Why It’s So Hard to Control Diabetes and What You Can Do to Help

envolve centerThis post originally appeared on the Envolve PeopleCare blog 

St. Louis, MO (March 6, 2018) – More than 30 million people in the United States are living with diabetes. Unlike some chronic diseases, managing diabetes is extremely complex. Successful diabetes management requires that people create new habits around medication adherence and glucose monitoring, dramatically change their diets, exercise, and more. In addition to each of these daily behaviors, people with diabetes must also carefully monitor their body for physical symptoms and signs of decline. Because these behavior changes are so difficult for people to make, fewer than 50 percent of patients adhere to treatment therapies, contributing to more than 75,000 diabetes deaths per year.

As behavioral scientists, we look at the low rates of diabetes control and try to understand what about the context, specific behaviors, and an individual’s psychology make it difficult to follow through. The concept of self-licensing and the ways people manage multiple goals can help us understand why disease control is particularly difficult in diabetes.


Self-licensing occurs when a person completes one action toward a goal but then feels free to do something else that might be counterproductive for that goal. For example, after going to the gym we may feel licensed to eat a less-healthy meal since we’ve just done something good for our goal of losing weight. Thanks to licensing, people might end up undoing the progress they just made!

Self-licensing can be very powerful. Studies show that even just making a plan to exercise or thinking about past good behavior can lead to overeating. When we think we’ve accomplished a goal, the goal becomes deactivated in our minds. This means that the goal is no longer salient to us, so it’s not top of mind. This serves to allow us to pursue other things. The problem comes in when the first goal is never really finished, or the other things we focus on are counterproductive to our original goal. This is dangerous when a goal requires consistent effort and is never truly finished, as with healthy eating or diabetes management.

Juggling Multiple Goals

The desire to consider something complete becomes even stronger when someone has many different goals that need to be accomplished. Think about the multiple goals someone might have and how often they might conflict with each other. On the one hand, we’re all motivated to stay healthy, live a long time, and control our diseases. But we’re also motivated to enjoy life in the moment. This means that we feel hunger, tiredness, stress, and busyness, and we want to check things off our list quickly.

We’re constantly balancing our multiple goals to optimize our overall wellbeing. For people living with diabetes, this means that it may be tempting to check the box next to diabetes on their  mental checklist after testing glucose so that they can move on to the other tasks for the day, making it difficult to follow through on all the steps required to manage diabetes.

So What Can We Do About This?

One strategy to reduce the effects of self-licensing is to link behaviors so that a health goal isn’t complete after just one action. When behaviors are sequenced, the first healthy behavior leads right into the next, keeping people on track. For example, we could prompt people to …

Eat an apple so you’re ready to check your glucose and insulin. Then you’ll feel energized for your walk. After your walk is the best time to take off your shoes and check your feet.

The other benefit of behavioral sequencing is that it allows behaviors to turn into rituals, which can have additional psychological value to an individual. Even if every step in the sequence described above isn’t truly necessary for diabetes management, weaving each of those steps together can make the health behaviors more enjoyable, easier to track, and easier to complete.

Another strategy for improving adherence is to help people find behaviors that serve multiple goals. If we know that people want to manage their diabetes, reduce their stress, and enjoy their leisure time, we may be able to help people find actions that accomplish multiple goals at once. For example, we could prompt people to do yoga …

Doing yoga is a great way to stay active with diabetes and also unwind from a stressful day. Yoga can help you kill two birds with one stone.

Managing diabetes can be a lot for someone to handle, especially when there’s so much going on in one’s daily life. Reducing self-licensing behavior through behavioral sequencing and satisfying multiple goals may help people stay on track with their health.

Julia O’Brien | Behavioral scientist

Julia O’Brien – Principal Behavioral Scientist

Julia O’Brien is a principal behavioral scientist and leads the Better Living and Health Group at the Center for Advanced Hindsight at Duke University. She has a Ph.D. in social psychology and a background in product research. She works with the Envolve Center’s Behavioral Economics (BE) team, which incorporates BE and social science into health-related behavioral modification programs.


Lindsay Juarez is a senior behavioral scientist

Lindsay Juarez – Senior Behavioral Scientist 

Lindsay Juarez is a senior behavioral scientist in the Center for Advanced Hindsight at Duke University. She has a Ph.D. in social psychology and specializes in goal pursuit and self-control.