by participants to the role of their families, including both supportive and non-supportive (or ‘sabotaging’) behaviours of family members. While there is fairly extensive literature on family dynamics in type 2 diabetes,2 ,3 this new article serves to remind us of family members’ potential to undermine patient self-management efforts. Without longitudinal outcome measures, however, participant comments during focus groups must be interpreted with caution. For example, the authors report that perceiving family members as non-supportive was associated with lower medication adherence. The mechanism of this association is unclear, since most of the comments quoted in the paper referred to sabotaging effects related to food rather than to medication taking (which is an individual behaviour typically less dependent on others). One wonders if some of the negative comments made by wives about husbands and parents about children may reflect deeper underlying relationship issues not directly related to diabetes itself.
Mayberry and Osborn's report points to one piece within the larger puzzle of the patient experience outside of the medical care environment. Two recent landmark papers further underscore the critical role of social networks in chronic, behaviourally related conditions. Using detailed relationship data, these investigators found that a person's chances of becoming obese increased by 57% if he or she had an obese friend, by 40% if his or her sibling became obese and by 37% if his or her spouse became obese.4 Conversely, healthy behaviours were also strongly influenced by social context: smoking cessation by a spouse increased a person's chances of quitting smoking by 67%, cessation by a sibling increased the chances by 25% and cessation by a friend by 36%.5 Taken together, these and other research studies underscore the tremendous impact of social context on lifestyle behaviours that are central to diabetes self-management. Indeed, a recent, groundbreaking Institute of Medicine report advocates a bold vision to improve the health of the nation by implementing structural changes in schools, workplaces, communities, media and food and beverage systems.6 Although politically controversial, efforts to address these behaviours through public health and social interventions may represent our best chance to turn the tide of the diabetes epidemic.