Motivational Interviewing to Conquer Barriers for Diabetes Management

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Diabetes is a chronic medical condition that occurs when the body cannot properly regulate blood glucose levels.¹ This can occur due to either the body’s inability to produce sufficient insulin, a hormone that helps regulate blood glucose, or when the body becomes resistant to the effects of insulin.¹ In the US, an estimated 38.4 million people were diagnosed with diabetes in 2021, along with approximately 97.6 million adults aged 18 and older who had prediabetes.² In 2020, a total of 7.86 million hospital discharges were reported, with diabetes being one of the listed diagnoses among US adults.²

Uncontrolled diabetes can lead to serious health complications, including cardiovascular, renal, nerve, and vision problems.¹As a result, the American Diabetes Association provides an extensive standard of care guidance for clinicians in optimizing diabetes management.³

Guideline-directed medication therapy (GDMT) for diabetes (Figure 1) involves following established clinical strategies to optimize disease management through evidence-based medication regimens.³ These guidelines assist health care providers in selecting the most appropriate medications based on the patient's needs, particularly taking age, comorbidities, and disease severity into consideration. However, medication nonadherence presents a significant challenge in diabetes care, with about 1 in 3 patients not taking their medication as prescribed.^3-4 Commonly identified barriers include inadequate health literacy, adverse side effects, prescription costs, language barriers, and poverty resulting in food insecurity, homelessness, and housing instability.^1,3-4

DPP-4i, dipeptidyl peptidase-4 inhibitor; GLP-1 RA, glucagon-like peptide-1 receptor agonist; SGLT2i, sodium-glucose transporter-2 inhibitor; SU, sulfonylureas; TZDs, thiazolidinediones.

Nonadherence can result in poor glycemic control, increased macro- and microvascular complications, and higher health care costs. Pharmacists can play a crucial role in identifying and addressing some of these barriers to medication nonadherence. Tackling medication nonadherence via tailored patient care is vital in improving GDMT effectiveness and outcomes.

In efforts to optimize medication therapies to improve patient outcomes, one of the strategies for diabetes management is motivational interviewing (MI).⁵ MI is an evidence-based approach to behavior change counseling that draws on techniques from various existing psychotherapy and health behavior change theory models.^5-6 It is a patient-centered process to gauge a patient’s readiness to act on target behaviors.MI also employs strategies and skills that respect the patient’s autonomy, fostering confidence and decision-making.⁵ MI encompasses 5 core elements: expressing empathy, rolling with resistance, developing discrepancy, supporting self-efficacy, and avoiding argumentation (Figure 2).⁶ The spirit of MI is a foundational method of interacting with patients, according to Miller and Rollnick, characterized by being patient-centered, collaborative, caring, nonjudgmental, honest, assertive, and direct.⁶ MI uses open-ended questions, reflective listening, and affirmations to create a supportive environment where patients feel heard and understood.^5-6 Table 1 illustrates techniques clinicians can use during MI.

Key components of MI include "change talk," which refers to an individual's reasons and arguments for change and their ambivalence about it. Reflective listening is essential to MI, as it helps clarify goals and concerns while drawing out the individual's reasons for change. Neutral, objective feedback is given to ground conversations about personal goals, highlighting discrepancies between current behaviors and personal aspirations. The strategic use of open-ended questions helps strengthen the individual's motivations for change and address ambivalence while emphasizing personal choice, enhancing self-confidence in their ability to change, and reinforcing the perceived importance of behavioral change.⁶ The goal of MI is to strengthen the patient’s commitment to change, particularly in managing chronic conditions, adopting healthier behaviors, and adhering to treatment plans.⁵

There is increasing evidence from clinical trials regarding the use of MI and its impact on medication adherence for achieving personal goals.^4-8 In a systematic review by Marlene Papus et al, 54 randomized controlled trials (RCTs) were evaluated to assess MI's efficacy in supporting medication adherence among adults with chronic conditions.⁵ Medication adherence showed significant improvement in adherence in 23 of the trials, and in 19 RCTs, MI interventions showed significant results on other outcomes (eg, risky behaviors, disease symptoms, and monitoring data).^4,5

Another study by Smith West et al illustrated the effectiveness of group sessions led by clinical psychologists for patients with type 2 diabetes. This study was conducted to evaluate the incremental benefit of MI.^7,8 The study included 217 overweight diabetic women with an average body mass index of 37 who were randomly assigned to a group-based behavioral weight control program with supplemental individual MI sessions, or the same weight control program with health education sessions. Women in the MI group lost significantly more weight than those in the control group at 6 months (4.7 vs 3.1 kg, P < .02).This superior weight loss was mirrored by enhanced adherence to the treatment program on all process variables examined over the initial 6 months: session attendance (19 vs 17, P < .006), number of weekly self-monitoring diaries submitted (17 vs 14, P < .002), average diary rating (1.4 vs 1.2, P = .002), and changes in caloric expenditure in moderate-to-vigorous exercise (955 vs 742 kcal, P < .04). The study indicated that enhanced engagement in the treatment program contributed to greater weight loss in the MI group at 6 months. This pattern remained consistent throughout the 12 months of follow-up, with women receiving MI showing larger weight losses at that mark. Overall, the available evidence on the impact of MI, especially when combined with other effective treatments, is promising.⁸

Pharmacists can utilize core elements of MI for patients with diabetes to improve medication adherence and overcome barriers related to nonadherence. Showing empathy and employing change talk strategies through reflective listening fosters trust between clinician and patient, enabling the patient to feel at ease discussing their challenges. Educating patients with diabetes on the importance of taking their medications and encouraging lifestyle modifications is crucial. Identifying specific reasons that prevent medication adherence and offering resources shows the clinician's commitment and desire to assist the individual.⁹

For instance, health literacy is common in lower-income communities, and educating individuals in these areas about their medications—including side effects, administration, and treatment goals—can enhance their understanding of the necessity for adherence. Addressing barriers to medication access (eg, cost) can be effectively managed by connecting patients with assistance programs from manufacturers and state initiatives, thereby preventing medication discontinuation. Another barrier may be access to healthier food products. Due to socioeconomic disparities, some cultures and communities have less access to healthier choices. Many cannot afford healthier choices, many work longer hours, leading to more stress, increased glucose levels, and poorer food choices. Developing a personalized plan and setting individual goals can support individuals in better managing their diets. Customizing care in MI ensures that each patient’s unique lifestyle, beliefs, and readiness to change are respected and integrated intotheir diabetes management plan. This cultivates awareness that the clinician is ready to work with them to set and achieve personalized goals.⁹

Continuous communication builds trust and enables health care providers to adapt strategies as patients’ needs, circumstances, and objectives evolve. Ongoing follow-up reinforces progress, uncovers new challenges, and maintains momentum toward sustainable behavior change in diabetes self-management. By tailoring interventions and maintaining consistent follow-up, health care providers can empower patients to take active roles in managing their diabetes and improving outcomes.

Effective diabetes management requires a multifaceted approach that combines medical treatment, lifestyle changes, personalized support, and ongoing follow-up to address the complex and individual nature of the disease. Pharmacists serve as essential patient advocates, striving to improve health outcomes by compassionately addressing barriers to medication adherence. By ensuring accessibility and fostering a supportive environment, pharmacists empower patients to adhere to their medication regimens, promoting their overall well-being with care and professionalism.

REFERENCES

1. Farmaki P, Damaskos C, Garmpis N, Garmpi A, Savvanis S, Diamantis E. Complications of the type 2 diabetes mellitus. Curr Cardiol Rev. 2021;16(4):249-251. doi:10.2174/1573403x1604201229115531

2. US Centers for Disease Control and Prevention. Diabetes - National Diabetes Statistics Report. May 15, 2024. Accessed May 14, 2025. https://www.cdc.gov/diabetes/php/data-research/index.html

3. ElSayed NA, Aleppo G, Bannuru RR, et al. Summary of Revisions: Standards of Care in Diabetes—2024. Diabetes Care. 2023;47(Supplement_1):S5-S10. doi:10.2337/dc24-srev

4. Nelson LA, Wallston KA, Kripalani S, LeStourgeon LM, Williamson SE, Mayberry LS. Assessing barriers to diabetes medication adherence using the Information-Motivation-Behavioral Skills Model. Diabetes Res Clin Pract. 2018;142:374-384. doi:10.1016/j.diabres.2018.05.046

5. Papus M, Dima AL, Viprey M, Schott A, Schneider MP, Novais T. Motivational interviewing to support medication adherence in adults with chronic conditions: Systematic review of randomized controlled trials. Patient Educ Couns. 2022;105(11):3186–3203. doi:10.1016/j.pec.2022.06.013

6. Steinberg M. Clinical Perspectives on Motivational Interviewing in Diabetes Care. Diabetes Spectr. 2011;24(3):179-181. doi:10.2337/diaspect.24.3.179

7. Welch G, Rose G, Ernst D. Motivational interviewing and diabetes: what is it, how is it used, and does it work? Diabetes Spectr. 2006;19(1):5-11. doi:10.2337/diaspect.19.1.5

8. West DS, DiLillo V, Bursac Z, Gore SA, Greene PG. Motivational interviewing improves weight loss in women with type 2 diabetes. Diabetes Care. 2007;30(5):1081-1087. doi:10.2337/dc06-1966