How we can uncover psychological factors that lead to better Type 2 diabetes management

The universe of treatments for Type 2 diabetes is vast, including 60 drugs and other innovations aimed at driving behaviour change, such as continuous glucose monitoring and digital tools that support healthier diets, exercise and medication adherence. Still, over 500 million people worldwide have the disease and the proportion of people with Type 2 diabetes who are considered 'well managed' — or having an HbA1c of 7% or below — is declining.

The inverse relationship between the availability of Type 2 diabetes treatments and the lack of progress on outcomes suggests there’s a need to better understand what’s really happening with Type 2 diabetes patient behaviour and decision-making. To get a closer look at this, ZS used health decision science, a multidisciplinary field that studies how people make decisions about their health, to understand how cognitive factors influence the behaviour of people living with Type 2 diabetes.

Our research sought to identify which mental models dominate in people with Type 2 diabetes and lead to good diabetes behaviours. Understanding which models are present can help us see what behaviour changes are possible. So, what is a mental model? Mental models are the frameworks each of us uses to describe, categorize and understand our knowledge and perceptions of how the world works. For example, someone may have a mental model about the age they perceive someone as elderly or a mental model that governs when they’re comfortable making medical decisions without a doctor’s advice. In short, they shape and inform our choices.

In our patient research, which included 411 quantitative respondents and 25 qualitative interviews with samples representative of the diversity of American Type 2 diabetes patients, we found that three mental models most often help people with Type 2 diabetes make better decisions about their diabetes management. These mental models are the dynamic lived environment, temporal dimension and diabetes awareness. We used innovative qualitative and quantitative research techniques, combined with machine learning, to examine the impact of each mental model on behaviour.

We concluded that interventions aimed at improving peoples’ diabetes management should focus on those three models, which have discrete behaviours that healthcare stakeholders can use to 'nudge' or encourage better management.

The dynamic lived environment is a way of understanding how our physical, social and cultural environments interact to shape the world we live in. The dynamic lived environment model captures how patients internalize these factors when managing their diabetes. In our research, 57% of patients said they received adequate emotional support in managing their disease. This is great, but it’s insufficient to initiate behaviour change in people with diabetes. For that, patients need physical support.

As one patient told us: “Often, I have to cook other meals because not everyone in my house is diabetic, so that is a struggle. I struggle with finding the time to exercise. I also struggle with taking my medication as prescribed. I forget a lot of time, especially when I’m in a hurry.”

We found that when household members mirror a diabetic’s diet and exercise regimens, thus providing physical support, 37% more patients follow healthful eating and exercise plans. Currently, only about 18% of Type 2 diabetes patients report that their household follows their diet and activity requirements, which means there’s a huge opportunity for patients and physicians to educate families about the importance of healthy lifestyle changes and dramatically improve adherence to Type 2 diabetes management.

Patients have distinct modes of weighing the present against the future when making decisions. This is known as the temporal dimension mental model and it governs how a person sees the world in terms of time. How things change over time, how events may be related to each other in time or how we make plans.

As one patient told us: “When I was first diagnosed with diabetes, I did not take the diagnosis seriously. It wasn’t until it started having effects on other parts of my life that I really started paying attention.”

One simple method for improving the odds of succeeding at a long-term task, such as weight loss is setting discrete, measurable goals, such as losing half a pound per week. Our research found that patients who weigh themselves at least once a week are 20% more likely to follow a healthy diet. Healthcare professionals can easily nudge patients and their household members towards these stepwise goals to improve adherence to needed Type 2 diabetes lifestyle changes.

One patient we spoke to said: “I was terrified when I first got the diagnosis… Medication, exercise and diet have all helped me improve my health and A1c. I think working with my doctor on the best plan for my care has been very important.” This is an example of the diabetes awareness mental model at work. It is an awareness and framing of key activities— such as a healthy diet, exercise and medication — as part of a complete diabetes management plan.

Our research found that while most people with Type 2 diabetes can identify core behaviours of disease management, there’s a gap in the integration of diet and exercise into daily life. For instance, 17% of patients don’t believe that taking medication as prescribed is a part of diabetes management and one in four has a similar view towards blood/sugar testing. Critically, however, patients who believe exercise is part of diabetes management are 45% more likely to participate in the recommended daily level of physical activity. This underscores the importance of establishing proper diabetes awareness throughout a patient’s journey.

The management decisions people with Type 2 diabetes must make every day presents a taxing mental burden. For too long, though, the providers who oversee their care have yet to notice or know how to address this decision fatigue. By taking the time to understand mental models and their role in patient decision-making, however, healthcare stakeholders can begin to offer more holistic, humane and sophisticated care that can help ensure long-term success.

The authors would also like to thank ZS employees Shara Neidell and Grace He for their contributions to this article.