A Spoonful of Sugar: Improving Medication Adherence through Behavioral Changes

Speaker: Martha M. Funnell, MS, RN, CDE

When assessing the reasons people do not adhere to their diabetes medications, healthcare professionals should consider why they are not taking them and what happens when they discontinue the drugs, according to Martha M. Funnell, MS, RN, CDE, associate research scientist at the University of Michigan Medical School.

Funnell, who spoke at the 2013 Cardiometabolic Risk Summit, said it is common for people to discontinue their medications. She noted a few reasons, including that patients are already taking several other medications, they believe the diabetes drugs are not effective, or they cannot afford to pay for them. A person with a chronic illness such as diabetes takes an average of 9 medications. 

“Living with a chronic disease is tough,” she said. “It’s overbearing. It’s hard work.”

Even though the FDA has approved several diabetes drugs in recent years and patients have more options than ever before, the adherence rates have not changed much. Rule of thumb: one-third of patients take their medications all of the time, one-third take their medications some of the time, and one-third never take their medications.

A retrospective cohort study followed 1221 patients in Canada who were prescribed a statin within a year of their first cardiovascular event between 1994 and 2001.1 After 1 year, 60.3% of the patients were adherent to their medications. The rate dropped to 48.8% at year 5. The authors said that if patients were adherent 2 years after their first cardiovascular event, their long-term adherence rates were typically high.

Positive Patient–Physician Relationship

To increase adherence rates, Funnell said it is crucial that patients have a positive relationship with their providers. In the DAWN [Diabetes Attitudes, Wishes and Needs]2 study, a cross-sectional survey of patients with diabetes in 13 countries, a low percentage of patients indicated they followed most of the medication recommendations and an even lower percentage of healthcare professionals thought their patients followed the guidelines. Of the patients in the United States, 33% with type 1 diabetes and 34% with type 2 diabetes said they followed the recommendations. However, only 7% of healthcare professionals thought patients with type 1 diabetes followed the guidelines and 2% thought patients with type 2 diabetes followed the guidelines.

Improved communication between patients and providers has proven effective. A search of medical literature from 1949 to August 2008 found that there is a 19% higher risk of nonadherence in patients if their physicians are poor communicators.3 In addition, patients are 1.62 times more likely to adhere to their medications if their physicians receive training in communication skills compared with if the physicians receive no training.

Instead of giving specific instructions, Funnell suggested that providers instead listen to their patients and provide more patient-centered care focused on physical, psychosocial, behavioral, and educational issues. Providers should ask patients how often they do not take their medications and why they do not adhere to the regimen.

“Telling people, ‘Do as I tell you’ hasn’t worked,” Funnell said. 

Educational Programs

In the DAWN24 study, the authors surveyed 8596 adults with diabetes from 17 countries. They found that 44.6% of patients had diabetes-related distress, which was defined as a “Problem Areas in Diabetes Scale 5” score of 40 or higher. However, only 23.7% of patients said someone on their healthcare team had asked them how diabetes affected their life. In addition, 48.8% of patients participated in diabetes educational programs in the previous 12 months—and 81.1% found the programs helpful.

Collaborative Medicine

In a discussion paper on patient communication,5 the authors surveyed 1068 adults in the United States who had seen a healthcare provider in the previous 12 months. Of the adults, 88% had insurance, 38% had at least 1 chronic condition, 52% were females, and 71% were white. The authors reported that 9 in 10 patients wanted their providers to work as a team, but only 4 in 10 said their providers actually worked as a team. 

Funnell recommended a shared decision-making approach that allows patients to participate in their treatment options with decisions based on clinical evidence as well as the patient’s values and preferences. She stressed that patients need to know as much information as possible about the medications they are prescribed, including recent studies on the drugs, feedback from previous patients, costs of the medications, and whether the drugs will be covered by insurance. Physicians should clearly outline how the patient should administer the drugs (oral or injection) and when they should take the medications.

In 2009, Bradd Silver, MD, and Donna Kay, MBA, introduced a model6 to improve communication between patients with type 2 diabetes and their providers. They suggested patients bring a list of questions for the physician, understand the providers’ time demands, share accurate symptoms, log blood sugar measurements, and define their healthcare team. Providers should collaborate with patients to best manage their diabetes—keep their language simple, respect the patient’s time, understand the patient’s stress and uncertainty, serve as an interpreter of medical information, and guide them to the most accurate websites to research their disease. ■


1.Healey J, Wharton S, Al-Kaabi S, et al. Stroke prevention in patients with atrial fibrillation: the diagnosis and management of hypertension by specialists. Can J Cardiol. 2005;21(6):485-488.

2.Hara K, Horikoshi M, Yamauchi T, et al. Measurement of the high-molecular weight form of adiponectin in plasma is useful for the prediction of insulin resistance and metabolic syndrome. Diabetes Care. 2006;29(6):1247-1255