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Nutritional supplements for diabetes sold on the internet: business or health promotion?
Health behavior, health promotion and society
Diabetes is one of the most widespread chronic disease. Although many medications are available for the treatment and prevention of diabetes, many people turn to nutritional supplements (NSs). In these years, the online sales have contributed to the growth of use of nutritional supplement. The aim of the research was to investigate the type of information provided by sales websites on NSs, and analyse the existence of scientific evidence about some of the most common ingredients found in available NSs for diabetes.
A web search was conducted in April 2012 to identify web sites selling NSs in the treatment of diabetes using Google, Yahoo and Bing! and the key word used was "diabetes nutritional supplements". Website content was evaluated for the quality of information available to consumers and for the presence of a complete list of ingredients in the first NS suggested by the site. Subsequently, in order to analyze the scientific evidence on the efficacy of these supplements a PubMed search was carried out on the ingredients that were shared in at least 3 nutritional supplements.
A total of 10 websites selling NSs were selected. Only half of the websites had a Food and Drug Administration disclaimer and 40% declared clearly that the NS offered was not a substitute for proper medication. A total of 10 NS ingredients were searched for on PubMed. Systematic reviews, meta-analyses or randomized control trials were present for all the ingredients except one. Most of the studies, however, were of poor quality and/or the results were conflicting.
Easy internet access to NSs lacking in adequate medical information and strong scientific evidence is a matter of public health concern, mainly considering that a misleading information could lead to an improper prevention both in healthy people and people suffering from diabetes. There is a clear need for more trials to assess the efficacy and safety of these NSs, better quality control of websites, more informed physicians and greater public awareness of these widely used products.
Diabetes is one of the most widespread chronic diseases. According to the World Health Organization (WHO), the number of people with diabetes rose from 220 million in 2009 to 346 million in 2011, 90% being diagnosed with diabetes Type 2 (T2D)
Diabetes, is a disease influenced by lifestyle changes, such as diet, and so target of complementary and alternative medicine, including nutritional supplements (NSs)
As defined by Food and Drug Administration (FDA)
NS use has gradually increased in both the United States (U.S.)
In the U.S. the use of NSs is higher in women, the elderly and people with healthier lifestyles and diets respect to other persons, but also in persons with chronic diseases such as diabetes mellitus
In recent years, online sales have contributed to the growth in the use of NSs, and currently an estimated 4% of total NS sales were carried out on internet
Considering the high prevalence of NS use and their easy access on the internet, the aim of the research was to investigate the type of information provided by websites selling NSs on the prevention and treatment of diabetes. The list of ingredients was also considered in order to analyse the existence of scientific evidence regarding their possible effects on diabetes.
Search strategy
The web search was conducted in April 2012, to identify websites selling NSs for the treatment and prevention of diabetes mellitus. The research was performed using 3 of the main search engines commonly used to seek information, Google, Yahoo and Bing!
Figure 1
Diagram selection of web sites selling diabetes nutritional supplements
Diagram selection of web sites selling diabetes nutritional supplements.
Under the "Diabetes" category we analysed the first nutritional supplement suggested by the website (the supplements were not shown in alphabetical order).
The content of each website was evaluated according to the main indications provided by the National Institute of Health Office of Dietary Supplements (NIH-ODS) on how to evaluate health information on the internet
Literature review
In order to analyse scientific evidence of the efficacy of these supplements, a PubMed search was carried out on ingredients shared by at least 3 NSs. The bibliographical search for the specific ingredient was carried out, in addition to the following key words defined using the MeSH Database on PubMed: "Diabetes Mellitus" [Mesh]. The search was limited to randomized controlled trials (RCTs), systematic reviews (SRs) and meta-analyses (MAs) studies conducted on humans in the last 10 years.
The authoritative fact sheets on NSs provided by the NIH-ODS and the references reported by the sales websites in relation to the ingredients selected in this study were also considered. The FDA website was also used as a resource.
The literature analysis focused on the findings regarding the efficacy of these ingredients in treating diabetes mellitus, the method of administration, the indications for specific diabetes-related diseases and the possible side effects.
A total of 10 websites selling NSs for diabetes were analysed (Table
Scientific references supporting the NS offered were present on 3 websites only. The characteristics of references retrieved on the three websites are shown in Table
We found a total of 71 different ingredients in the 10 NSs selected and some of them were present in more than one supplement (Figure
Figure 2
Research on PubMed regarding the ingredients of nutritional supplements (NSs)
Research on PubMed regarding the ingredients of nutritional supplements (NSs). MAs, meta-analyses; NSs, nutritional supplements; RCTs, randomized control trials; SRs, systematic reviews.
A total of 10 NS ingredients were searched for on PubMed as they were present in at least 3 NSs. All the ingredients except two (
In Additional file
Additional file 1
Characteristics of references retrieved on the websites selling nutritional supplements
Click here for file
Reduction in fasting blood glucose, the most commonly used outcome measure, was statistically significant (p <; 0.05) for
Another outcome taken into account was the reduction in haemoglobin A1c, which was statistically significant (p <; 0.05) for
Adverse effects were rarely considered: in two of four studies for ALA, one of two studies for
This study provides an overview of NSs for the prevention and treatment of diabetes available on the internet, and focuses on the type of information provided by the websites as well as the scientific evidence supporting these products.
NSs have gained in popularity in recent years and their use by the population has increased considerably because they are readily available and are considered "natural" substances that can improve or prevent a number of conditions
We analysed the content of 10 websites selling NSs for the treatment and prevention of diabetes, based on some of the NIH-ODS
In general, adequate medical information was lacking. Although NSs do not require FDA approval of their safety and efficacy, they are products offered to support people with diabetes and even mitigate the risk of disease-related complications in addition to prevent diabetes. For this reason, websites should take particular care when providing information. It should be noted that potential users, such as people with a chronic disease, already take drugs regularly. The risk of drug-NS interactions should not in fact be ruled out
Additional concern could arise from the possibility of counterfeit products available on the Internet. NSs are less regulated than drugs and therefore more easily subject to counterfeiting
It should be emphasised that NSs are not a substitute for medical products, but only half of the websites stated this clearly, four via the FDA disclaimer and one in the FAQ section. It is interesting to note that when this was specified, the testimonials could be misleading. For instance, a company claimed in the FAQ section that the NS was not a drug substitute, although one customer reported: "
It should be also noted that FDA states that a NS marker can make no health claims unless approved and that it is illegal to sell a NS and promote it on its label or in labelling as a treatment, prevention or cure for a specific disease or condition
These are many the reasons why it is necessary to consult a physician before taking a NS, but only five websites suggested contacting one, two of them only in the case of pregnancy, breastfeeding or suspected health problems.
This message should be presented clearly on the websites since it has been shown that only a small percentage of NS users (20-30%) inform their physician about supplement use
The risks for consumers regarding the misleading information provided by online companies selling heath related products direct to the consumer such as drugs
In the last years has been spreading the idea that people, in a view of a better prevention, need to be able to perform decision-making actions which are beneficial for the enhancement of their own health
So it is also crucial that people acquire the ability to evaluate the information critically in order to be aware about their purchase and to use NS appropriately.
One of the NIH-ODS recommendations on how to evaluate health information on the internet
Only three websites provided scientific evidence supporting the NS offered. Few references actually concerned the effects on diabetes, however, and the majority of the articles were not recent (before 2002) (Table
An analysis of literature in the last ten years about the most widely present ingredients found in NSs offered by the websites selected showed that scientific evidence is still lacking. There were RCTs and MAs or SRs for all but one of the ingredients selected, but the average number of subjects included in the majority of RCTs is 43 and the average number of studies included in MAs or SRs is 7. There is therefore a clear lack of large studies, particular RCTs, and the results are conflicting. These findings are in agreement with several studies seeking scientific evidence regarding NSs and diabetes
It is also interesting to note that the daily dosage of ingredients present in the NS, where indicated, was not very comparable to the dosage tested in the studies retrieved. In some cases the two dosages differed considerably, as in the case of
To our knowledge this is the first study focusing on NSs for the prevention and treatment of diabetes that are sold directly to the consumer on the internet. Concerns about the presence on the market of products of dubious efficacy are compounded with concerns about the misleading information – or lack of it – on the selling websites. Another point to underlined is the lack of a possible mediator, particularly a health professional, in the purchase of these products.
Some limitations of the study are the low number of websites retrieved and the fact that they are only in English. It is also reasonable to assume that this number will increase, as shown by data regarding use of the internet as a source of health information
Another limitation of this study is that our evaluation of the scientific evidence in support of NSs only took into account one ingredient present in more than three products. It should be noted, however, that it is difficult to conduct research on NSs because product composition varies considerably from manufacturer to manufacturer, and different products have been studied. The ingredients are present in combination with other different ingredients in the NS and even the dosage varies greatly. It is therefore necessary to study the efficacy of NSs on diabetes, not the single ingredients, especially in the case of products claiming to reduce the risk of a disease or health-related condition, since potentially adverse effects and drug interactions cannot be entirely ruled out.
In conclusion, easy internet access to NSs lacking adequate medical information and strong scientific evidence is a public health concern, mainly considering that a misleading information could lead to an improper prevention especially in healthy people and improper management of a disease in people suffering from diabetes. It is necessary to develop appropriate and reliable information to enable consumers to make an informed decision about the product prior to purchasing it. Furthermore, health care providers should be more informed about these widely used products. It is also evident that more research to validate the efficacy and safety of these NSs is called for.
ALA: Alpha lipoic acid; NHANES: National Health and Nutrition Examination Survey; NIH-ODS: National Institute of Health Office of Dietary Supplements; NS: Nutritional supplement; FDA: Food and Drug Administration; MA: Meta-analysis; RCT: Randomized controlled trial; SR: Systematic review; T2D: Type 2 diabetes.
Competing interests
The authors declare that they have no competing interests.
Authors' contributions
The article was conceived by all authors. LC took responsibility for drafting the article. MC and LC carried out the Web search and interpreting of the data. EC, DF, LC and UG had a substantial role in critical revision. All the authors have given their final approval of the version for publication.
The authors gratefully acknowledge "Quality and Technology Assessment, Governance and Communication Strategies in Health Systems" Study and Research Centre - University of Brescia, Viale Europa 11, 25123 Brescia, Italy for the support.
Alternative therapies useful in the management of diabetes: A systematic review
Use of dietary supplements in the United States, 1988–94
Dietary supplements in a national survey: Prevalence of use and reports of adverse events
Dietary supplement use in the United States, 2003–2006
Dietary supplement use and medical conditions: the VITAL study
National Institutes of Health State-of-the-Science Conference Statement: multivitamin/mineral supplements and chronic disease prevention
Complementary and alternative medicine use among adults with diabetes in the United States
Online dietary supplement resources
Effect of alpha-lipoic acid on blood glucose, insulin resistance and glutathione peroxidase of type 2 diabetic patients
The effects of lipoic acid and α-tocopherol supplementation on the lipid profile and insulin sensitivity of patients with type 2 diabetes mellitus: a randomized, double-blind, placebo-controlled trial
Nutritional supplementation for type 2 diabetes: a systematic review
Nutritional supplements and their effect on glucose control
Gymnema sylvestre for diabetes mellitus: a systematic review
Oral magnesium supplementation reduces insulin resistance in non-diabetic subjects – a double-blind, placebo-controlled, randomized trial
Beneficial effect of chromium supplementation on glucose, HbA1C and lipid variables in individuals with newly onset type-2 diabetes
Effects of chromium brewer's yeast supplementation on body mass, blood carbohydrates, and lipids and minerals in type 2 diabetic patients
Chromium effects on glucose tolerance and insulin sensitivity in persons at risk for diabetes mellitus
Characterization of the metabolic and physiologic response to chromium supplementation in subjects with type 2 diabetes mellitus
Effects of combination of zinc and vitamin A supplementation on serum fasting blood sugar, insulin, apoprotein B and apoprotein A-I in patients with type I diabetes
Effects of melatonin and zinc on glycemic control in type 2 diabetic patients poorly controlled with metformin
Regular daily intake of black tea improves oxidative stress biomarkers and decreases serum C-reactive protein levels in type 2 diabetic patients
The effect of an extract of green and black tea on glucose control in adults with type 2 diabetes mellitus: double-blind randomized study
Chromium picolinate and biotin combination improves glucose metabolism in treated, uncontrolled overweight to obese patients with type 2 diabetes
Chromium picolinate and biotin combination reduces atherogenic index of plasma in patients with type 2 diabetes mellitus: a placebo-controlled, double-blinded, randomized clinical trial
Biotin supplementation reduces plasma triacylglycerol and VLDL in type 2 diabetic patients and in nondiabetic subjects with hypertriglyceridemia
Momordica charantia for type 2 diabetes mellitus
Hypoglycemic effect of bitter melon compared with metformin in newly diagnosed type 2 diabetes patients
Fenugreek bread: a treatment for diabetes mellitus
Advising patients who use dietary supplements
Interactions between supplements and drugs: deciphering the evidence
Dietary supplements and probiotics for diabetes
Mission impossible? Regulatory and enforcement issues to ensure safety of dietary supplements
Herb and supplement use in the US adult population
What do herbalists suggest to diabetic patients in order to improve glycemic control? Evaluation of scientific evidence and potential risks
Quality of online pharmacies and websites selling prescription drugs: a systematic review
Where there's a web, there's a way: commercial genetic testing and the Internet
The on-line promotion and sale of nutrigenomic services
Misuse (and abuse?) of the concept of empowerment. The case of online offer of predictive direct-to-consumer genetic tests
Patient empowerment: myths and misconceptions
Use of complementary and alternative medicine supplements in patients with diabetes mellitus
Diabetes and Herbal (Botanical) Medicine
Patterns of dietary supplement use among older men and women in the UK: findings from the Hertfordshire Cohort Study
Magnesium intake and risk of type 2 diabetes: a meta-analysis
Oral magnesium supplementation improves insulin sensitivity and metabolic control in type 2 diabetic subjects: a randomized double-blind controlled trial
Magnesium intake and risk of type 2 diabetes: meta-analysis of prospective cohort studies
Glucose and insulin responses to dietary chromium supplements: a meta-analysis
Zinc supplementation for the prevention of type 2 diabetes mellitus
Meta-analysis of the effect of herbal supplement on glycemic control in type 2 diabetes
Pre-publication history
The pre-publication history for this paper can be accessed here:


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Bobcats top BucksNov 24, 2013 - 6:50 AM Milwaukee Bucks would be an understatement.
Al Jefferson outscored the entire starting lineup of the Bucks Saturday night, as the Charlotte Bobcats dominated Milwaukee, 96-72, at Bradley Center.
Jefferson had 19 points, one more than Milwaukee's starting five of Ersan Ilyasova, Caron Butler, Zaza Pachulia, Luke Ridnour and O.J. Mayo.
Khris Middleton had 20 points and John Henson added 10 for Milwaukee, which shot 35.3 percent from the field and lost its eighth consecutive contest.
Gerald Henderson had 17 points for the Bobcats, who won at Milwaukee for just the second time in the last 17 meetings.
"I thought our defense was pretty good to start and pretty consistent the whole game," Bobcats coach Steve Clifford said.
Ilyasova was the top scoring starter for the Bucks with seven points. Sloppy play by the home team played a factor, as 15 turnovers converted into 25 Charlotte points.
Point guard Brandon Knight, who has been hampered by a hamstring injury, had three points on 1-of-8 shooting for the Bucks. Milwaukee played without Larry Sanders (thumb) and Carlos Delfino (foot).
The Bobcats never trailed, but were up only 46-39 at the half. The bottom fell out for the Bucks in the third quarter when they went 4-of-19 from the field. Middleton had seven of his team's 12 points, but the Bobcats totaled 28 in the period.
Charlotte led by as many as 28 in the fourth quarter.
"We totally let this city down tonight on the way we played, on our energy and on our intensity," Bucks coach Larry Drew said. "As I told the guys, as long as I'm going to be our head coach here that will never happen again as far as they like it or they don't."
Game Notes
This is Milwaukee's longest skid since concluding the 2007-08 season with eight straight defeats ... The Bucks, who play at Detroit Monday, haven't dropped nine in a row in a single season since March 7-22, 1998 ... Ramon Sessions had 13 points, Josh McRoberts 12 and Kemba Walker 11 for the Bobcats, who held a 52-36 rebounding advantage.
Nov 23 10:49 PM
End of 3rd
Nov 23 10:14 PM
Nov 23 9:36 PM
End of 1st
Nov 23 9:11 PM
- 24
rootsRUWTbot Added 9 roots
Hornets 22, Bucks 15 1st - 2:51Nov 23 9:04 PM
- 15
rootsRUWTbot Took away 10 roots
Hornets 21, Bucks 10 1st - 4:55Nov 23 8:57 PM
1st Quarter - 11:59
Nov 23 8:42 PM
- 25
rootsRUWTbot Added 25 roots
Hornets vs. BucksAug 7 8:47 AM
Related News
- Bucks say IRS, FBI investigating email scam targeting team May 19
- Hornets PG Kemba Walker has another surgery on left knee May 9
- Hornets future unclear with 4 starters becoming free agents May 2
- NBA Playoff Capsules May 1
- Heat roll past Hornets in Game 7, 106-73 May 1
- Game 7's to decide Miami-Charlotte, Toronto-Indiana series Apr 30
- Hornets-Heat Preview Apr 30
- NBA Playoff Capsules Apr 30
- Wade, Heat force Game 7 with 97-90 win over Hornets Apr 29
- Batum 'running on adrenaline' in Game 6 after birth of child Apr 29
- LeBron 'not fond' of NBA's reviews of officiating Apr 29
- Blazers, Hornets can cap comebacks, Raptors also can advance Apr 29

subset: commoncrawl


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Rowville (South)
Service age groups
This topic has been updated with 2016 Census data for the LGA or other primary area only. What's this?
Rowville (South) had a similar proportion of pre-schoolers and a lower proportion of persons at post retirement age than the City of Knox in 2011.
The Age Structure of Rowville (South) provides key insights into the level of demand for age based services and facilities such as child care. It is an indicator of Rowville (South)'s residential role and function and how it is likely to change in the future.
Service age groups divide the population into age categories that reflect typical life-stages. They indicate the level of demand for services that target people at different stages in life and how that demand is changing.
To get a more complete picture Rowville (South)'s Age Structure should be viewed in conjunction with Household Types and Dwelling Types.
Derived from the Census question:
'What is the person's date of birth or age?'
Total population
Source: Australian Bureau of Statistics, Census of Population and Housing (opens a new window) 2006 and 2011. Compiled and presented by .id (opens a new window), the population experts.
(Usual residence data)
Compiled and presented in profile.id by .id, the population experts.
Compiled and presented in profile.id by .id, the population experts.
Dominant groups
Analysis of the service age groups of Rowville (South) in 2011 compared to the City of Knox shows that there was a higher proportion of people in the younger age groups (0 to 17 years) and a lower proportion of people in the older age groups (60+ years).
Overall, 27.5% of the population was aged between 0 and 17, and 12.7% were aged 60 years and over, compared with 22.8% and 18.6% respectively for the City of Knox.
The major differences between the age structure of Rowville (South) and the City of Knox were:
- A larger percentage of 'Parents and homebuilders' (25.7% compared to 22.0%)
- A larger percentage of 'Primary schoolers' (11.2% compared to 8.5%)
- A smaller percentage of 'Young workforce' (9.6% compared to 12.6%)
- A smaller percentage of 'Seniors' (4.4% compared to 6.9%)
Emerging groups
From 2006 to 2011, Rowville (South)'s population increased by 366 people (3.5%). This represents an average annual population change of 0.69% per year over the period.
The largest changes in the age structure in this area between 2006 and 2011 were in the age groups:
- Older workers and pre-retirees (50 to 59) (+356 people)
- Young workforce (25 to 34) (-307 people)
- Seniors (70 to 84) (+240 people)
- Empty nesters and retirees (60 to 69) (+226 people)


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You won't be able to dismiss this by usual means (escape or click button), but you can close it programatically based on user choices or actions.
"The paper (standard that they use) was a great quality, as always with their products. The colors were soft and delicate like I wanted. We aren't having a formal event, so these work great for the laid back feel we wanted. We only have two food selections, and the cards look good with the two lines."
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The Tavern Littleton is now open on West Main Street
Littleton is the sixth Tavern location.
The Tavern Hospitality Group, which owns the six Tavern locations, the Soiled Dove Underground and Cowboy Lounge, has expanded its empire to Littleton. Yesterday, the Tavern Littleton opened its doors at 2589 West Main Street.
This is a smaller version of the Tavern Downtown, which was named the best sports bar in America earlier this year.
"We were drawn to the area because of the quaint feel of West Main Street and the businesses and stores there," says Helen Wood, director of marketing for the Tavern Hospitality Group. "The characteristics of that community lend themselves to the idea of a unique neighborhood tavern."
The Littleton location has the same clean, modern, television-heavy decor that the other Tavern locations feature. The two-tiered patio with a fireplace and both indoor and outdoor seating should be a hit once the weather stops so closely resembling that of New Jersey.
This Tavern offers drink specials Monday through Friday from 2 p.m. to close, as well as weekend brunch, trivia on Tuesday, and other specials and events. There's also a lunch-loyalty program that should be a hit with Littleton business owners.
"Each of our taverns take on the personality of the neighborhood in which it's located," says Wood. "The size is much more conducive to a smaller neighborhood."
Inside the Tavern Littleton.
A fireside seat.
For more information, call 303-730-7772.
Related Location
2589 W. Main St.
Littleton, CO 80120
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You may click here to file online for homestead exemption. If you have any questions, comments, or need our services, please contact us at (904) 827-5500 or visit us at 4030 Lewis Speedway, Suite 203, Saint Augustine, FL 32084.
General Functions of the Property Appraiser's Office
The Property Appraiser is constitutionally mandated with two main duties. They are to assess property and to administer exemptions. Contrary to popular belief, the Property Appraiser does not determine the amount of taxes each property owner pays. Your Property Appraiser and staff place fair market values on over 125,000 real and nearly 12,000 tangible personal properties in St. Johns County totaling roughly 22 billion dollars. The office also administers nearly 70,000 exemptions. Administering exemptions has become very complex since the passage of Save Our Homes and Portability.
In carrying out its primary mission, the Property Appraiser's Office performs many other functions. Some important duties are maintaining the assessment roll by adding or deleting parcels, keeping updated information of all property ownership records and deed transfers, updating and maintaining property maps, administrating agricultural classifications, and processing tangible personal property returns.
It is important that your elected officials ascertain the needs of their constituents and provide those services. The ability to access the assessment roll on the Internet and online services, including exemption filing, are direct responses to those needs.


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The Royal Rifles of Canada were a Canadian Army unit based in Quebec City. They entered a senior hockey team twice.
In 1920-21 they won the Quebec City League title. They then lost the provincial final to McGill University.
In 1940-41 they had a team in the Quebec Senior Hockey League. They finished third and lost the semi final.
Rifles who played in the NHLEdit
- Billy Cameron (played in 1920-21)
- Maurice Courteau (played in 1940-41)
- Fred Lowrey (played in 1920-21)
- Stu Smith (played in 1940-41)


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Various ways of understanding compliance: a psychiatrist s view
- Hector Dalton
- 1 years ago
- Views:
1 Various ways of understanding compliance: a psychiatrist s view Rafał Jaeschke, Marcin Siwek, Dominika Dudek Summary The notion of compliance is commonly considered to be synonymous to the degree to which a patient correctly follows medical advice. Nowadays this definition is criticised for being a remnant of a paternalistic tradition in the relations between physicians and their patients. The authors discuss the contemporary views on the issue of compliance (seen either as the element of patient-practitioner interaction, self-care behaviour, as a cognitive-motivational process, or as an ideology), and highlight possible implications of those views for psychiatric practice. compliance / psychiatry / philosophy WHAT COMPLIANCE IS (OR RATHER: WHAT IT SEEMS TO BE) Classical perspective and its criticisms The problem of patients co-operation in the process of treatment and their attitude towards this process has been an object of research since Depending on the assumed definition, population included in the trial, nosological issues and adopted ways of measurement, compliance rates vary in a wide range between 10 and 85% [1]. Although compliance has been analysed from various perspectives (including medicine, nursing, psychology, sociology, health economics and even philosophy), there is no consensus around the definition of this notion. Rafał Jaeschke 1, Marcin Siwek 1,2,3, Dominika Dudek 1,2,3 : 1 Adult Psychiatry Department, University Hospital, Kraków, Poland. 2 Department of Psychiatry, Jagiellonian University, Collegium Medicum, Kraków, Poland. 3 Institute of Pharmacology, Polish Academy of Sciences. Correspondence address: Rafał Jaeschke, Adult Psychiatry Department, University Hospital, 21a Kopernika Str., Kraków, Poland. This research has not been aided by any grant. The term compliance was introduced into the field of medical sciences by David L. Sackett in 1976 [2]. His definition of this idea (developed by Haynes, Sackett and Taylor two years later) has been the most widely acknowledged (or at least: the most frequently cited) conceptualisation of compliance so far. It states that compliance is the extent to which a person s behaviour (taking medications, following a recommended diet or executing life-style changes) coincides with medical or health advice [3]. With its relative simplicity (and perhaps proximity to common sense ) this construct has also been harshly criticised because of its implicit paternalistic background. It seems to be rooted in a tradition of an oblique relationship between patient and physician with dominant position of the latter. Helvi Kyngäs, Mary E. Duffy and Thilo Kroll point out at a quite radical (but not impossible in the realm of clinical practice) implication of Sackett s hint about compliance. In their opinion the definition quoted above makes it virtually impossible for the patient to be involved in therapeutic process on the basis of partnership. This kind of a primary submission to the authority of healthcare personnel leads directly to a loss of autonomy. Finally, they strongly em-
2 50 Rafał Jaeschke et al. phasise (citing opinions of various authors [4, 5, 6]) that: this definition has been rejected because of its paternalism and its implication that healthcare personnel have the right to authority over the patient s behaviours and actions [1]. Hensook S. Kim also noticed that Sackett s perspective on compliance does not take into account the fact that apparently identical behaviours might arise from completely different motivations. Seemingly good compliance might be a result as different processes as coercion, conformity or poles apart therapeutic alliance [5]. What differs the relationship between patient and physician in psychiatry from similar relations in other fields of medicine? The differences implications for the issue of compliance In the realm of psychiatry the geometry of relationship between a physician and a patient gains paramount importance. The oblique (authority-based) relationship, although quite common in somatic medicine, usually leads nowhere in terms of establishing strong therapeutic alliance in psychiatry. According to the prominent Polish psychiatrist Antoni Kępiński relationship between physician and patient is a reflection of one out of two general cognitive patterns making it possible to explore the outside world. The first one an oblique (volitional) plane of cognitive contact reflects the humane tendency for putting the surrounding universe in order. This can be considered to be the source of scientific cognition: The human feels confident if the world acts in accordance to his ideas; if he can manage the environment; if he can influence it; when he feels like being a master. He considers the environment to be an obstacle to his plans and aims. He wants to get rid of this hurdle; he wants to subdue it. [7] This cognitive pattern has some undeniable advantages at least from physician s point of view. It makes it easier for a doctor to avoid the traumatic experience of the encounter with somebody else s suffering. Or in terms of the philosophy of Emmanuel Lévinas it serves as a protection from the experience of meeting The Other: the fathomless point [8] calling for ethical responsibility. [9] Lévinas himself expounded this drama in a much more drastic way: My relation to the other is not some benign benevolence, compassionate care or respect for the other s autonomy, but is the obsessive experience of a responsibility that persecutes me with its sheer weight. [10] As this demand is unfulfillable, then how can the subject weaken the devastating burden of superego [8]? It seems that one of possible strategies bases on separating the disease from the person. It is much easier to take position of a scientist involved in the analysis of somatic pathology at a cost of moving away from the world of someone s subjective experiences someone who imperceptibly became an object of scientific investigation. The second cognitive pattern pointed out by Kępiński ( horizontal or volitional plane of cognitive contact, as he called it) derives from the ability of recognising other people s emotional states, gained in the environment of the early relationship between mother and child. Although knowledge achieved this way is much more difficult to verify than data gained by using the scientific method, the author claims that reliability of emotional information achieved this way cannot be underestimated. Kępiński argues that: Not only it is the oldest way of recognising the surrounding world, but also the most important one. ( ) Objectivity and truthfulness of the cognition of somebody else s psychological state is the necessary condition of staying alive. [7] The evolution from the oblique to the vertical attitude towards patient seems to be a defining element of psychiatric practice. But this kind of regression from a scholar to a child (the process of regaining the ability of feeling other people s emotions regardless of masks, curtains and entanglements) has its price. The cost is a direct, traumatic (in a Lévinasian sense, where a trauma is something that comes from outside the self, the irruption of a heteronomous fact that can strike without warning, like a terrorist explosion [10]) exposition to the world of the other s emotions. In the realm of emotional interplay between two subjects it is much more difficult (if not impossible) to defend ego behind the firewall of authority of A Doctor. Nevertheless, the ultimate award is also high: only this kind of relationship makes it possible to pass from compliance in a conservative sense (i.e. following
3 Various ways of understanding compliance: a psychiatrist s view 51 the instructions of a physician-mentor ) to concordance the partnership between a physician and a patient, where the latter person is a rightful subject, fully engaged in the two-way communication with a doctor and actively shaping the decision-making process. [11] Beyond relationship: alternative perspectives on compliance The history of research on the issue of compliance can be succinctly described as the history of attempts to define this notion, as well as related terms. So, there is nothing peculiar in the fact that there do exist much wider conceptions of compliance than those that just confine to the microcosm of relations between patient and physician. According to Kyngäs et al. compliance can be seen: 1. as the element of the patient-practitioner interaction, 2. as self-care behaviour, 3. as a cognitive-motivational process, 4. as an ideology [1]. Each of those perspectives are discussed below. Untangling the onomastic maze First of all, let us tidy-up the mess around the meaning of words closely related to compliance. As we mentioned above, such terms as compliance, adherence and therapeutic alliance are often considered to be synonymous. Nevertheless, they do not mean the same. According to B.P. Madden both compliance and adherence refer to the interaction between patient and physician, while therapeutic alliance is related with the process of interaction itself [1, 12]. In the interpretation given by J. Fawcett the difference between compliance and adherence comes down to different layout of responsibilities. While adherence emphasise physician s role in the establishment of therapeutic relationship, compliance seems to stress patient s responsibility for following doctor s instructions (yet again, this perspective is rooted in the conservative point of view, where patient s actions are a function of physician s authority) [1, 13]. Both notions of adherence and compliance seem to apply to the oblique relationships between patient and practitioner, although the word adherence is intended to be less judgmental [1, 14] J. Wilder, R. Plutchnik and H. Conte suggested that in the term of compliance responsibilities of patient and physician focus in equal parts (quote: compliance [is] as much a function of their [patients] interactions with psychiatric personnel and of the suitability of the recommendations as it is of personal characteristics of the patients themselves. [15, 16]. Concordance seems to be a much more modern term, stressing partnership between patient and practitioner. According to R. Gray, T. Wykes and K. Gournay: Concordance emphasizes patient rights, the need for information and the importance of two-way communication and decision-making. In stark contrast with a compliance model, a concordance model suggests that patients have the right to make decisions (such as stopping medication) even if clinicians do not agree with the decision. [11] Compliance in the context of interaction between physician and patient In the viewpoint of Dracup and Meleis (1982) compliance is a dynamic process in which patient and physician together make decisions about a suitable healthcare regimen. They define the notion as: The extent to which an individual chooses behaviours that coincide with a clinical prescription, the regimen must be consensual, that is, achieved through negotiations between the health professional and the patient. [1, 4]. B. Vivian points out at the important role of a nurse in the process of compliance. In the author s opinion the nurse s task is to assist the patient and his or her family with compliance [17]. This statement assumes an active role (i.e. the joint responsibility) of all parties involved in the therapeutic process [6]. In the article published in 1989, L.C. Hussey and K. Gilliland linked compliance with the idea
4 52 Rafał Jaeschke et al. of mutuality. According to their definition compliance is: The positive behaviour that patients exhibit when moving toward mutually defined therapeutic goal [1, 18]. The term of mutuality can be understood as: A connection with or understanding of another that facilitates a dynamic process of joint exchange between people. The process of being mutual is characterised by a sense of unfolding action that is shared in common, a sense of moving toward a common goal, and a sense of satisfaction for all involved [1, 19]. As we can see, an implementation of mutuality to the theoretical construct of compliance shifts the latter idea from the region of paternalism into the realm of autonomy and empathy. Compliance seen as self-care behaviour Self-care behaviour is one of the most important concepts in health promotion. It is used to describe decisions and actions that an individual can take to cope with a health problem or to improve his or her health [20]. Compliance can be understood as an element of self-care behaviour, while noncompliance is a self-care deficit [21]. Nevertheless we have to note that while self-care by definition is performed on behalf of maintaining health and well-being, than compliance might be just an effect of following orders of a physician [1]. Sometimes it might have more in common with passive aggression than with self-care. On the other hand, while lack of self-care always is a threat for wellbeing, than in some situations compliance deficit may be helpful as a reflection of patient s common sense as a form of defence against healthcare professional s wrong decisions. Compliance as a cognitive-motivational process Within the cognitive-behavioural paradigm compliance can be conceptualised as a resultant of patient s attitudes and opinions leading to concrete intentions towards recommended therapeutic plan. In this perspective, Kyngäs et al. gave the following perspective on the notion: Compliance has been defined as the patient s active, intentional and responsible process of selfcare, in which the patient works to maintain his or her health in close collaboration with healthcare staff. This definition includes both self-care behaviour as an outcome of the patient s process and actions (activity, responsibility and collaboration with healthcare personnel) and a commitment to self-care. [1, 22, 23] It is important to note at this point that cognitive-behavioural therapy (CBT) has been proven to be very effective in enhancing compliance. Acquisition of new skills and knowledge is the cornerstone of this therapeutic paradigm. By gaining insight into the assumptions of treatment, as well as by understanding his or her role in this process, it is easier for the patient to get involved into collaboration with the clinician and at the same time to become a subject within the relationship with the healthcare professional. [24] Compliance as an ideology In his intriguing considerations on the role of ideology in contemporary culture and politics, Slavoj Žižek (one of the most prominent representatives of Frankfurt School s Critical Theory [25] these days) noted that the most elementary definition of ideology can be found in Karl Marx s Capital: Sie wissen das nicht, aber sie tun es They do not know it, but they are doing it [26]. This observation leads to the conclusion that: The very concept of ideology implies a kind of basic, constitutive naïveté: the misrecognition of its own presuppositions, of its own effective conditions, a distance, a divergence between so-called social reality and our distorted representation, our false consciousness of it. [27] In the realm of healthcare, ideology is understood as a system of shared beliefs concerning behavioural norms and values [1, 28]. Let us add: very often it is a system of implicit beliefs based on the recognition of physician s authority. J.A. Trostle pointed out that this ideological bias finds its reflection in research strategies, interpretation of outcomes of clinical trials and their implications for the clinical practice. The reason for this status quo is the fact that: Research has defined patient behaviour in terms of professional expectations, and has ignored health-related behaviour that contradicts the profession s view of its own centrality in health care. [1, 28] Thankfully, this pessimistic view does not seem to be fully valid anymore. As we mentioned
5 Various ways of understanding compliance: a psychiatrist s view 53 above, in recent years there has been a major shift in the opinions about the nature of compliance and patient s role in this process. Nowadays compliance is a decision taken by the patient [1, 29] and this opinion is being systematically built in the system of healthcare professionals assumptions (also the implicit ones) about their occupations creating a new ideology. CONCLUSIONS Although the issue of compliance has been an object of research for the past sixty years, the interpretation of this notion still raises controversies. The existence of numerous (vague at times) terms related to compliance (e.g. adherence, concordance, mutuality, or therapeutic alliance) does not make the task any easier. The earliest definition of compliance (provided by D.L. Sackett) is being increasingly rejected nowadays, as it confines the problem to the dichotomy between (dominant) physician s recommendations and (submissive) patient s positive response. This historic assumption (being a kind of a cornerstone of an oblique relationship between a healthcare professional and a patient) seems to be particularly inadequate in psychiatry, as it usually leads nowhere in terms of creating strong therapeutic alliance. Establishing concordance (the partnership between a physician and a patient, where the latter person is a rightful subject, fully engaged in the two-way communication with a doctor and actively shaping the decision-making process) seems to be a much more suitable way of achieving therapeutic progress in the discipline of psychiatry. Apart from the construct of compliance as an intrinsic feature of the patient-practitioner interaction, the notion can also be seen as a variant of patient s responsibility (self-care behaviour) or psychological (cognitive-motivational) process. In the field of Critical Theory compliance can be analysed in terms of ideology, i.e. a system of shared implicit beliefs concerning behavioural norms and values (in this case: organising interpersonal relationships in the realm of the healthcare). REFERENCES 1. Kyngäs H, Duffy ME, Kroll T. Conceptual analysis of compliance. J Clin Nurs. 2000; 9(1): Sackett D. Introduction and the magnitude of compliance and noncompliance, In: Sackett DL, Haynes RB, editors. Compliance with Therapeutic Regimens. Baltimore: The Johns Hopkins University Press; p Haynes RB. Introduction. In: Haynes RB, Sackett DL, Taylor DW, editors. Compliance in Health Care. Baltimore: The Johns Hopkins University Press; p Dracup A, Meleis AJ. Compliance: and interactional approach. Nurs Res. 1982; 31(1): Kim HS. The Nature of Theoretical Thinking in Nursing. Norwalk: Appleton-Century-Crafts; Kontz MM. Compliance Redefined and Implications for Home Care. Holist Nurs Pract. 1989; 3(2): Kępiński A. Poznanie chorego. Kraków: Wydawnictwo Literackie; 2002(1978). 8. Žižek S. In Defense of Lost Causes. London: Verso Books; Lévinas E. Totality and Infinity. Dodrecht: Kluver Academic Publishers; Critchley S. Infinitely Demanding: Ethics of Commitment, Politics and Resistance. London: Verso Books; Gray R, Wykes T, Gournay K. From compliance to concordance: a review of the literature on interventions to enhance compliance with antipsychotic medication. J Psychiatr Ment Health Nurs. 2002; 9(3): Madden BP. The hybrid model for concept development: Its value for the study of therapeutic alliance. ANS. Adv Nurs Sci. 1990; 12(3): Fawcett J. Compliance: Definitions and Key Issues. J Clin Psychiatr. 1995; 56(Suppl. 1): Moore KN. Compliance or collaboration. The meaning for patients. Nurs Ethics. 1995; 2(1): Wilder J, Plutchnik R, Conte H. Compliance with psychiatric emergency room referrals. Arch Gen Psychiatr. 1977; 34(8): Mitchell AJ, Selmes T. Why don t patients attend their appointments? Maintaining engagement with psychiatric services. Adv Psychiatr Treat. 2007; 13: Vivian B. Reconceptualizing Compliance in Home Health Care. Nurs Forum. 1996; 31(2): Hussey LC, Gilliland K. Compliance, low literacy and locus of control. Nurs Clin North Am. 1989; 24(3): Henson RH. Analysis of the concept of mutuality. Image J Nurs Sch. 1997; 29(1): McGowan P. Self-care behaviour. Encyclopedia of Public Health [document on the Internet] March [cited 2011 March 5]. Available from: 21. Bakker RH, Kastermans M. Is compliance part of selfcare or is non-compliance of selfcare deficit? (abstract in English). Veerpleegkunde. 1994; 9(2):
6 54 Rafał Jaeschke et al. 22. Mączka G, Grabski B, Gierowski JK, Dudek D. Group psychoeducation in the complex treatment of bipolar disorder Kraków experiences. Psychiatr Pol. 2010; 44(1): Mączka G, Siwek M, Skalski M, Dudek D. Patients and doctors attitudes towards bipolar disorder do we share out beliefs? Psychiatr Pol. 2009; 43(3): Schmidt NB, Woolaway-Bickel K. The Effects of Treatment Compliance on Outcome in Cognitive-Behavioural Therapy for Panic Disorder. Quality Versus Quantity. J Consult Clin Psychol. 2000; 68(1): Critical Theory. Stanford Encyclopedia of Philosophy [document on the Internet] March [cited 2011 May 2]. Available from: 26. Marx K. Capital: A Critique of Political Economy. Seattle: Create Space; 2010(1867). 27. Žižek S. The sublime object of ideology. London: Verso Books; Trostle JA. Medical Compliance as an Ideology. Soc Sci Med. 1998; 27(12): Taytard A. Assessing compliance in asthma patients. Eur Respir J. 1992; 5(1): Table 1. Various definitions of compliance and related terms Term Definition Reference The degree to which the patients adhere to the regimen recommended by their physician. Encyclopaedia Britannica Online, 2011 The degree to which a patient carries out the recommendation of the treating physician. Sadock & Sadock, 2007 The extent to which a person s behaviour (taking medications, following a recommended diet or executing life-style changes) coincides with medical or health advice. Haynes, 1978 Compliance The patient s active, intentional and responsible process of self-care, in which the patient works to maintain his or her health in close collaboration with healthcare staff. Kyngäs, 2000; Mączka, 2009; Mączka, 2010 The extent to which an individual chooses behaviours that coincide with a clinical prescription, the regimen must be consensual, that is, achieved through negotiations between the health professional and the patient. Dracup & Meleis, 1982 The positive behaviour that patients exhibit when moving toward mutually defined therapeutic goal. Hussey & Gilliland, 1989 Adherence Adherence to (or compliance with) a medication regimen is generally defined as the extent to which patients take medications as prescribed by their health care providers. The word adherence is preferred by many health care providers, because compliance suggests that the patient is passively following the doctor s orders and that the treatment plan is not based on a therapeutic alliance or contract established between the patient and the physician. Osterberg & Blaschke, 2005 Concordance The partnership between physician and patient, where a latter person is a rightful subject, fully engaged in the two-way communication with a doctor and actively shaping the decision-making process. Gray, 2002
7 Various ways of understanding compliance: a psychiatrist s view 55 Mutuality The connection with or understanding of another that facilitates a dynamic process of joint exchange between people. The process of being mutual is characterized by a sense of unfolding action that is shared in common, a sense of moving toward a common goal, and a sense of satisfaction for all involved. Henson, 1997 Therapeutic alliance In psychotherapy, therapeutic alliance is the synthesis of three related components: client and therapist agreement on goals of treatment, client and therapist agreement on how to achieve the goals (task agreement), the development of personal bond between the therapist and client. Bordin, 1979, as cited in Andrusyna, 2001
8 PSYCHIATRY TODAY The official journal of the Serbian Psychiatric Association published twice a year since 1969, and distributed throughout the country and abroad. Except for psychiatrists, its readers are also members of other health-related professions: psychologists, social-workers, speech therapists, special educators, medical and psychology students, etc. During the past years this journal has been contributing significantly to the promotion of scientific research in the field of psychiatry in Serbia. By exchange with other international professional journals, it facilitates connections with colleagues from abroad, and contributes to scientific achievements in the field of psychiatry. Editorial board is composed of national and international experts. Psychiatry today is indexed in the following databases: PsychoInfo, Psychological Abstracts, Ulrich's International Periodicals Directory, SocioFak.
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I do digital artwork and 2D animation. If you wanna work collaborative with me, just have a look through my submissions and then PM me!
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Hi NewGrounds!
Just finished putting together all the footage from my live streams and condensing it into a 7 minute time lapse video. You can watch it HERE. and you can also see the final product in the Art portal HERE.
I always post my stuff on NewGrounds first, The community is definitely smaller in recent years but is still the best place for upcoming artists to get their work seen by a few thousand eyes - compared to maybe double digits (or triple if you're lucky) on YouTube. Having said that, if you want to watch my live streams as they happen, it might be worth subscribing.
Not sure what to paint next, totally open to suggestions. Let me know, and follow me right here on NG too!
(shameless self-plug over)
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