Type 2 Diabetes Self-Management: Controlling a Dynamic System

Abstract

People with type 2 diabetes risk disability and early death when they fail to control their blood glucose levels. Despite advances in medicine, pharmacology, human factors, and education, dangerous glucose levels remain endemic. To investigate cognitive barriers to control, we observed American Diabetes Association (ADA) certified training programs; reviewed ADA and National Institute of Health diabetes Web sites; and interviewed patients with type 2 diabetes using a critical decision method. A consistent picture emerged. The prevailing rules and procedures approaches are not preparing patients for the dynamic control task they face. Patients are often unable to understand and use the rules and procedures provided. They are unprepared to detect problems, make sense of dynamic relationships, and manage complex situations. Our results suggest that glucose self-regulation is better conceptualized as a dynamic control challenge requiring complex processes, including problem detection, sensemaking, decision making, and planning/replanning. The mismatch between most patient training and the dynamic demands of glucose regulation helps explain limitations in existing training and poor patient outcomes. We argue that constructs gleaned from naturalistic decision-making research in other complex domains can help many but not all patients develop the cognition necessary for effective blood glucose self-management.