I was thrilled to serve as guest editor of this Diabetes Spectrum From Research to Practice section, “Behavioral Interventions to Promote Diabetes Self-Management.” My enthusiasm for this special section results from my conviction that patient behavior is the cornerstone of diabetes management. Although health care providers can inform and support diabetes self-management through practical strategies,1 I would venture to guess that 95% of diabetes management happens outside of clinics, beyond providers' awareness, and without direct provider influence. It is patients who make the day-to-day and moment-to-moment decisions that accumulate to form patterns, habits, and eventually a lifestyle.
In the several decades that I have followed trends in diabetes treatment, there have been truly remarkable advances in diabetes technology such as home blood glucose monitoring, continuous subcutaneous insulin infusion, and continuous glucose monitoring. New therapeutic agents have been developed, and hormones other than insulin that are important to glucose control can now be replaced. These advances have improved the health of many patients and should not be understated.
Yet, these advances are beneficial only to the extent that patients use them appropriately. To do so, patients require knowledge, problem-solving skills, motivation, environmental support, and the ability to cope effectively with life's many stressful interferences. Even when used appropriately, medical technology does not address the multiple lifestyle changes that patients with diabetes are asked to make, including eating a healthy diet, increasing their physical activity, managing stress, and adopting a daily routine that accommodates self-management behaviors.
Medical technology is also no match for the numerous deleterious contextual factors that impinge on healthy lifestyles, including inequitable distribution of economic resources, a struggling health care system, pervasive availability of unhealthy foods, limited environmental support for physical activity, and marketing of tobacco and other toxins to vulnerable populations. Because of the behavioral challenges of daily diabetes self-management and despite the technological advances in diabetes care, our patients have limited resources, and perhaps limited free will, in their management decisions.
Yet, the series of articles in this From Research to Practice section shows that individual behavior can in fact be shaped and that behavioral interventions can indeed help patients make better choices for their own diabetes self-management, even in the context of difficult circumstances. Our first article, by Kristina P. Schumann, MA, et al. (p. 64), reports on the efficacy of a theory-based intervention that teaches low-income, low-literacy, African-American patients the process of effective problem-solving for diabetes self-management. Next, Margaret Grey, DrPH, RN, FAAN, describes a series of studies that test an intervention to teach youths with type 1 diabetes to cope more effectively with stress (p. 70). The third article, by Manuel Barrera, Jr., PhD, et al. (p. 75), shows that, with a strong dose of a multifaceted behavioral intervention, even multiple lifestyle behaviors can be changed in both white and Latina women. Contributors Vicki DiLillo, PhD, and Delia Smith West, PhD (p. 80) then explain how motivational interviewing can help with lifestyle changes to promote weight loss in overweight patients with type 2 diabetes. Finally, Tricia S. Tang, PhD, et al. suggest that patient-to-patient peer support may be a promising approach to provide ongoing intervention in a resource-strapped health care environment (p. 85). Some of these behavioral interventions not only improve behavioral and psychosocial outcomes, but also have a positive impact on glycemic control.
These important lines of research, while demonstrating the benefits of behavioral interventions, raise as many questions as they answer. First, which theories and respective interventions are superior? The efficacy of a single intervention is relatively easy to demonstrate when compared to usual care. Yet this common study design does not compare one theory-based intervention to another, thus preventing a test of competing behavior-change theories.2
Second, for whom do these interventions work best? Clinicians want to know how to match patients to treatments and are increasingly sensitive to the cultural fit (or lack thereof) between given patients and interventions.
Third, what are the mechanisms of action of these interventions? A recent meta-analysis3 suggests that multicomponent interventions targeting emotional, social, or family processes that facilitate diabetes management are more potent than interventions just targeting one direct behavioral process. Identifying active ingredients and determining the necessary and sufficient doses of those ingredients would allow us to focus resources on the most crucial elements of an intervention.
Fourth, how can we maintain lasting behavior change once we have initiated it? Results from numerous weight loss interventions demonstrate a need for greater consideration of behavior maintenance strategies.4
And finally, how can we effectively disseminate interventions to the larger population of people with diabetes? Even the most effective interventions are useful only to the degree that patients have access to them. The Internet, telemedicine, peers and community health workers, and mobile electronic devices all hold promise in this regard.
Thus, the magnitude of the behavioral diabetes research agenda is impressive, and the answers will not come quickly or in a straightforward manner. In the meantime, the interventions discussed in this research section give patients some of the tools they need—the behavioral technology—to more effectively navigate their world with diabetes. They also give health care providers greater ability to inform and support their patients with diabetes.
