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October 4, 2000

The Problem With Compliance in Diabetes

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JAMA. 2000;284(13):1709. doi:10.1001/jama.284.13.1709-JMS1004-6-1

What's the hardest thing about taking care of people with diabetes? Many health professionals would answer that patients with diabetes do not do what they are told. It is common to hear them express frustration and sorrow that their patients just don't follow their diet or exercise plans, that they don't check their blood sugars or even take their medicines.

Behavioral scientists have studied the problem of noncompliance (or nonadherence) extensively. They have tried to find the right approach or technique to convince patients to follow medical advice. In talking with both health professionals and people with diabetes, we have come to believe that the traditional approach to the care of diabetes and other chronic diseases may actually promote noncompliance. The adage that every system is perfectly designed for the results that it achieves is true for the way most physicians presently deliver diabetes care. While it might be appropriate for patients with acute disease to turn over responsibility for their treatment to health care experts, this method is likely to fail when health professionals try to take responsibility for the care of chronic disease. Chronic disease care is fundamentally different. It requires a different vision and a redefinition of the patient-physician relationship.1

More than 95% of diabetes care is done by the patient, and health professionals have very little control over how patients manage their illness between office visits. Patients manage their diabetes on a daily basis within the context of the other goals, priorities, health issues, family demands, and other personal concerns that make up their lives; they have the right to set goals and decide how they will manage their illness because they have to carry out those decisions and live with the consequences. Physician-directed, compliance-oriented care is not an effective approach. Because diabetes is a self-managed disease, patients are more than passive recipients of medical expertise. For diabetes care to succeed, patients must be able to make informed decisions about how they will live with their illness.

Our definition of noncompliance is 2 people working toward different goals. Diabetes care often becomes a struggle although both physicians and patients generally want positive health outcomes and good quality of life. Patients often become frustrated and dissatisfied if they feel that they are being judged and blamed for their inability or unwillingness to achieve medical goals, or if the physician does not consider their goals to be important. Once patients are viewed as collaborators who establish their own goals, the whole concept of compliance becomes irrelevant. When patients work toward their own goals, their motivation is intrinsic. Because true and lasting motivation comes from within, patients are able to make and sustain changes in their behavior using this patient-centered approach.2,3

In our work with patient empowerment we have found that this orientation leads to effective care that eliminates the problem of noncompliance. There are at least 2 steps in this process. First, roles and responsibilities need to be redefined to match the reality of diabetes care. Second, patients and physicians must create relationships that promote collaboration and partnership.46

We find that if physicians view themselves as experts whose job is to get patients to behave in ways that reflect that expertise, both will continue to be frustrated. However, when health professionals let go of the traditional view of provider-centered care and recognize the patient as the primary decision-maker, they become more effective practitioners.

This new vision has led to patient-provider relationships that are based on mutual expertise and responsibility. Once physicians recognize patients as experts on their own lives, they can add their medical expertise to what patients know about themselves to create a plan that will help patients to achieve their goals. We found that when health professionals actively support patients' efforts to achieve their own goals, the resulting commitment and self-motivation leads to positive outcomes.7,8

Assessing patients' goals, capabilities, priorities, skills, supports, and barriers puts them at the center of the interaction about disease management. One simple but powerful strategy is to start each visit by asking questions such as, "What are your concerns?" or "What would you like to get from today's visit?" To learn about patients' goals and priorities, ask "What's hard for you?" "What confuses, concerns or frightens you?" "What's most important for you?" and "How can I help you reach your goals?" The physician's role is to assess and understand the patient, and to offer both emotional support and clinical expertise to help patients achieve their goals.

So, what can we do about the problem of noncompliance? In our experience, once health professionals eliminate the idea of noncompliance from their vision and approach to patients, it disappears as a problem.

Anderson  RMFunnell  MM Compliance and adherence are dysfunctional concepts in diabetes care.  Diabetes Educ. 2000;26597- 604Article
Funnell  MMAnderson  RMArnold  MS  et al.  Empowerment: an idea whose time has come in diabetes education.  Diabetes Educ. 1991;1737- 41Article
Anderson  RMFunnell  MM The Art of Empowerment: Stories and Strategies for Diabetes Educators.  Alexandria, Va American Diabetes Association2000;
Funnell  MM Lessons learned as a diabetes educator.  Diabetes Spectrum. 2000;1369- 70
Glasgow  REAnderson  RM In diabetes care moving from compliance to adherence is not enough.  Diabetes Care. 1999;22090- 2091Article
Anderson  RMFunnell  MM Theory is the cart, vision is the horse: reflections on research in diabetes patient education.  Diabetes Educ. 1999;2543- 51Article
Anderson  RMFunnell  MMButler  PMArnold  MSFeste  CC Patient empowerment: results of a randomized controlled trial.  Diabetes Care. 1995;18943- 949Article
Anderson,  RM Patient empowerment and the traditional medical model: a case of irreconcilable differences?  Diabetes Care. 1995;18412- 414