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Diabetes & Metabolism 36 (2010) 476–483

Original article

How patients’ attitudes and opinions influence self-care behaviours in type 2diabetes. Insights from the French DIABASIS Survey

H. Mosnier-Pudar a, G. Hochberg b, E. Eschwege c, S. Halimi d, M.-L. Virally e,P.-J. Guillausseau e, C. Touboul f, S. Dejager g,∗

a Cochin Port-Royal Diabetes and Endocrine Center, AP–HP, Paris, Franceb Hôpital Sud-Francilien, Corbeil-Essone, France

c Inserm U780 Epidemiological & Statistical research, Villejuif, Franced Endocrinologie diabétologie nutrition, CHU de Grenoble, Grenoble, France

e Service de médecine B, Lariboisiere Hospital, AP–HP, Paris, Francef TNS Healthcare, Montrouge, France

g Novartis Pharma, SAS, 2 & 4, rue Lionel-Terray, BP 308, 92506 Rueil-Malmaison, France

Received 17 May 2010; received in revised form 9 August 2010; accepted 12 August 2010Available online 14 October 2010

bstract

Aim. – This study evaluated the profiles of patients with type 2 diabetes (T2DM) to identify sets of opinions and attitudes towards the diseasehat might influence self-care behaviours.

Methods. – Altogether, 1,092 patients with T2DM, aged 45 or older from a large representative French cohort, completed a self-questionnairexploring their knowledge and perceptions of diabetes, its impact on various aspects of daily life and self-management practices. Canonical andluster analyses were used to identify sets of homogeneous ‘profiles’ of patients linking attitudes and opinions to specific disease-related behaviourssuch as changes in lifestyle, drug compliance, treatment satisfaction, impact on everyday life and weight gain).

Results. – Demographics of the T2DM study population were previously reported along with the main results (60% male; mean age: 66 years;ean age at diagnosis: 55 years; mean BMI: 29 kg/m2). Five distinct patient types emerged from the typological approach: ‘committed’ (25%);

carefree’ (23%); ‘bitter’ (19%); ‘disheartened’ (19%); and ‘overwhelmed’ (15%). Each patient type defined a set of attitudes and beliefs towards2DM that influenced disease-related behaviours, leading to different degrees of diabetes self-management.Conclusion. – The DIABASIS survey provides important information for diabetes care by identifying distinct patients’ profiles that express

ifferent degrees of difficulty in implementing self-management. For this reason, patients in each category require different kinds of customizedupport from their physician to induce behavioural changes that may be key in improving their metabolic control.

2010 Elsevier Masson SAS. All rights reserved.

eywords: Type 2 diabetes; Patient profiles; Behaviour; Beliefs; Self-management

ésumé

Comment les opinions et les attitudes des patients vis-à-vis de leur diabète de type 2 influencent leur implication dans sa prise en charge ? Lesecons de Diabasis.

Objectif. – Décrire des profils de patients diabétiques de type 2 (DT2) afin d’identifier leurs opinions et attitudes vis-à-vis du diabète susceptibles’influencer leur engagement dans la prise en charge de la maladie.

Méthodes. – Mille quatre-vingt-douze patients DT2 âgés de 45 ans ou plus, issus d’un large échantillon représentatif francais, ont répondu à un

utoquestionnaire explorant leurs connaissances et leurs perceptions vis-à-vis du diabète, son impact sur différents aspects de leur vie quotidiennet leur niveau d’implication dans sa prise en charge. Des analyses multivariées explicatives de type canonique ont été utilisées pour identifier desrofils homogènes de patients liant certaines attitudes et opinions sur leur diabète à des comportements spécifiques (modification du mode de vie,bservance thérapeutique, satisfaction du traitement, retentissement sur la vie quotidienne et prise de poids).

∗ Corresponding author. Tel.: +33 1 55 47 63 39; Fax: +33 1 55 47 65 93.E-mail address: sylvie.dejager@novartis.com (S. Dejager).

262-3636/$ – see front matter © 2010 Elsevier Masson SAS. All rights reserved.oi:10.1016/j.diabet.2010.08.004

H. Mosnier-Pudar et al. / Diabetes & Metabolism 36 (2010) 476–483 477

Résultats. – Les caractéristiques démographiques de la population ont été rapportées avec les résultats princeps de l’étude. L’approche typologiquea permis d’identifier cinq types distincts de profils patients : les « patients actifs et impliqués » (25 %), les « insouciants » (23 %), les « aigris » (19 %),les « découragés » (19 %) et les « accablés » (15 %). Chaque profil est défini par ses croyances et/ou attitudes vis-à-vis du DT2 qui conditionnentles comportements et possibilités d’implication dans la prise en charge de la maladie.

Conclusions. – Diabasis fournit des informations importantes pour la prise en charge du DT2. L’étude permet d’identifier des profils types depatients pour qui la vision de la maladie et les difficultés de prise en charge sont très différentes. Chaque profil requiert une approche personnalisée,

afin de faciliter des changements comportementaux adaptés pouvant concourir à l’amélioration du contrôle métabolique.© 2010 Elsevier Masson SAS. Tous droits réservés.

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ots clés : Diabète de type 2 ; Profils patients ; Comportements ; Croyances ;

. Introduction

Type 2 diabetes (T2DM) is a chronic disease in which lifestyleodifications and self-management are critical components of

are. The DIABASIS survey highlighted the importance of aollaborative relationship between T2DM patients and theirealthcare professional (HCP), and patients’ family support, toroviding encouragement and promoting accountability [1]. Inddition, important gaps were identified, such as poor knowl-dge of diabetes causation, helplessness and anxiety at the timef diagnosis, as well as the need for more information and dis-ussion with the physician at that critical time, little awareness ofhe need for physical activity, medication-related concerns (com-lexity of drug regimens and high frequency of side-effects), andatients’ expectations of medication and disease management.

Research on diabetes has established that, to improve glu-ose control and long-term health outcomes, patients need tombark on – and maintain – a complex range of self-careehaviours (such as following a diet, engaging in regular exer-ise and taking medication). A high level of patient participations needed for effective management, so promoting effectivend workable self-management merits more attention from theCP. However, little is known of the successful strategies that

ncourage patients to take an active and responsible role in self-anagement. Recent reports have shown that the individual’s

ge, personal history and personal beliefs concerning the causend treatment of diabetes are related to self-care practices [2,3].nderstanding these underlying factors may be essential for

ssessing an individual’s educational needs and implementinguccessful behavioural interventions. However, there are scantata on patients’ ‘profiles’, especially in France.The aim of thisnalysis of the DIABASIS survey was to evaluate the ‘typol-gy’ (multifaceted profiles) of patients and how it affected theiranagement of T2DM.

. Methods

.1. Study design

The design of this national survey, conducted betweenecember 2007 and January 2008 in a representative sample

f the French population aged ≥ 45 years, has been described inetail elsewhere [1]. In brief, self-questionnaires were mailedut by a polling agency (TNS Healthcare Sofres) to a rep-esentative cohort of the general population aged ≥ 45 years.

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emographic data were collected (age, gender, socioprofes-ional status, marital status, income level and size of cityf residence), together with 37 questions related to the dis-ase. The collected responses were checked for consistencynd completeness, and then computerized using a double-entryystem. A total of 14,201 individuals returned the question-aires (77% response rate) and, of these, 1,092 respondersad T2DM. The present analysis is focused on the lat-er.

.2. Statistical analysis

A typological approach was used to allow complex patients’ata to be organized in ways that described patterns of dis-ase management. This kind of approach identifies similaritiesmong patients who share a common score profile rather thanorrelations or differences (t tests) among variables recordedcross all patients [4]. Patients were first classified using a set ofhe patients’ scores, and then examined for relationships betweenelonging to a particular patient profile and any other vari-bles of interest. If coherent and meaningful, the profiles thusbtained can reflect common patient styles for self-care fromhich patient-tailored interventions can be developed.Quantitative variables are expressed as means ± standard

eviation (SD). Categorical variables are described by numbersnd relative proportions in the relevant categories. Where appro-riate, differences between groups were compared by Student’stest (if the size of the groups to be compared was > 30) foruantitative data or by the Z test for categorical data. Statisticalesults were considered significant at P ≤ 0.05.

To identify homogeneous sets of attitudes correlating to spe-ific behaviours, an explanatory multivariable analytical methodf canonical typology was used [5]. The canonical analysis gen-rated two axes that summarized the links between the tworoups of variables: behavioural variables (those to be explained)n the y axis (pertaining to changes in lifestyle, treatment satis-action, side-effects, weight gain and diabetes-related distress);nd attitude-related variables (those that are explanatory) on theaxis (a combination of lifestyle attitudes and feelings towards

he disease). This allowed the identification of a set of attitudeshat influenced specific behaviours. The parameters included in

he model were, on the one hand, variables relating to the impactnd burden of the disease – satisfaction with treatment (Q 23),dverse events (Q24), weight gain (Q25), disease burden (Q28)nd lifestyle modifications (Q29–31) – and, on the other hand,

4 tes & Metabolism 36 (2010) 476–483

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Table 1Demographic and clinical characteristics of the T2DM DIABASIS populationaged over 45 years with T2DM.

Number of questionnaires sent 14,201Number of questionnaires from T2DM patients’ 1,092Prevalence of T2DM (%) 7.7

Demographic dataGender ratio (male/female) (%) 60Mean age (years) 66Mean age at diagnosis (years) 55Mean BMI (kg/m2) 28.9Overweight patients (BMI > 25 kg/m2) (%) 77

Disease managementDiet & lifestyle treatment (%) 10Drug treatment (%)Among drug-treated patients 90

Oral antidiabetic drugs (OADs) only (%) 81Monotherapy (%) 44Bitherapy (%) 27Tritherapy or more (%) 10

OAD + insulin (%) 10Insulin only (%) 9

Metformin (%) 60Sulphonamide (%) 53

Frequency of blood glucose controlHbA1c three times a year or more (%) 37at least twice a year (%) 59at least once a year (%) 77

HbA1c mean ± SD (%) 7.0 ± 1.1Range (%) 5.0–15.6

Physicians seen for T2DM in the past year by patients (%)General practitioner (GP) 93Diabetologist 29Cardiologist 35Ophthalmologist 41

Side-effects (adverse events) overall (%) 61Hypoglycaemia (%) 24

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ehavioural variables – patients’ opinions and behaviours (Q33nd Q34).

To avoid creating a ‘non-treated patient’ cluster, those whoere treated by diet alone were excluded from the initial anal-sis, as they could not answer the question about treatmentatisfaction. For the final analysis, each non-treated patient wasttached to the patient type that he/she most closely resembled.

Score centring was used to level out the individual differ-nces in scoring (between individuals who generally overratend those who underrate). A factorial analysis was then per-ormed to replace the high number of variables with a limitedumber of ‘summary’ variables.

The aim of the typology was to position patients according tooth canonical axes using stepwise discriminant analyses. Forhe first classification, a k-means algorithm was applied to obtainlusters of individuals (on the basis of a first random sample of0 individuals), a process that was repeated 100 times [5]. Anscending hierarchical classification was then applied to deter-ine the best clustering, defined as minimizing the number of

roups while maximizing the differences between them. Patientsere then distributed across five groups along both axes, plac-

ng each group at a point the most distant from each other and,ithin each group, as homogeneously as possible.The two canonical axes were: the y axis – behaviour, or abil-

ty to change – ranging from patients to whom the disease isburden to those who are able to adapt and are not overly

istressed by the disease; and the x axis – attitude/opinion, orcceptance/self-involvement – ranging from patients in denialo those who accept the consequences of the disease on theirifestyle.

Throughout the present report, for all percentages showingdifference in a subtype of patients vs. what is observed in

he general population (for example, 37% vs. 22% overall), theifference was statistically significant (P < 0.05).

. Results

.1. Patient population

The main characteristics of the T2DM population were: 60%ale; mean age: 66 years; mean age at diagnosis: 55 years;ean body mass index (BMI): 29 kg/m2 (39% were overweight

nd 37% were obese); and mean duration of disease: 11 yearsTable 1). The disease was mostly diagnosed (80%) and managed93%) by primary-care physicians (PCP). In 74% of cases, theiagnosis was made following routine biological testing. Feel-ngs of anxiety/fear at disease onset were reported by 43% ofatients overall. The disease was managed by a diabetologist innly 29% of cases.

The disease was relatively well controlled. In the 12 monthsrior to the survey, glucose control was acceptable in most cases,ith 45% of patients having an HbA1c < 7%; the mean HbA1cas 7%. Ten percent of patients were under a diet-and-lifestyle

anagement regime only, while 90% were using drug therapy: of

he latter, 81% were treated with oral antidiabetic drugs (OADs)lone, 10% with both OADs and insulin and 9% with insulinlone. The mean time from diagnosis to insulin initiation was

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Gastrointestinal complaints (%) 34Weight gain (%) 23

MI: body mass index.

3.8 years. Of the OADs, metformin and sulfonylureas werehe most frequently prescribed drugs (60% and 53%, respec-ively), whereas thiazolidinediones (TZDs) represented 11% ofrescriptions. In addition, 44% of patients were treated withonotherapy, 27% were using bitherapy and 10% were using

hree or more OADs; 50% reported implementing a change iniet and 30% in exercise. The overall level of compliance withrugs was good (83%), and 61% of patients reported adversevents (24% were hypoglycaemia).

.2. Typology and patient profiles

Five patient types emerged from the canonical analysis:committed’ (25%); ‘carefree’ (23%); ‘bitter’ (19%); ‘disheart-ned’ (19%); and ‘overwhelmed’ (15%) (Fig. 1). The most

vident differences between categories were the patients’ com-itment to lifestyle changes, especially exercise, and their

upport needs for diabetes management. Each category’s distin-uishing features and patients’ profiles are summarized below.

H. Mosnier-Pudar et al. / Diabetes & Metabolism 36 (2010) 476–483 479

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ig. 1. The five patients’ profiles positioned along the two axes generated byehaviours in type 2 diabetes.

he patients’ main demographic and clinical characteristics forach of the five types are presented in Table 2. The percentagesefer to the responses (to the self-questionnaire) by the patientsn one specific profile vs. those of the whole DIABASIS surveyopulation (where P < 0.05).

.2.1. Committed patients (25%)This group of patients makes self-management a priority;

hey take action. They believe that their previous dietary habitsnd lack of exercise contributed to the onset of their diabetes.hey express guilty feelings and tend to link the disease to

heir previous way of life with self-blame (37% vs. 22% over-ll). These patients used to enjoy indulging in good food andre former bons vivants, appreciating the good things in life,

nd believe they bear the primary responsibility for their dis-ase.

This group has the best knowledge of the disease (63%s. 57% overall knew what the HbA1c was used for),

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able 2ain demographic and disease characteristics of patients according to the five profile

Committed (25%) Carefre

ender (% male) 74.4 66.6ean age (years) ± SD 66.49 ± 10.0 67.19 ±

atients (%) aged ≥ 65 years 55.1 55.8ean duration of diabetes (years) ± SD 11.9 ± 11.8 12.0 ±ean BMI (kg/m2) ± SD 28.28 ± 4.6 28.65 ±bese patients (%) 30.9 35.2urrent body weight (kg) 81.4 81.4ean HbA1c (%) ± SD 6.8 ± 1.1 6.9 ± 1

atients (%) with HbA1c ≤ 6.5% 30.4 30.1atients (%) with perception of poor health status 18.7 12.6

MI: body mass index.

ical analysis to identify homogeneous sets of attitudes correlating to specific

nd is more committed to following lifestyle advice. Theseatients care about what they eat: they have stopped snack-ng; reduced the overall quantity of food they eat, especiallyugary and fatty foods; and organize their own food-shopping,ocial life and restaurant invitations. Over half have startedhysical activities (53% vs. 30% overall), and the major-ty declares having no difficulty in exercising (60% vs. 38%verall).

Their physicians are viewed as partners in their treatment,nd they also describe their close family members and friends asupportive. They declare being more compliant with drugs (90%s. 83% overall), and report fewer adverse drug effects (48% vs.1% overall) and less diabetes-related distress in general.

As a result, these patients do not perceive the disease as

burden in their everyday life, and cope well with personal

sentimental and sexual life), family, professional and socialdjustments. They actively manage their disease and are moreompliant than average.

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e (23%) Bitter (19%) Disheartened (19%) Overwhelmed (15%)

46.5 53.1 49.910.7 64.10 ± 10.6 66.98 ± 10.3 66.97 ± 10.6

44.0 57.2 56.311.2 11.6 ± 11.2 13.6 ± 14.2 12.5 ± 11.2

4.7 28.98 ± 5.9 28.99 ± 5.2 30.21 ± 5.936.6 42.3 41.981.5 80.6 82.7

.2 7.3 ± 1.0 6.9 ± 0.9 7.0 ± 1.016.6 26.3 26.432.5 29.0 40.0

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.2.2. Carefree patients (23%)These individuals are not deeply concerned about having dia-

etes. At disease onset, only a few expressed anxiety (16%s. 43% overall), while 36% (vs. 20% overall) were indiffer-nt. They see themselves as being in good health in general (in7% of cases vs. 74% overall), and only 37% (vs. 51% overall)onsider the disease serious.

There are slightly more men than women in this group (67%s. 60% overall). They do not believe they have to modify theirifestyle because they take their medications. This means that,hile drug compliance is good (90%), self-care is minimal in

his group: 94% have not changed their eating habits (vs. 50%verall) and 89% have not changed their exercise habits at all. Onhe other hand, they show higher-than-average drug compliance90% vs. 83% overall), and report fewer adverse events (47%s. 61% overall).

They do not involve their family in their disease manage-ent and believe that diabetes does not have an impact on

heir family or social daily life. Indeed, diabetes is not a bur-en for these patients and does not disturb their day-to-daypersonal, family, professional or sentimental) life. In gen-ral, they minimize their situation; the disease is taken caref by the drug and does not further interfere with their lives.owever, it is possible that they are not truly more compliant

han average, but only that their denial of non-compliance isreater.

.2.3. Bitter patients (19%)Unfairness and revolt (53% vs. 23% overall) are the main

eelings expressed by this group. They do not feel guilty overhe disease and do not believe that their previous lifestyle wasnvolved in its onset. Most of them believe that their familyistory and genetic background are solely responsible for theiriabetes.

These patients are more often female (53% vs. 40% overall)nd, as their daily life is impaired by diabetes, they complainbout the effects of the disease. For them, the routine of livingith diabetes is a negative experience, perceived as a heavy bur-en on every aspect of daily life (meals, social and professionalife, sentimental and sexual life). They encounter difficultiesn implementing healthy eating habits, and half (49% vs. 29%verall) complain about the inconvenience of a regular exerciseoutine.

They perceive themselves as having to put up with the diseasend its drug therapy, and do so with more frequent complaints ofdverse events (80% vs. 61% overall), such as hypoglycaemia,bdominal pain and diarrhoea, while having a lower rate of treat-ent satisfaction (41% vs. 25% overall). They more frequently

se insulin treatment (25%) and have lower compliance thanverage. Their glucose control is also poorer, with higher HbA1cevels (7.3% vs. 7.0% overall).

Family support is more prominent and visits to HCPs (both

eneral practitioners and specialists) are more frequent, with anverage total of 10 visits in the past year vs. six visits over-ll. They also seek more advice from specialists (diabetologists,ardiologists and ophthalmologists).

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Metabolism 36 (2010) 476–483

These patients see diabetes self-management as an unde-erved burden that intrudes on their daily life. Even when theyecognize the risk of complications, they still have major diffi-ulties in changing their lifestyles and adhering to treatment.

.2.4. Disheartened patients (19%)There are slightly more women than men in this group (47%

s. 40% overall) and they have little control over the daily routinef living with diabetes. Having low motivation, they also haveore difficulties in controlling their diet (constantly swinging

etween periods of restriction and overindulgence). Some arebsessed by diet (18% vs. 12% overall), but are easily discour-ged; they also frequently complain of weight gain (45% vs.3% overall) and are more likely to be obese (42% vs. 37%verall).

Because of their difficulties in implementing long-lasting,ustained changes in lifestyle, they simply give up. Thisight explain why they declare a low impact of the dis-

ase on their daily habits, socializing and, especially, theirrofessional lives (94% vs. 44% overall) despite complain-ng more frequently of drug-related adverse events (69% vs.1% overall). Another reason why this group does not feelhat diabetes overly impacts their lives could be the limitedelf-care practices that they implement. The obstacles facedy these patients, such as overweight and low motivation, areey considerations that need to be taken into account in theiranagement.

.2.5. Overwhelmed patients (15%)This group of patients initially reacted to their diabetes diag-

osis with anxiety and fear (44% vs. 30% overall), and expressore feelings of depression (42% vs. 7% overall). They also feel

oth revolted (41% vs. 23% overall) and guilty (31% vs. 22%verall), and tend more often to avoid talking about the diseaseor fear of being stigmatized (24% vs. 11% overall).

These patients are more often female (50% vs. 40% overall),ore frequently perceive their health as being bad (40% vs. 25%

verall) and feel that diabetes is a heavy burden on every aspectf life. They are more obsessed with diet (25% vs. 12% overall),ut have difficulties in sticking to one (16% vs. 10% overallwing from periods of restriction to overindulgence). They alsoave greater difficulties in exercising (40% vs. 29% overall) and,s a consequence, more frequently gain weight (35% vs. 23%verall), with an average gain of 8 kg since starting treatment;2% (vs. 37% overall) of them are obese.

On average, these patients have poor compliance with med-cation. They also report more frequent adverse events (inarticular, hypoglycaemia, reported by 61%) and more frequentnsulin use (25%), thereby contributing to less treatment sat-sfaction (41% had low satisfaction rates vs. 25% overall). Inddition, they express a need for more information, especiallyoncerning drug therapy (61% vs. 49% overall).

Living with diabetes is considered a heavy burden on every

spect of their daily life, impacting especially on relationshipsithin their inner circle (42% vs. 12% overall) and in theirrofessional life (44% vs. 27% overall). Also, their supportrom family and medical professionals is stronger: their fam-

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ly helps them to modify their eating habits, and encouragesheir compliance with treatment and appointments with health-are professionals. More of these patients visit a diabetologist39% vs. 29% overall).

This group of patients has a high level of dissatisfaction,xperiences considerable difficulty in managing their diabetesnd needs more active support to cope with their burden.

. Discussion and conclusion

The present analysis of the DIABASIS study provides insightnto T2DM patient self-management by identifying five distinctatient types (described above). Each type of patient constitutesset of opinions and attitudes towards the disease that influences

heir disease-related behaviours, leading to different degrees ofommitment to diabetes self-management. These findings couldssist the HCP in understanding what motivates or inhibits aiven patient type, and could be the key to helping HCPs adaptheir approach to break the vicious circle of lack of control thateads to discouraging self-management.

The most apparent patients’ differences are in their clini-al characteristics – namely, body weight and medical treatment.isheartened and overwhelmed patients are more overweight,

nd bitter and overwhelmed patients are more frequently treatedith insulin. In addition, overwhelmed patients appear to have

eelings of depression more frequently and are overall less sat-sfied with treatment. Previous studies have already associatedeverity of depression with poorer adherence to dietary guide-ines and medication regimens [6,7], and higher BMI scores8]. This could explain the difficulties faced by this group withelf-management. One aspect of the depression these patientsxperience has been linked to side-effects of diabetes medica-ions [7]. The main side-effect with significant implications foriabetes management is hypoglycaemia, reported significantlyore often in the overwhelmed group (61%). Hypoglycaemia

nd fear of hypoglycaemia have both been shown to negativelympact diabetes management, glucose control and subsequentealth outcomes [9,10]. Diabetic patients who fear hypogly-aemic episodes may go to great lengths to maintain bloodlucose at levels in a higher-than-normal range just to avoiduch events [10,11].

Differences in the degree to which patients believe they canlter the disease course through playing an active role in theirwn care is probably key and, indeed, committed patients tendo be less distressed over their disease and more able to maintainifestyle changes. In contrast, bitter patients, who did not acceptesponsibility for their disease – believing that family historynd genetics are the only causes of diabetes – are not as goodt implementing lifestyle changes and are unlikely to take anctive role in their disease management. The belief that ascribesariable importance to lifestyle vs. genetic factors in disease cau-ation and the patients’ own commitment to diabetes care havelready been acknowledged by others [3,10,12]. The carefree

roup differs from the others in that their approach is mainlyiomedical – they believe that disease management is simplybout taking a drug. They are relatively unconcerned about theirisease and make no effort to change their behaviours, whereas

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Metabolism 36 (2010) 476–483 481

heir drug compliance is better than the other patient types. Thiss not surprising as they are convinced that the drug regimen ishe answer to their disease; it also leads to a lack of commitmento lifestyle changes. It ascribes to a different illness model thanhe other groups, who have a more holistic, psychosocial model13].

The carefree group also differs from the other groups inamily support. As diabetes does not impact their daily life,hese patients do not involve their close family in the man-gement of the disease and, consequently, do not need familyupport. This is in contrast to the bitter and overwhelmed groups,or whom family support is more prominent. For these patientypes, the characteristics of the patients’ family setting shoulde taken into account to ensure the effectiveness of interven-ions, as these characteristics could significantly influence theatient’s self-care behaviours [14]. The literature indicates thathe individuals in a patient’s support network can also influencehe behavioural response to illness [15]. It appears that patientsnd their ‘significant others’ generally share the same percep-ion of the disease, although the partners’ influence on patients’ehaviour is minimal and typically limited to supporting changesn lifestyle and, particularly, physical activity. This could explainhy, in our surveyed population, greater family support was not

learly associated with a higher commitment to diet and exerciseuidelines.

Changes in self-management behaviours (dietary changes,egular exercise) impact both the patient and his social milieu15], so it is not surprising that patients who perceive diabetess a burden on their social life have greater difficulties in imple-enting new behaviours. The overwhelmed group, in particular,nds that their professional life is especially affected by the dis-ase, and these patients are likely to find it particularly difficult toaintain lifestyle changes when professional demands increase,

s has been found in other studies [16]. It is also highly likelyhat the fear of hypoglycaemia experienced by the overwhelmedroup extends beyond the patient and has an impact on theiramily, friends and work colleagues.

Patients who find it difficult to adhere to treatment and whoxperience numerous difficulties in implementing a healthyifestyle turn to the healthcare system for support, implyingreater services use. The role of the HCP is to encouragend motivate patients to take their disease management seri-usly. This means that the relationship that develops betweenhe patient and HCP, and the level of satisfaction with the ser-ices received, have an influence on the patient’s perceptionf the disease and the role he/she plays in its management17–19]. Committed patients tend to be satisfied with their rela-ionship with their physicians, and see them as partners ratherhan decision-makers. Ultimately, however, treatment decisionsre up to the patient, who therefore needs to receive meaning-ul information in a way that allows him to make his own mindp. This approach leads to better adherence to lifestyle changeshan when instructions are given in a controlling or authori-

arian manner. This idea of supporting patients’ autonomy waslso reported by Williams et al. [20], who found better gly-aemic control in patients who perceived their HCPs in thisight.

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82 H. Mosnier-Pudar et al. / Diabe

While the present study did not explore the influence ofatients’ attitudes on glycaemic control, others have found aorrelation [2,3,21]. In Sweden, 259 participants were recruitedrom T2DM patients attending an educational programme deliv-red by pharmacists [16]. A questionnaire designed to explorehe patients’ attitudes towards self-management was adminis-ered at the end of the program. HbA1c was measured in theseatients on four occasions throughout the programme, and threeategories or self-management profiles were identified: ‘diseaseanagers’ (55%); ‘compliant’ (31%); and ‘disheartened’ (10%).lthough these patients did not differ initially in metabolic con-

rol, by the end of the programme, the disease managers hadchieved significantly better and more sustained metabolic con-rol than the compliant who, in turn, did better than the smallestroup, the disheartened, who failed to achieve any reduction inbA1c [16]. Another study in which 44 T2DM patients were

ategorized according to their glycaemic control (from poor,ith HbA1c > 8.0%, to excellent, with HbA1c < 6.5%) found

imilar results [3]. The patients also participated in a one-on-ne semistructured interview, which investigated their personalackgrounds and self-management philosophies. The final fiveategories included the ‘committed’ and ‘tentative’, who hadood control; and the ‘hopeful’, ‘hassled’ and ‘overwhelmed’,ho had poor control [3]. These two reports confirm the correla-

ion between HbA1c levels and personal attitudes, regardless ofhether the investigators’ starting point was based on patients’rofiles or degree of glycaemic control. One US study, conductedith a nationwide sample of Veterans Affairs (VA) patients withiabetes, found that patients who were more actively engaged inheir diabetes self-care had significantly lower HbA1c levels andlso used the recommended diabetes services to a greater extent22]. Our present study appears to be in line with these findings inhat the categories with greater difficulties in accepting and man-ging diabetes, such as the bitter group, tended to have pooreretabolic control. However, due to the cross-sectional design

f all these studies, a cause-and-effect relationship betweenelf-management and glycaemic control cannot be firmly estab-ished.

The DIABASIS survey offers important information for dia-etes care, as a deeper understanding of patients’ perceptions ofhe disease is key to optimizing customized care. Distinct typesf behaviours that influence patients’ ability to make optimalse of available treatments and services are discernible. How-ver, some methodological limitations of DIABASIS need to becknowledged. The survey was based not on samples randomlyelected from the whole population, but on the permanent cohortf a polling agency (frequently used in epidemiological studies).his has to be weighed against its main advantage of feasibility:

he low cost and simplicity of the quota method facilitates thetudy of large samples with regular updates. Another limitation ishe fact that adaptation to a chronic disease is a dynamic process,nd patients’ roles vis-a-vis their disease management fluctuateonsiderably over time [21]. In people whose attitudes towards

iabetes are variable, two factors – weight and age – appearo influence changes in their views and, in turn, their shift intonother category. The DIABASIS survey was cross-sectionalnd captured patients’ perceptions at a single point in time. For

aFo

Metabolism 36 (2010) 476–483

his reason, it would be useful to repeat it over time to see ifnd how self-management in these patient categories changes.inally, symptoms and co-morbidities, which can also influenceatients’ self-management commitments, were not investigated2,3,23] and, in particular, there were no data on complications,hich may also have a significant impact on patients’ attitudes.

n addition, the interpretation that individuals apply to their ownhysical changes and the influence that will have on their self-anagement practices need to be further explored. Finally, a

imitation inherent to such typological analyses is that they aressentially retrospective in nature and so, when the HCP firstees a patient, there is no way to know into which category thearticular patient belongs.

Nevertheless, this large-scale survey provides further insightsnto attitudes and beliefs towards T2DM, and identifies fiveatient profiles that express different levels of difficulty in imple-enting self-management practices. Each profile is based on a

umber of factors – many of which are subjective – that needo be taken into account for consistent and complete diabetesare. Patients in each category require different kinds of supportrom their HCP to promote effective self-management and theehavioural changes that could be key in improving metabolicontrol.

onflict of interest statement

All of the authors, except for C. Touboul of TNS Health-are, were members of the DIABASIS Scientific Committee.rofessor S. Halimi is also on the advisory panel for Novartisnd has received speaker’s and consultant’s fees from Novar-is as well as other pharmaceutical companies (Abbott, Amgen,stra-Zeneca, Bayer, Boehringer Ingelheim, Eli Lilly, Glaxo-mithKline, LifeScan, Merck Sharp & Dohme-Chibret, Novoordisk, Pfizer, Roche Diagnostics, Roche Pharma, Sankyo,anofi Aventis, Servier, Takeda and Therval). Professor P.-. Guillausseau is on the advisory panel for Novartis, andas received speaker’s and consultant’s fees from Novartiss well as other pharmaceutical companies (Eli Lilly, Glax-SmithKline, Novo Nordisk, Pfizer, Roche, Sanofi Aventis,ervier, Takeda and Therval). Dr M.L. Virally is a consul-

ant for Novartis. Dr E. Eschwège has received fees fromstra-Zeneca, GlaxoSmithKline, Merck-Lipha, Novartis, Novoordisk, Roche Pharma, Sanofi Aventis, Servier and Takeda.r Helen Mosnier-Pudar has received speaker’s and consul-

ant’s fees from Novartis as well as other pharmaceuticalompanies (Eli Lilly, Novo Nordisk, Pfizer, Roche, Sanofiventis, Takeda and LifeScan), and Dr Ghislaine Hochbergas received speaker’s fees from Novartis, among otherompanies. Dr Sylvie Dejager is an employee of Novartisharma.

cknowledgements

The authors gratefully acknowledge the participating patientsnd their families, the operational support of TNS Healthcarerance, and the helpful discussions with and editorial commentsf Felicity Neilson.

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unding: The work was supported by Novartis Pharmaceuticalsorporation.

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