People with type 1 diabetes must cope, often from childhood, with the requirements of insulin replacement therapy and the need to pay special attention to diet, exercise, and many other aspects of daily living. Those who develop type 2 diabetes later in life also have to adapt to regimens of medications and lifestyle modification that make significant demands on them and their time. It is, therefore, not surprising that good glycaemic control - the primary aim of diabetes management - remain elusive in many cases. In one audit, only 58.4% of all patients with diabetes reached glucose control targets of HbA_1c < 7.5% in 2006.¹

It has been recognised for many years that patients with diabetes frequently fail to reach HbA_1c targets. However, the insight that this is often due to a neglect of the psychosocial aspects of the disease, rather than simply a failure of medical management, is one that emerged from the pioneering DAWN (Diabetes Attitudes, Wishes and Needs) survey. DAWN was initiated in 2001 by Novo Nordisk in collaboration with the International Diabetes Federation. This survey highlighted the need for a new approach to diabetes care that looks beyond blood glucose measurements and prescribed diet and exercise routines to the person behind the disease.

The DAWN study and its findings

The widely-published DAWN study is based on the theory that diabetes is best managed by the patient and care team working effectively together. It explored the perceptions, attitudes, and interactions of more than 5,000 people with diabetes and nearly 4,000 healthcare professionals engaged in diabetes care. The DAWN study was conducted in 13 countries, in order to allow cross-country comparisons. The study sought to:²

• Increase understanding of patient perceptions
• Identify barriers to, and solutions for, more effective self-management
• Gain insights into caregiver attitudes and responsibilities
• Develop information that would help to improve diabetes care

Possible drivers of effective self-management Adapted from Alberti G, 2002.2

The DAWN study examined a number of possible factors that may drive effective self-management of diabetes and found that social support and emotional well-being have a major impact on treatment success. However, at the time of the study, standards of care did not include evidence-based approaches to dealing with psychosocial issues and improving outcomes.²

A striking finding of the study was that 4 out of 10 patients with diabetes reported a feeling of poor well-being, with little difference between type 1 and type 2 diabetes. Only about 10% of those studied characterized their well-being as good.² People without support networks, such as family, work colleagues, or friends - and, especiallly people living alone - were more likely to have poor well-being and to manage their diabetes less effectively.²

The DAWN study found high levels of distress among patients with diabetes, especially at the time of diagnoses, when 85% reported stress, anxiety, depression, or negative emotions.³ More than half of those interviewed were anxious about their weight, concerned that their diabetes could get worse, or worried about hypoglycaemic events.² Despite the frequency of these psychological and emotional concerns, however, few patients reported having received psychological treatment for such diabetes-related problems³ and a majority of healthcare providers reported a lack of confidence in their ability to identify and evaluate their patients’ psychological needs.²

Other important findings of the DAWN study were related to barriers to the effective use of medications for glycaemic control in insulin-naive type 2 diabetes, particularly to the use of insulin. Patients generally gave a low rating when asked if insulin treatment would help them to manage their disease better, although this varied considerably from one country to another.⁴ Belief in insulin efficacy was especially low, and patients were also more likely to view insulin initiation as a sign that they had 'failed' to properly follow their previous treatment.⁴ Healthcare providers also often endorsed negative attitudes towards starting insulin, with approximately one third preferring to wait until it was 'absolutely essential'. Specialists, however, were less likely than other providers to delay insulin initiation.⁵ Physicians who preferred to delay the introduction of insulin also preferred to delay the start of oral antidiabetic drugs.⁴

The findings of the DAWN study highlighted the need for a new approach to diabetes treatment that takes into account key psychosocial issues in the lives of patients with diabetes, in conjunction with appropriate medical management. As many healthcare providers express a desire to improve their skills in this area, evidence-based tools and support materials are needed.

Share	6 8	Send to a colleague
URL