In the United States, the prevalence of diabetes has risen substantially over the past few years. Multiple studies have shown that better control of risk factors in patients with diabetes can reduce the long-term complications of this disease. These risk factors include glycosylated hemoglobin (HbA_1c) levels, blood pressure, and lipids. Patient self-management has been effective in lowering the incidence of complications. Unfortunately, not all patients are willing or able to take on this management in an effective manner. Repeated efforts to educate patients who are not ready to accept lifestyle changes can be frustrating for physicians and their patients. To provide a better understanding of patients' readiness to change their behavior, the transtheoretic, or stages-of-change, model was developed. This model of stages of readiness to change has been successfully applied to other areas of patient care where lifestyle changes are important, such as smoking cessation, alcohol abuse, and weight loss. Peterson and Hughes studied the impact of a simple tool characterizing readiness to change among patients with diabetes who were enrolled in an educational intervention.

The participants in the study were patients with diabetes who were referred to a diabetes educational program and had HbA_1c levels of 9 percent or higher. The participants were asked four questions to determine their stage of readiness for change (see accompanying table). Based on their replies to the four questions, participants were categorized into pre-contemplation, contemplation, preparation, action, and maintenance stages of change. Intensive diabetic education was offered to all participants, and they continued to receive routine diabetic care from their referring physician. HbA_1c levels were measured for 24 months after the participants finished the educational program.

Patients in the preparation and action stages of change attained significantly lower levels of HbA_1c in a shorter period of time than those who were in the precontemplation and contemplation stages. At 12 months, the average reduction of HbA1c in patients in the precontemplation and contemplation stages was 1.06; in those in the preparation stage it was 1.82; and in those in the action stage it was 2.56. In addition, patients in the preparation and action stages were more likely to have more HbA_1c measurements than their counterparts in the precontemplation and contemplation stages.

The authors conclude that using a simple tool to determine stages of change can identify patients more likely to have a positive response to diabetic educational interventions. The tool might be used to develop the most effective diabetic interventions for patients and target specific patient needs.

editor's note: Most family physicians know the frustration of dealing with patients who have uncontrolled diabetes. Despite multiple efforts to educate, provide lectures, praise the patient for small gains, and have frank discussions about the adverse outcomes of uncontrolled diabetes, patients often make little improvement in their HbA_1c levels. This situation can lead to frustration for physicians and patients. The stages-of-change model has been used successfully in other areas where behavior changes are important. This study applies that model to patients with diabetes. By using this model, physicians can identify patients who are willing to change and assist them in making that change. It also can help identify those who are not ready to change and provide a clear and concise message about the need for behavior changes. The targeted message should reduce the frustration that physicians and patients face when dealing with lifestyle changes that are important in the management of diabetes.—k.e.m.