Original Research

Time requirements for diabetes self-management: Too much for many?

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Practice recommendations
  • The care physicians commonly recommend may be too time-consuming for many patients. Find out how much time is available and ask about the pressures on that time.
  • If time requirements are onerous, help patients set priorities to maximize health.

Background: In Crossing the Quality Chasm, the Institute of Medicine laid out principles to improve quality of care and identified chronic diseases as a starting point. One of those principles was the wise use of patient time, but current recommendations for chronic conditions do not consider time spent on self-care or its impact on patients’ lives.

Objective: To estimate the time required for recommended diabetes self-care.

Methods: A convenience sample of 8 certified diabetes educators derived consensus-based estimates of the time required for all self-care tasks recommended by the American Diabetes Association.

Results: For experienced patients with type 2 diabetes controlled by oral agents, recommended self-care would require more than 2 extra hours daily. Elderly patients and those with newly diagnosed disease, or those with physical limitations, would need more time. Exercise and diet, required for self-care of many chronic conditions, are the most time-consuming tasks.

Conclusion: The time required by recommended self-care is substantial. Crossing the Quality Chasm suggests how clinicians and guideline developers can help patients make the best use of their self-care time: elicit the patient’s perspective; develop evidence on the health consequences of self-care tasks; and respect patients’ time.

To what extent does the time needed to perform diabetes self care diminish patients’ willingness to follow recommendations? Are there means of making self care more acceptable? Consider the following observations about chronic disease in general.

The Institute of Medicine has highlighted the extent to which medical care falls short of its potential. Crossing the Quality Chasm recommended 10 principles to reorient health systems; among them:

  • shared information and decision-making to better reflect patient preferences
  • evidence-based decision making
  • continuous decrease in waste of “resources or patient time.”

Chronic conditions were identified as “a starting point” for applying these recommendations since they are “the leading cause of illness, disability, and death in the United States, affecting almost half of the population and accounting for the majority of health care resources used.”1

Self-care, or self-management, is essential to good care of diabetes, one of the most common chronic conditions. Funnell and Anderson noted that “[m]ore than 95% of diabetes care is done by the patient.”2 Physicians offer instruction, but day-to-day implementation depends on patients themselves, who care for their diabetes “within the context of the other goals, priorities, health issues, family demands, and other personal concerns that make up their lives,”2 When their advice is not followed, and patients’ health suffers, physicians are frustrated by what can seem their patients’ refusal to do the best for their condition.

Researchers have examined a broad range of potential reasons for noncompliance with diabetes self-care recommendations, from patients’ attitudes and beliefs, to health motivation, readiness to change, language barriers, medication regimens, and trust in the medical profession.3-9 Although self-management programs have become more patient-centered,10-15 a review of patient-centered approaches in diabetes noted that “it is apparent that factors other than knowledge are needed to achieve long-term behavioral change.”16 A review of medication compliance concluded that “current methods of improving medication adherence for chronic health problems are mostly complex, labor-intensive, and not predictably effective.”17 Something crucial to success has yet to be identified.

An important missing link may be the time demands of self-care. Evaluations have considered program design and outcomes, but not how the length of diabetes self-care regimens affects patient outcomes. Indeed, scant attention has been paid to time requirements18 and little is known about how much time current recommendations take. To begin to draw attention to time requirements as a potential barrier to good self-management, we present estimates of the time required by recommended diabetes self-care.


Certified diabetes educators (CDEs) teach self-care skills and evaluate adherence. Their training is based on the American Diabetes Association’s (ADA) Clinical Practice Recommendations,19 which represent the standard of care for diabetes. The guidelines of the American Association of Diabetes Educators20 cover additional self-care elements, such as stress management and social support. We assembled a convenience sample of 8 CDEs, all registered dietitians or registered nurses, from a large teaching hospital and the nearby community. They averaged 13 years of experience as CDEs and 90 patients/month (range, 30–150). An experienced moderator led the meeting; proceedings were tape-recorded and transcribed.

We identified each self-care task in the ADA’s 2002 recommendations; the selections were confirmed by a practicing nurse clinician. We asked the CDEs to add other tasks they considered necessary for the best self-care. Since the focus was on extra time needed for self-care of diabetes, we excluded self-care that most people already do, such as tooth brushing, but retained care that most people should do but generally do not (exercising or preparing healthy foods).21-24

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