Interview with Dr. Bill Polonsky: Why Don’t Some People Take Their Diabetes Medications?
By Yrenly Yuan, Ava Runge, Lynn Kennedy, and Adam Brown
Plus, what people with diabetes and healthcare providers can do
Behavioral diabetes expert Dr. Bill Polonsky recently spoke to diaTribe and shared his thoughts on how to help people with diabetes succeed in taking their medications. What drives people to skip taking medications, and what can be done about it?
Dr. Polonsky is a renowned clinical psychologist and certified diabetes educator who focuses on the emotional and psychological aspects of having diabetes. He founded the Behavioral Diabetes Institute, where he works to help patients succeed with treating their diabetes.
Dr. Polonsky explained the two major barriers to consistently taking a drug, particularly insulin: (i) the inconvenience of taking it; and (ii) people’s fundamental beliefs about whether the medication is working.
First, people often doubt whether or not their medications actually work, causing some to stop taking them altogether. This is especially true in diabetes, where the benefits of using insulin or other medications may not be immediately apparent – eye, kidney, and nerve damage takes many years of high blood glucose to develop. Others avoid dosing insulin or taking prescription medications because they serve as an unwelcome reminder: “I have diabetes.”
To address these obstacles, Dr. Polonksy advocated for better therapy convenience and more open and honest conversations between healthcare providers and patients. He also touched on controversial terms like “adherence” and “compliance.” See below for highlights from the conversation.
Interview with Dr. Polonsky
diaTribe: Can you please explain the purpose of your recent study on insulin therapy in people with type 2 diabetes?
Dr. Polonsky: Our medications work pretty well when people take them, and we can confidently say that medications don’t work well when people don’t take them. The problem isn’t that we need more powerful medications, it’s that we need to work in a more collaborative and powerful fashion with patients in order to help them be successful and use the tools that we do have.
diaTribe: Can you also explain to us the effects of diabetes stress or feelings of dissatisfaction or discouragement? How does that impact people with diabetes?
Dr. Polonsky: To be fair, some of those reasons don’t have much to do with patients. I really don’t want to be blaming patients, because we strongly believe that no one is unmotivated to live a long, healthy life. So there are two large contributors to not taking medications, which are inconvenience – a big factor – and people’s fundamental beliefs about their medication. For instance, they might have conscious or unconscious doubts about the efficacy of their medication.
A large body of research on this topic is called a necessity-concerns framework. We could look at a person’s mindset between pros and cons of diabetes medication, and you can quickly see the dilemma: you don’t have a lot of immediate, tangible evidence that what you’re doing is effective, because the real outcome is actually down the road, avoiding the long-term complications. Also for many people, the idea of taking a prescribed medication means you’re sick. You take a prescribed medication because someone told you you’re sick and you don’t want to get sicker, but you take vitamins and minerals and supplements because you’ve been convinced of the opportunity of becoming healthier. It’s primarily marketing. I’ve always said imagine insulin, for example, and call it vitamin I. I think people will be much more comfortable about starting it and taking it. Our medicines are preventative medicines, because type 2 diabetes is a relatively invisible disease until it’s not. So our goal is to prevent it from becoming visible.
diaTribe: What solutions do you think there are? Should everyone with diabetes go to psychologists and psychiatrists to help them manage their diabetes?
Dr. Polonsky: No, I wouldn’t say that’s practical. The immediate solution is convenience. We can achieve this through more combination products so people might be able to take less pills a day. If there’s a treatment that people have to think less about, that will help patients with their insulin regimens.
diaTribe: It is so important also for healthcare providers to have trust with the patients, which is what you focus on. Do you think more doctors and nurses should be trained in some of the skills you’ve developed?
Dr. Polonsky: Yes, if healthcare professionals had some of these skills, they could provide people with a sense of hope, and this could help them to act as an obstacle identifier and remover. [Editor’s Note: If you are a healthcare professional looking for resources from Dr. Polonsky, click here.]
diaTribe: What about the difference between “adherence” and “compliance”? How harmful is using this type of language? How do you talk to your patients in order to have the best communication?
Dr. Polonsky: Well, the term “compliance” is really bad, “adherence” is sort of bad, and avoiding both terms is okay. The real issue is that we want to support patients in taking positive actions for themselves – it’s not about them doing what I tell them to do. So we use the term adherence, which is a little better than compliance, but still not the best. I think we’re still searching for a word that doesn’t have the idea that the doctor knows best and is telling you what to do. But we don’t have to use a noun. I’ll ask people how they’re doing. I’ll say something like, “One of things that we know is that almost everybody has trouble remembering to take their medications from time to time like it has been prescribed. Have you been having any problems with that?” But it does get wordy.
diaTribe: Which changes do you think will most improve the success of diet and exercise interventions for people with prediabetes?
Dr. Polonsky: I think urban planning is huge, but that’s a large issue that no one in my field can solve. It could also be behavioral economics, taxing junk food, and making healthy choices the convenient choices.