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Am Fam Physician. 2000;61(3):644-647

to the editor: Primary care physicians handle more than 75 percent of all ambulatory visits made by patients with diabetes, a disease that affects 16 million Americans, kills 160,000 annually and accounts for one of every $7 related to health care.1 A recent article in Diabetes Care2 reported that primary care providers rate diabetes as “harder to treat” than five other chronic conditions. Explanations ranged from the characteristics of diabetes itself, to the lack of support from the health care system, to “horrible struggles” [sic] with patients because of food restrictions, to patients who fail to follow medical recommendations.

The treatment of patients with diabetes has undergone dramatic changes over the past 10 years. Major studies have shown that the culprit of complications is chronic hyperglycemia and not any particular food.3 These studies have emphasized the importance of tailoring treatments to the individual patient's needs and lifestyle, with no one treatment plan privileged over another—as long as the goal of normalizing blood glucose is attained. Furthermore, the American Diabetes Association has eliminated the use of the term “diabetic diet,” which it now considers inappropriate because numerous factors are known to influence metabolic response to food. Yet, often times physicians (and even patients) attribute unexplained hyperglycemia to patients “cheating” on prescribed diets that frequently exclude sugar and other specific foods. Noncompliance is considered a major barrier in treating patients with diabetes. While several studies address the other side of the patient noncompliance equation,4 a few1,5 examine the medical adequacy of recommendations.

Our study6 involved focus groups within two Internet-based diabetes support groups using the cited information2 as a generating tool. Participants commented on physicians' statements, and both sets of statements were compared. Unlike physicians, patients perceived the following factors as major barriers to compliance: (1) physicians' insufficient knowledge about diabetes (making vague statements such as “Your diabetes is mild,” “You [patients with type 2 diabetes] shouldn't use insulin,” or “Stay away from sugar”), (2) physicians' limited ability to handle psychosocial aspects of diabetes and (3) physicians' tendency to blame patients for treatment failures.

Albeit preliminary, our findings should warn physicians about oversimplifying barriers to diabetes care. If medical recommendations are inappropriate, compliance would be counterproductive. Furthermore, compliance itself might be inadequate in addressing a disease that requires a dynamic relationship between technical expertise of treatment and the experiential knowledge about living with diabetes.6 Quality diabetes care calls for patients' active participation and change within the health care system, as well as for a major restructuring at the level of physician education,1 in medical school and continuing education. An encompassing approach to diabetes care should serve as a foundation to rethink barriers to treatment, improve the quality of medical interventions, decrease the financial burden of diabetes and orient research resources.

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