Patients’ impatience is an independent determinant of poor diabetes control

Differential signaling effects of blood glucose on delay discounting in individuals with and without type 1 diabetes

Based on the signaling hypothesis of blood glucose (BG), a rise in BG levels signals a positive energy budget for healthy individuals but cellular starvation for individuals with type 1 diabetes. We examined this novel prediction and its intervention implications in the context of delay discounting, the degree to which delayed rewards are discounted, and the regulatory effects of insulin ingestion. We recruited 44 adults with type 1 diabetes (mean age 30.8 years, diabetes duration 15.4 years) and recorded their BG levels. The delay discounting rate was measured using the intertemporal choice task, where participants were required to choose between sets of smaller-and-sooner (SS) and larger-and-later (LL) rewards. In addition, 82 age-matched healthy participants were recruited to provide a baseline comparison on delay discounting. Random forest analysis showed that among many diagnostic factors, delay discounting was most dominating in differentiating the individuals with type 1 diabetes from the control participants. A hierarchical linear mixed model revealed that participants with type 1 diabetes had a stronger preference for SS rewards (p < .001) after controlling for covariates. Participants who had insulin delivered before the last meal exhibited a stronger preference for LL rewards compared to after-meal delivery. In contrast, subjective measures (e.g., self-reported hunger) failed to predict the participants' actual BG levels and delay discounting rates. In sum, individuals with type 1 diabetes tend to discount future rewards excessively compared to the control participants. Pre-meal insulin ingestion was associated with a higher LL preference for future rewards.

Examining the association between delay discounting, delay aversion and physical activity in Chinese adults with type-2 diabetes mellitus

BACKGROUND

The role of physical activity in diabetes is critical, influencing this disease's development, man-agement, and overall outcomes. In China, 22.3% of adults do not meet the minimum level of physical activity recommended by the World Health Organization. Therefore, it is imperative to identify the factors that contributing to lack of physical activity must be identified.

AIM

To investigate the relationship among delay discounting, delay aversion, glycated hemoglobin (HbA1c), and various levels of physical activity in Chinese adults diagnosed with type 2 diabetes mellitus (T2DM).

METHODS

In 2023, 400 adults with T2DM were recruited from the People's Hospital of Linxia Hui Autonomous Prefecture of Gansu Province. A face-to-face questionnaire was used to gather demographic data and details on physical activity, delay discounting, and delay aversion. In addition, HbA1c levels were measured in all 400 participants. The primary independent variables considered were delay discounting and delay aversion. The outcome variables included HbA1c levels and different intensity levels of physical activity, including walking, moderate physical activity, and vigorous physical activity. Multiple linear regression models were utilized to assess the relationship between delay discounting, delay aversion, and HbA1c levels, along with the intensity of different physical activity measured in met-hours per week.

RESULTS

After controlling for the sample characteristics, delay discounting was negatively associated with moderate physical activity (β = -2.386, 95%CI: -4.370 to -0.401). Meanwhile, delay aversion was negatively associated with the level of moderate physical activity (β = -3.527, 95% CI: -5.578 to -1.476) in the multiple linear regression model, with statistically significant differences.

CONCLUSION

Elevated delay discounting and increased delay aversion correlated with reduced levels of moderate physical activity. Result suggests that delay discounting and aversion may influence engagement in moderate physical activity. This study recommends that health administration and government consider delay discounting and delay aversion when formulating behavioral intervention strategies and treatment guidelines involving physical activity for patients with T2DM, which may increase participation in physical activity. This study contributes a novel perspective to the research on physical activity in adults with T2DM by examining the significance of future health considerations and the role of emotional responses to delays.

Relationship between delay discounting, delay aversion and psychosocial domains of diabetes care

PURPOSE

Delay discounting and aversion are important areas for diabetes management; however, little has been done to understand the relationship with psychosocial outcomes among adults with type 2 diabetes.

METHODS

This study used data from 365 adults with type 2 diabetes to evaluate relationships between delay discounting and aversion and psychosocial outcomes. Delay discounting and aversion were measured with the validated Quick Delay Questionnaire. Psychosocial outcomes included depression, measured by the PHQ, anxiety by the GAD scale, perceived stress by the PSS, and social support by the Duke Social Support and Stress Scale. Multiple linear regression was used to assess the relationship between delay discounting and aversion on psychological health and social support controlling for relevant covariates.

RESULTS

Mean age of the sample was 61.8 years, 54.5 % were NHB, 41.8 % NHW, and 3.7 % Hispanic/Other. After adjusting for covariates, delay aversion was significantly associated with depression (beta = 0.35; p < 0.001), anxiety (beta = 0.52; p < 0.001), perceived stress (beta = 0.22; p < 0.001), and lower family support (beta = -0.62; p < 0.05). Delay discounting was significantly associated with depression (beta = 0.32; p < 0.001), anxiety (beta = 0.46; p < 0.001), and perceived stress (beta = 0.26; p < 0.001).

LIMITATIONS

This data is cross-sectional, future work should examine the longitudinal relationship while also including additional psychosocial outcomes.

CONCLUSIONS

Delay discounting and aversion are significantly associated with poor psychosocial outcomes, including lower social support. As the body of evidence grows, additional research is needed to better understand the construct, mechanisms, and the impact of choice settings to better inform intervention development.

How is Patient Adherence Possible? A Novel Mechanistic Model of Adherence Based on Humanities

Patient non-adherence is a major contemporary medical issue because of its consequences in terms of frequency, morbidity and mortality, and health care costs. This article aims to propose a mechanistic model of adherence based on the tenet that non-adherence is the default option, as long-term adherence in chronic diseases requires sustained effort. The real question becomes, how is patient adherence possible? By focusing on adherent patients, the paper explains the mental mechanisms of adherence using concepts largely drawn from humanities, philosophy of mind, and behavioral economics and presents the findings of empirical studies supporting these hypotheses. The analysis first demonstrates the relationship between patient adherence and temporality and the influence of character traits. Further, it points out the importance of habit, which allows adherence to become non-intentional, thereby sparing patients' cognitive efforts. Finally, it points out the importance of the quality of the interaction between the person with a chronic disease and the health professional. These features explain why adherence is a syndrome (the healthy adherer phenotype), separating people into those who are safe and those who are at risk of non-adherence, non-control of diabetes, and complications. The concepts presented in this article summarize 20 years of personal clinical and philosophical reflection on patient adherence. They are mainly illustrated by examples from diabetes care but can be applied to all chronic diseases. This novel model of adherence has major practical and ethical implications, explaining the importance of patient education and shared medical decision-making in chronic disease management.

Adherence to Oral Antidiabetic Drugs in Patients with Type 2 Diabetes: Systematic Review and Meta-Analysis

Poor adherence to oral antidiabetic drugs (OADs) in patients with type 2 diabetes (T2D) can lead to therapy failure and risk of complications. The aim of this study was to produce an adherence proportion to OADs and estimate the association between good adherence and good glycemic control in patients with T2D. We searched in MEDLINE, Scopus, and CENTRAL databases to find observational studies on therapeutic adherence in OAD users. We calculated the proportion of adherent patients to the total number of participants for each study and pooled study-specific adherence proportions using random effect models with Freeman-Tukey transformation. We also calculated the odds ratio (OR) of having good glycemic control and good adherence and pooled study-specific OR with the generic inverse variance method. A total of 156 studies (10,041,928 patients) were included in the systematic review and meta-analysis. The pooled proportion of adherent patients was 54% (95% confidence interval, CI: 51-58%). We observed a significant association between good glycemic control and good adherence (OR: 1.33; 95% CI: 1.17-1.51). This study demonstrated that adherence to OADs in patients with T2D is sub-optimal. Improving therapeutic adherence through health-promoting programs and prescription of personalized therapies could be an effective strategy to reduce the risk of complications.

Associations between impulsivity and self-care adherence in individuals diagnosed with Type 2 or prediabetes

Diabetes is a chronic disease requiring extensive self-care. Different impulsivity constructs, including choice-based and self-report personality measures are associated with decreasing diabetes self-care adherence. However, both choice-based and self-report impulsivity have never been measured for individuals diagnosed with either Type 2 or prediabetes in the same study. The current study examined the relationship between impulsivity and diabetes self-care in 101 adults diagnosed with either Type 2 or prediabetes. Results indicated that increasing self-reported impulsiveness was significantly correlated with decreasing Type 2 diabetic self-care, whereas the choice-based measure was not associated with any self-care measure. No association between impulsivity and self-care was significant for individuals diagnosed with prediabetes. Path analyses showed that self-reported impulsiveness directly and positively predicted problems controlling blood sugar levels in individuals diagnosed with either prediabetes or Type 2 diabetes. However, self-reported impulsiveness only indirectly and negatively predicted exercise and diet adherence via diabetes management self-efficacy for individuals diagnosed with Type 2 diabetes. These results show what specific impulsivity constructs and diabetes management self-efficacy may be incorporated into interventions for increasing specific self-care behaviors.

Effects of 6-month episodic future thinking training on delay discounting, weight loss and HbA1c changes in individuals with prediabetes

People with prediabetes are at risk for type 2 diabetes. They may discount the future delay discounting (DD), and not engage in preventive health behaviors. Episodic future thinking (EFT) can reduce DD when future scenarios are cued, but research is needed to assess long-term effects of EFT and when EFT is not cued. This study tested EFT training compared to control for people with prediabetes enrolled in a 6-month weight loss program on DD, weight, HbA1c, and physical activity. Results showed a reliable EFT effect on reducing DD in cued (p = 0.0035), and uncued DD tasks (p = 0.048), and significant overall changes in weight (p < 0.001), HbA1c (p, 0.001) and physical activity (p = 0.003), but no significant differences in these outcomes by group (p’s > 0.05). Sixty-eight percent of the sample ended below the prediabetes HbA1c range. These results suggest that DD can be modified over extended periods, and the effects of EFT can be observed without EFT cues. However, these data do not suggest that changes in weight, HbA1c or physical activity were due to EFT training. The study was initiated before the COVID-19 pandemic which provided the opportunity to compare differences for people treated in-person or remotely. Analyses showed no differences in DD, weight, HBA1c or physical activity outcomes were observed between in-person and remote treatment, suggesting telehealth is a scalable approach to treating prediabetes.

Choice bundling, unpacked: Observed and predicted effects on intertemporal choice in an additive model of hyperbolic delay discounting

One method known to increase preference for larger, later rewards (LLRs) over smaller, sooner rewards (SSRs) is choice bundling, in which a single choice produces a series of repeating consequences over time. The present study examined whether effects of choice bundling on preference for LLRs: (1) increase with the number of rewards in the bundle (i.e., bundle size); (2) are independent of differences in reward magnitude between conditions; and (3) accord with predictions of an additive model of hyperbolic delay discounting, in which the value of a bundle of rewards can be expressed as the summed discounted value of all rewards in that bundle. Participants (N = 252) completed a choice task to assess valuation of monetary LLRs at bundle sizes of 1 (control), 3, and 9 rewards per choice (ascending/descending order counterbalanced). To control for the magnitude effect, the total reward amounts were held constant across conditions. Choice bundling significantly increased LLR preference (p < .001), with the largest effect observed at the largest bundle size. The descending bundle-size order produced significantly greater LLR preference than the ascending order (p < .05), although order did not significantly interact with bundle size. Difference scores between observed measures and those predicted by an additive model of hyperbolic discounting were small and not significantly different than zero, but were not equivalent to zero. Future research should investigate the clinical utility of choice bundling for reducing the maladaptive health behavior (e.g., substance use) with which delay discounting is associated.

The Role of Impulsive Decision Making on Health Behavior Related to Cardiovascular Disease Risk Among Older Adults With Hypertension

The purpose of the current study was to investigate whether older adults who are more impulsive also tend to engage in more health behaviors associated with increased risk for cardiovascular disease (CVD). We analyzed data from the Health and Retirement Study. Logistic regression analysis was performed to determine the likelihood of medication adherence, alcohol consumption, and exercise among older adults with hypertension. Adjusted regression results revealed higher impulsive decision making was associated with greater likelihood of obesity (odds ratio [OR] = 2.96, 95% confidence interval [CI] [1.00, 8.92]), lower likelihood of medication adherence (OR = 0.37, 95% CI [0.15, 0.92]), and regular drinking (OR = 0.36, 95% CI [0.15, 0.87]). Higher impulsive decision making was associated with lower likelihood of regular exercise only in unadjusted models. Older adults with hypertension who had higher impulsive decision making engaged in health behaviors associated with increased risk for CVD. Health care providers should consider the range of strategies offered through behavioral economics to improve health in these at-risk populations. [Journal of Gerontological Nursing, 47(11), 22-30.].

[Uncontrolled type 2 diabetes in primary care health center: Modifiable factors and target population]

Objetivos

Detectar factores modificables y poblaciones diana asociados al mal control de la diabetes tipo 2 (DM2) en atención primaria.

Diseño

Estudio descriptivo transversal restrospectivo.

Emplazamiento

Centro de salud de Barranco Grande, Tenerife.

Participantes

selección aleatoria de pacientes con DM2 atendidos por 12 médicos de familia y 12 enfermeras.

Mediciones principales

Además del control de la DM2, se obtuvieron datos sociodemográficos, clínicos, hábitos de vida y seguimiento de medidas preventivas y terapéuticas. Tras análisis bivariado, se ajustó un modelo multivariado multinivel tomando el cupo médico-enfermero como efecto mixto de segundo nivel y el resto como variables de primer nivel.

Resultados

Fueron reclutados 587 pacientes (46,5% mujeres), tratados con 1,9±1,1 fármacos antidiabéticos, con 4,1% de incumplimiento terapéutico, y padeciendo un 13,8% inercia terapéutica. El 23,7% mostraba mal control de DM2, siendo peor (p<0,05) en sexo masculino, edad <65 años, evolución DM2 ≥5 años, dieta inadecuada, síndrome metabólico, ratio triglicéridos/HDL≥3, complicaciones de la DM2, índice Charlson<5, visitas a enfermera<3/año, sin ECG en el último año y mayor número de fármacos prescritos para DM2. El cupo médico-enfermero se asoció al mal control con un coeficiente intraclase de 0,01.

Conclusiones

Los hombres menores de 65 años con larga evolución de DM2 son población diana para intensificar intervenciones. El incumplimiento terapéutico, dieta inadecuada, falta de adhesión a los protocolos de seguimiento y ratio triglicéridos/HDL>3 son factores sobre los que intervenir. La asociación del cupo médico-enfermero con el control de la DM2 es débil, probablemente por adecuado seguimiento de los programas preventivos.

Examining the Relationship Between Delay Discounting, Delay Aversion, Diabetes Self-care Behaviors, and Diabetes Outcomes in U.S. Adults With Type 2 Diabetes

OBJECTIVE

Delay discounting and delay aversion are emerging areas for understanding diabetes management; however, few data exist on their relationship with multiple diabetes self-care behaviors and diabetes outcomes.

RESEARCH DESIGN AND METHODS

This cross-sectional study included 356 adults with type 2 diabetes across three racial/ethnic groups receiving care from two primary care clinics. The primary predictors were delay discounting and delay aversion. Outcomes included self-care behaviors, quality of life (QOL; mental health component score [MCS], physical component score), and A1C. Multiple linear regression models were run to examine the association between predictors and the outcomes, A1C, QOL, and each self-care behavior.

RESULTS

Higher delay discounting was associated with lower engagement in self-care behaviors for general diet (B = -0.06; 95% CI -0.12; -0.01), specific diet (B = -0.07; 95% CI -0.12; -0.03), and foot care (B = -0.10; 95% CI -0.17; -0.02). Higher delay aversion was associated with lower engagement in self-care behaviors for general diet (B = -0.06; 95% CI -0.10; -0.01), specific diet (B = -0.03; 95% CI -0.07; -0.01), foot care (B = -0.11; 95% CI -0.17; -0.05), and lower MCS (B = -0.38; 95% CI -0.71; -0.06).

CONCLUSIONS

In a diverse sample of adults with type 2 diabetes, higher delay discounting and higher delay aversion were significantly related to lower engagement in self-care behaviors. High delay aversion was specifically related to lower QOL. These findings offer new knowledge by highlighting the role that delay-related behaviors may have in the performance of self-care behaviors and the impact on QOL. Work is needed to further elucidate these relationships. Specifically, these results highlight the importance of targeting value and decision-making for diabetes self-management.

Delay Discounting, Glycemic Regulation and Health Behaviors in Adults with Prediabetes

The majority of people with prediabetes transition to type 2 diabetes. Research has suggested that persons with type 2 diabetes are likely to discount the future and focus on immediate rewards. This study was designed to assess whether this process of delay discounting (DD) is associated with glycemic regulation, medication adherence and eating and exercise behaviors in adults with prediabetes. Participants included 81 adults with prediabetes who were also prescribed hypertension or dyslipidemia drugs, which is common for people with prediabetes. Participants completed adjusting amount DD $100 and $1000 tasks, as well assessments of glycemic control (Hemoglobin (Hb) A1c), medication adherence, diet quality, and objectively measured physical activity. Relationships between DD and these variables were assessed. Results showed higher rates of DD were related to higher HbA1c; as well as poorer medication adherence, lower diet quality and lower physical activity. Hierarchical regression showed that the association between minority status, a known risk factor for type 2 diabetes, was moderated by DD, as minorities with higher DD had greater HbA1c values. Delay discounting may represent a novel target to prevent progression from prediabetes to type 2 diabetes.

Time preferences, diabetes self-management behaviours and outcomes: a systematic review

AIM

Time preferences, i.e. individuals' degree of patience/impatience in intertemporal choice, have been found to be associated with suboptimal health behaviours and health outcomes such as smoking, physical inactivity, unhealthy food intake and obesity. In this systematic review, we aimed to synthesise reported associations between time preferences, diabetes self-management behaviours, including use of diabetes technology, and outcomes.

METHODS

We searched MEDLINE, EMBASE, PsycINFO, CINAHL, EconLit and all databases in the Web of Science Core Collection. Peer-reviewed studies of people with diabetes that included at least one diabetes-related behaviour or outcome and a measure of time preferences were included. Non-English language studies were excluded.

RESULTS

A total of 961 records were identified, of which 12 articles were included. Three studies analysed both time-consistent and time-inconsistent preferences, three studies solely analysed time-inconsistent preferences and six studies did not explicitly define a time preference model. Measured outcomes across studies included self-care activities, such as medication-taking, exercising and eating a healthy diet, and biomedical outcomes, such as HbA_1c and diabetes-related complications. There were 10 cross-sectional studies and two panel-data studies. No studies explicitly analysed the relationship between time preferences and diabetes technology use.

CONCLUSIONS

Associations between measures of time preferences, diabetes self-management behaviours and clinical outcomes exist. Higher discount rates determined by both time-consistent and time-inconsistent models predict less diabetes-related self-care and worse outcomes. These findings may add to explanations of the observed variation in diabetes-related health and provide new insights for tailoring interventions and policies aimed at improving diabetes self-management.

Reinforcer pathology: Common neural substrates for delay discounting and snack purchasing in prediabetics

Reinforcer pathology theory stipulates that individuals with both (a) high preference for smaller, immediate over larger, delayed rewards; and (b) high demand for unhealthy commodities are uniquely susceptible to poor health outcomes. Specifically, two behavioral economic tasks (delay discounting, assessing preference for smaller, immediate or larger, delayed rewards; and purchasing, assessing purchases of commodities over changes in price) have been independently associated with conditions such as overweight/obesity and problem substance use. In the present study, we examined possible shared neural regions involved in the processes of delay discounting and demand for snack foods in a prediabetic sample. Fifty-four participants completed both of these tasks. Conjunction between delay discounting and purchasing task results indicates substantial common neural substrates recruited during these two tasks, consistent with interpretations of executive control, interoception, and attention, in the prefrontal cortex, insula, and frontoparietal cortex (superior/middle frontal cortex and superior/inferior parietal lobules), respectively. Collectively, these results suggest possible neural substrates in which the two behavioral risk factors of reinforcer pathology may interact during real-world decision-making in prediabetes.

Role of delay discounting in predicting change in HBA1c for individuals with prediabetes

The majority of people with prediabetes transition to type 2 diabetes. Weight gain is a known predictor of increasing the risk of diabetes, but another reason may be a focus on immediate rewards and discounting of the future. Delay discounting (DD: devaluation of future consequences) is related to obesity and poor glycemic control in persons with type 2 diabetes. This study was designed to assess whether changes in DD are associated with HbA1c change beyond BMI change in individuals with prediabetes. Hierarchical regression showed changes in BMI (p = 0.008) and the $1000 DD task (p = 0.04) were associated with HbA1c change beyond demographic characteristics, with the full model accounting for 25.8% of the variance. Those with greater BMI increases and greater increases in discounting of the future showed the greatest increases in HbA1c. DD represents a novel target to prevent progression from prediabetes to type 2 diabetes.

Genomic basis of delayed reward discounting

Delayed reward discounting (DRD) is a behavioral economic measure of impulsivity, reflecting how rapidly a reward loses value based on its temporal distance. In humans, more impulsive DRD is associated with susceptibility to a number of psychiatric diseases (e.g., addiction, ADHD), health outcomes (e.g., obesity), and lifetime outcomes (e.g., educational attainment). Although the determinants of DRD are both genetic and environmental, this review focuses on its genetic basis. Both rodent studies using inbred strains and human twin studies indicate that DRD is moderately heritable, a conclusion that was further supported by a recent human genome-wide association study (GWAS) that used single nucleotide polymorphisms (SNP) to estimate heritability. The GWAS of DRD also identified genetic correlations with psychiatric diagnoses, health outcomes, and measures of cognitive performance. Future research priorities include rodent studies probing putative genetic mechanisms of DRD and human GWASs using larger samples and non-European cohorts. Continuing to characterize genomic influences on DRD has the potential to yield important biological insights with implications for a variety of medically and socially important outcomes.

Implication Of Character Traits In Adherence To Treatment In People With Gout: A Reason For Considering Nonadherence As A Syndrome

OBJECTIVE

Various aspects of nonadherence to therapy (including medication and lifestyle nonadherence) often appear together. Here we report the association between treatment adherence in gout and the two character traits of patience and obedience, which may explain this observation.

METHODS

Data were collected from a cross-sectional study conducted in a French cohort of 1441 adult patients. Patience was assessed using the choice between receiving €1500 in 1 year or €500 immediately. Obedience was evaluated with a single question assessing the use of the seatbelt in the rear seat of a car. Adherence to recommendations for medication, beverage, food and physical activity and smoking status was assessed using self-report questionnaires.

RESULTS

Patience and obedience were strong determinants of adherence to medication in multivariate analysis (OR 2.056, 95% CI [1.414-2.989], P< 0.001; OR 1.844, 95% CI [1.273-2.671], P=0.001). In univariate analysis, adherence to medication was also associated with compliance with dietary directives (P<0.001), lower alcohol consumption on an ordinary day (P< 0.001), never consuming soda (P<0.001) or beer (P<0.001), practice of physical activity (P=0.002), being a nonsmoker (P<0.001) and monitoring serum levels of uric acid regularly (P=0.011). Multiple-correspondence analysis illustrated the associations of these different aspects of adherence (medication, diet and exercise, smoking status and monitoring of disease control) with patience and obedience. Finally, we observed a link between patience and obedience (P< 0.001).

CONCLUSION

Character traits, which shape preferences, may cause the clustering of different aspects of nonadherence in the form of a syndrome, elucidating the still enigmatic link between nonadherence to placebo and mortality in randomised clinical trials. This concept may also explain, at least in part, the difficulty of improving adherence to long-term therapies and may lead to ethical issues.

Temporality in chronic diseases and adherence to long-term therapies: From philosophy to science and back

This narrative review exhibits the construction and validation of a hypothesis to explain how treatment non-adherence in people with chronic disease, a major issue in contemporary medicine, occurs. I propose that non-adherence to long-term therapies is at least in part due to failure to prioritize the future, which is caused by a condition I dub disruption in time projection. This article gives the rationale for this hypothesis, which is largely grounded on philosophical arguments. Then, it demonstrates the plausibility of the hypothesis: on the one hand, it is consistent with certain epidemiological data found in the literature. On the other, it is possible to predict the underlying mechanisms of this lack of prioritization from recent achievements of neuro-economics and neuroscience. Next, it reviews empirical data that provide an experimental verification for this explanatory hypothesis. Finally, a general evolutionary and philosophical meaning for adherence is proposed, considering the advantages of its preconditions, namely, patience and foresight.

Holistic psychosocial determinants of adherence to medication in people with type 2 diabetes

BACKGROUND

The aim of this study was to determine whether adherent and non-adherent patients with type 2 diabetes can be differentiated according to psychosocial characteristics.

METHODS

A total of 1214 patients were included in the analysis. Data were derived from a cross-sectional observational study of adults with diabetes of the Access Santé (Access Health) panel of Kantar Health France. Patients completed a questionnaire on adherence to medication, psychological determinants (trust in physicians, constancy of habits, patience, temporal horizon, health locus of control, obedience, psychological reactivity, prevention vs promotion, optimism vs pessimism) and social deprivation.

RESULTS

Of these 1214 subjects, 46.2% were considered strictly adherent to antidiabetic medication, as reflected by negative answers to all six questions suggesting a non-adherent behaviours, whereas 48.9% provided 1-2 positive answers and 4.9% provided 3-6 positive answers, and were considered non-adherent. In addition to the effect of younger age (P=0.03), multivariate logistic regression analysis demonstrated the following psychosocial determinants of non-adherence: chance locus of control (P=0.02); lack of trust in physicians (P=0.010); and pessimism (P=0.021). Multiple factor analysis identified adherence and social deprivation as dimensions separating three distinct patient populations: (i) non-adherent; (ii) adherent and socially deprived; and (iii) adherent and non-socially deprived. It also revealed that patience, obedience, cautious behaviour, optimism, trust in physicians and constancy of habits were associated with adherence.

CONCLUSION

Of the multiple determinants of adherence, trust in physicians and constancy of habits represent modifiable factors, and constitute targets to prevent non-adherence because they can be reinforced through patient education and improved physician - patient relationship. Also, psychosocial determinants of adherence differ widely between socially deprived and non-deprived patients.

Disruption in time projection and non-adherence to long-term therapies

OBJECTIVE

Patients' non-adherence to medical prescriptions is a crucial issue in contemporary medicine because it can jeopardize care efficacy. Non-adherence is especially frequent in patients with chronic diseases. In this article, we propose that a particular condition, which we call disruption in time projection, is a cause of non-adherence to medication therapies in chronic diseases.

METHODS

A questionnaire was administered to 120 hospitalized people with type 2 diabetes addressing three psychological constructs defining time projection: patience/impatience in a fictive monetary scenario (preferring to receive €1,500 in 1 year or €500 today), magnitude of temporal horizon (greater or lesser ability to imagine future events) and perception of the degree of physical similarity of current self to self at 1 year, 5 years and 10 years from the present. In addition, the questionnaire evaluated adherence to medication, social deprivation and depression.

RESULTS

In the multivariate analyses, two factors were associated with adherence to medication: patience (P<0.001) and long temporal horizon (P=0.006). Two factors were associated with HbA1c ≥8% (64 mmol/mol): non-adherence to medication (P=0.003) and short temporal horizon (P=0.011). Three factors were associated with long temporal horizon: adherence to medication (P<0.001), patience (P<0.001) and the existence of grandchildren (P=0.002). Social deprivation (P<0.001), non-adherence (P<0.001), female gender (P=0.002) and short temporal horizon (P=0.050) were associated with impatience. Finally, an association of adherence to expected similarity in the future to current self, impatience, short temporal horizon, social deprivation and depression was also shown in a multiple correspondence analysis.

CONCLUSION

What we termed a disruption in time projection may be a unique determinant for non-adherence to long-term therapy and, therefore, may influence the outcome of chronic diseases. We hypothesize that this is involved in both intentional and unintentional non-adherence and that it represents the loss of a protective mechanism. If this novel concept is to be confirmed in other settings and generalized to other chronic diseases, the recognition of its role in disease prognosis may help orient the teaching and practice of medicine.

Is patient empowerment the key to promote adherence? A systematic review of the relationship between self-efficacy, health locus of control and medication adherence

Background

Current health policies emphasize the need for an equitable doctor-patient relationship, and this requires a certain level of patient empowerment. However, a systematic review of the empirical evidence on how empowerment affects medication adherence—the extent to which patients follow the physician’s prescription of medication intake—is still missing. The goal of this systematic review is to sum up current state-of-the-art knowledge concerning the relationship between patient empowerment and medication adherence across medical conditions. As our conceptualization defines health locus of control and self-efficacy as being crucial components of empowerment, we explored the relationship between these two constructs and medication adherence.

Methods

Relevant studies were retrieved through a comprehensive search of Medline and PsychINFO databases (1967 to 2017). In total, 4903 publications were identified. After applying inclusion and exclusion criteria and quality assessment, 154 articles were deemed relevant. Peer-reviewed articles, written in English, addressing the relationship between empowerment (predictor) and medication adherence (outcome) were included.

Findings

High levels of self-efficacy and Internal Health Locus of Control are consistently found to promote medication adherence. External control dimensions were found to have mainly negative (Chance and God attributed control beliefs) or ambiguous (Powerful others attributed control beliefs) links to adherence, except for Doctor Health Locus of Control which had a positive association with medication adherence. To fully capture how health locus of control dimensions influence medication adherence, the interaction between the sub-dimensions and the attitudinal symmetry between the doctor and patient, regarding the patient’s control over the disease management, can provide promising new alternatives.

Discussion

The beneficial effect of patients’ high internal and concurrent physician-attributed control beliefs suggests that a so-called “joint empowerment” approach can be suitable in order to foster medication adherence, enabling us to address the question of control as a versatile component in the doctor-patient relationship.

Think fast: rapid assessment of the effects of episodic future thinking on delay discounting in overweight/obese participants

Accumulating laboratory-based evidence indicates that reducing delay discounting (devaluation of delayed outcomes) with the use of episodic future thinking (EFT; mental simulation of future events) improves dietary decision-making and other maladaptive behaviors. Recent work has adapted EFT for use in the natural environment to aid in dietary and weight control by engaging participants in EFT repeatedly throughout the day. These efforts may benefit from minimizing the amount of time required for measurement and implementation of EFT. Using Amazon Mechanical Turk in the present study, we show that EFT effectively reduces delay discounting in overweight/obese participants (N = 131) using the recently developed 5-trial, adjusting-delay discounting task, which can be completed rapidly (25 s) and is therefore ideally suited for ecological momentary assessment. Moreover, measures of delay discounting from this task were strongly correlated with those from the commonly used adjusting-amount task (r = .859). Significant effects of EFT on discounting, however, depended on the number of future events participants generated and imagined. Use of a range of events and future time frames (as is typical in the literature) significantly reduced delay discounting, whereas use of only a single event did not.

Delay discounting of gains and losses, glycemic control and therapeutic adherence in type 2 diabetes

OBJECTIVE

Delay discounting is the tendency to prefer smaller, sooner rewards to larger, later ones. Poor adherence in type 2 diabetes could be partially explained by a discounted value of health, as a function of delay. Delay discounting can be described with a hyperbolic model characterized by a coefficient, k. The higher k, the less future consequences are taken into account when making decisions. This study aimed to determine whether k would be correlated with glycated hemoglobin and adherence in type 2 diabetes.

METHODS

Ninety-three patients were recruited in two diabetology departments. Delay discounting coefficients were measured with a computerized task. HbA1c was recorded and adherence was assessed by questionnaires. Potential socio-demographic and clinical confounding factors were collected.

RESULTS

There was a positive correlation between delay discounting of gains and HbA1c (r=0.242, P=0.023). This association remained significant after adjusting for potential confounding factors (F=4.807, P=0.031, η²=0.058). This association was partially mediated by adherence to medication (β=0.048, 95% CI [0.004-0.131]).

CONCLUSIONS

Glycemic control is associated with delay discounting in patients suffering from type 2 diabetes. Should these findings be replicated with a prospective design, they could lead to new strategies to improve glycemic control among these patients.

The development of the ProMAS: a Probabilistic Medication Adherence Scale

Current self-report medication adherence measures often provide heavily skewed results with limited variance, suggesting that most participants are highly adherent. This contrasts with findings from objective adherence measures. We argue that one of the main limitations of these self-report measures is the limited range covered by the behaviors assessed. That is, the items do not match the adherence behaviors that people perform, resulting in a ceiling effect. In this paper, we present a new self-reported medication adherence scale based on the Rasch model approach (the ProMAS), which covers a wide range of adherence behaviors. The ProMAS was tested with 370 elderly receiving medication for chronic conditions. The results indicated that the ProMAS provided adherence scores with sufficient fit to the Rasch model. Furthermore, the ProMAS covered a wider range of adherence behaviors compared to the widely used Medication Adherence Report Scale (MARS) instrument, resulting in more variance and less skewness in adherence scores. We conclude that the ProMAS is more capable of discriminating between people with different adherence rates than the MARS.

Achieving HbA1c targets in clinical trials and in the real world: a systematic review and meta-analysis

PURPOSE

To review the proportion of diabetic patients reaching recommended therapeutic goals, as reported in intervention trials and observational studies, and to analyse the factors associated with success or failure in achieving these targets.

METHODS

A systematic review and meta-analysis through a Medline and Embase search for "diabetes" and "HbA1c" has been performed between 1 January 1995 and 1 March 2012 on randomised clinical trials and observational studies on type 1 (T1DM) or type 2 diabetes (T2DM) enrolling at least 200 patient*year.

RESULTS

Out of 169 patient groups in RCTs with results available for analysis, the overall proportion of patients reaching HbA1c ≤ 7 % was 36.6 (34.1-39.1) %. Of these, 8 groups included T1DM subjects [proportion at target (PAT) 27.2 (22.7-32.3) %] and 161 T2DM patients [PAT 37.1 (34.5-39.7) %]. In patients with T2DM on oral agents, at multivariate analysis, higher success rate was associated with higher age and body mass index (BMI), lower duration of diabetes, lower proportion of Caucasians and more recent publication year. Among the insulin treated, only duration of diabetes retained a significant association with success rate. Among 41 groups from cross-sectional studies, 6 and 22 were composed of patients with T1DM and T2DM, respectively, and the remaining 13 included both types. Patients at target for HbA1c were 19.8 (12.4-30.1), 36.1 (31.5-41.0), and 39.0 (32.9-45.3) %, respectively. Higher age, lower BMI, shorter duration of diabetes and a higher proportion of males and Caucasians were associated with a higher success rate.

CONCLUSIONS

Available data show that a wide distance remains between recommended targets and actual achievements in routine clinical practice.

Two character traits associated with adherence to long term therapies

Adherence is defined as the adequacy between the behaviours of patients and their medical prescriptions. Adherence is a general behaviour, which can explain why patients in the placebo arm of randomised clinical trials have a lower mortality rate when they are adherent. We propose that this behaviour is related to two character traits: patience (capacity to give priority to the future) and, more provocatively, obedience. To support this claim, we bring arguments from the literature and from two published personal studies. We previously showed that type 2 diabetic patients who respond as non-adherers to a questionnaire on adherence to medication and to whom one proposes a fictitious monetary choice between receiving 500 euros today or waiting one year to receive 1500 euros never make the remote choice. We also showed that obese diabetic patients who declare that they do not fasten their seat belt when they are seated in the rear of a car are more often non-adherent concerning medication than those patients who claim that they follow this road safety recommendation. Thus, one of the roles of empowerment and patient education could be to encourage the patients, if they wish it, to replace passive adherence behaviours with conscious active choices.

Obedience and motivation as mechanisms for adherence to medication: a study in obese type 2 diabetic patients

OBJECTIVE

To clarify the mechanisms of adherence.

METHODS

A cross-sectional, multicenter French study using a self-questionnaire administered by 116 general practitioners to 782 obese type 2 diabetic patients.

RESULTS

The analysis of 670 completed questionnaires revealed a strong association between the adherence to medication and the behavior of fastening the seatbelt when seated in the rear of a car. Multivariate analysis indicated that this behavior was an independent determinant of adherence to medication (odds ratio [OR] 2.3, 95% confidence interval [CI] 1.4-3.6, P < 0.001) with the same OR as the motivation to adhere to medical prescriptions (OR 2.2, 95% CI 1.3-3.6, P = 0.003) in a model with good accuracy (area under the receiver operating characteristic curve 0.774). A multiple correspondence analysis suggested that adherence to medication and seatbelt behavior are "homologous" behaviors, with homology between phenomena defined by the fact that they share a common etiology.

CONCLUSION

ADHERENCE MAY HAVE TWO DIMENSIONS: passive (obedience, the main determinant of seatbelt behavior) and active (motivation). This conclusion has theoretical and practical implications. Firstly, empowerment through patient education can be defined as a process that replaces the passive mechanism of adherence in patients' minds with an active, conscious choice. Secondly, recognizing these two dimensions may help to establish a tailored patient-physician relationship to prevent nonadherence.