Diabetes self-management education for adults with type 2 diabetes mellitus: A systematic review of the effect on glycemic control

If DSME Were a Pill, Would You Prescribe It?

EDITOR'S NOTE: This address was delivered by Margaret A. Powers, PhD, RD, CDE, President, Health Care & Education, of the American Diabetes Association (ADA), at the ADA's 76th Scientific Sessions in New Orleans, La., on 11 June 2016. Dr. Powers conducts research and has a clinical practice as a registered dietitian and diabetes educator at the International Diabetes Center at Park Nicollet in Minneapolis, Minn. Her research focuses on improving diabetes outcomes, including factors that affect the clinical, psychosocial, and behavioral aspects of diabetes. Dr. Powers has been an ADA volunteer for more than 25 years, including serving as a founding editor of Diabetes Spectrum. She is the lead author of the 2015 joint Position Statement on Diabetes Self-management Education and Support published by the ADA, American Association of Diabetes Educators, and Academy of Nutrition and Dietetics. She is the recipient of the ADA's Outstanding Educator in Diabetes Award and has published research, authored numerous articles and chapters, published five books, and is an international presenter. Dr. Powers holds a doctorate in education with a focus on performance improvement from Capella University. She received her Master of Science from the University of Illinois at Chicago and her Bachelor of Science from Michigan State University. She completed her dietetic internship at Cook County Hospital in Chicago.

Insulin adherence and persistence among Chinese patients with type 2 diabetes: a retrospective database analysis

OBJECTIVE

To assess adherence and persistence to insulin therapy and identify its associated factors among Chinese insulin-naïve patients with type 2 diabetes (T2D).

METHODS

Tianjin Urban Employee Basic Medical Insurance claims database was used (2008-2011). Adult patients with T2D who initiated insulin therapy during January 2009 through December 2010 and were continuously enrolled for 12 months pre-(baseline) and 12 months post-initiation (follow-up) were included. Patients who had a ≥80% medication possession ratio were deemed adherent, while patients who had no gaps of ≥90 days in insulin therapy were deemed persistent. Associated factors of insulin adherence and persistence were detected by univariate and multivariate analyses.

RESULTS

A total of 24,192 patients were included; the patients had a mean age of 58.9 years, with 49.5% being female. About 51.9% of the patients had human insulin as initiation therapy, while 39.1% were initiated with insulin analog and 9.0% with animal-derived insulin. Premixed insulin (77.3%) was prescribed most often in comparison with basal (11.8%) and prandial (10.9%) insulin. Only 30.9% of patients were adherent, and the mean (standard deviation) medication possession ratio was 0.499 (0.361). About 53.0% of patients persisted insulin therapy during follow-up, and the mean time to nonpersistence was 230.3 (145.5) days. Patients initiated with analog were more likely to be adherent (adjusted odds ratio: 1.07, P=0.036) and persistent (adjusted hazard ratio: 0.88, P<0.001) compared with those initiated with human insulin. Patients initiation with basal insulin had lower adherence relative to premixed (adjusted odds ratio: 0.79, P<0.001). Patients comorbid with hypertension or dyslipidemia, initiated with prandial insulin, and with baseline severe hypoglycemic events were more likely to be nonadherent/nonpersistent.

CONCLUSION

The insulin adherence and persistence among Chinese patients with T2D are generally poor. Initiation with insulin analog or premixed insulin may result in better adherence/persistence to insulin therapy.

2016 Health Care & Education Presidential Address: If DSME Were a Pill, Would You Prescribe It?

This address was delivered by Margaret A. Powers, PhD, RD, CDE, President, Health Care & Education, of the American Diabetes Association (ADA), at the ADA's 76th Scientific Sessions in New Orleans, LA, on 11 June 2016. Dr. Powers conducts research and has a clinical practice as a registered dietitian and diabetes educator at the International Diabetes Center at Park Nicollet in Minneapolis. Her research focuses on improving diabetes outcomes including factors that affect the clinical, psychosocial, and behavioral aspects of diabetes. Dr. Powers has been an ADA volunteer for more than 25 years, including serving as a founding editor of Diabetes Spectrum She is the lead author of the 2015 joint Position Statement on Diabetes Self-management Education and Support published by the ADA, American Association of Diabetes Educators, and Academy of Nutrition and Dietetics. She is the recipient of the ADA's Outstanding Educator in Diabetes Award and has published research, authored numerous articles and chapters, published five books, and is an international presenter. Dr. Powers holds a doctorate in education with a focus on performance improvement from Capella University. She received her Master of Science from the University of Illinois at Chicago and her Bachelor of Science from Michigan State University. She completed her dietetic internship at Cook County Hospital in Chicago.

Theory-based self-management educational interventions on patients with type 2 diabetes: a systematic review and meta-analysis of randomized controlled trials

AIM

To synthesize the effects of theory-based self-management educational interventions on patients with type 2 diabetes (T2DM) in randomized controlled trials.

BACKGROUND

Type 2 diabetes is a common chronic disease causing complications that put a heavy burden on society and reduce the quality of life of patients. Good self-management of diabetes can prevent complications and improve the quality of life of T2DM patients.

DESIGN

Systematic review with meta-analysis of randomized controlled trials following Cochrane methods.

DATA RESOURCES

A literature search was carried out in the MEDLINE, EMBASE, CINAHL, PSYCINFO, and Web of Science databases (1980-April 2015).

REVIEW METHODS

The risk of bias of these eligible studies was assessed independently by two authors using the Cochrane Collaboration's tool. The Publication bias of the main outcomes was examined. Statistical heterogeneity and random-effects model were used for meta-analysis.

RESULTS

Twenty studies with 5802 participants met the inclusion criteria. The interventions in the studies were based on one or more theories which mostly belong to mid-range theories. The pooled main outcomes by random-effects model showed significant improvements in HbA1c, self-efficacy, and diabetes knowledge, but not in BMI. As for quality of life, no conclusions can be drawn as the pooled outcome became the opposite with reduced heterogeneity after one study was excluded. No significant publication bias was found in the main outcomes.

CONCLUSION

To get theory-based interventions to produce more effects, the role of patients should be more involved and stronger and the education team should be trained beyond the primary preparation for the self-management education program.

Impact of Demographic, Socioeconomic, and Psychological Factors on Glycemic Self-Management in Adults with Type 2 Diabetes Mellitus

Diabetes mellitus (DM) is reported as one of the most complex chronic diseases worldwide. In the United States, Type 2 DM (T2DM) is the seventh leading cause of morbidity and mortality. Individuals with diabetes require lifelong personal care to reduce the possibility of developing long-term complications. A good knowledge of diabetes risk factors, including obesity, dyslipidemia, hypertension, family history of DM, and sedentary lifestyle, play an essential role in prevention and treatment. Also, sociodemographic, economic, psychological, and environmental factors are directly and indirectly associated with diabetes control and health outcomes. Our review intends to analyze the interaction between demographics, knowledge, environment, and other diabetes-related factors based on an extended literature search, and to provide insight for improving glycemic control and reducing the incidence of chronic complications.

The Effects of Intensive Nutrition Education on Late Middle-Aged Adults with Type 2 Diabetes

Objective: Many patients with type 2 diabetes find it difficult to maintain good glycemic control. Undesirable glycemic control occurs greatly due to deficiencies of nutritional knowledge and difficulty in obtaining dietary prescriptions. The late middle-aged and elder individuals are the main populations that are affected by type 2 diabetes. The main purpose of this study was to investigate whether intensive nutrition education would make benefits for late middle-aged patients with type 2 diabetes. Method: 196 patients between 50 to 65 years old meeting type 2 diabetes criteria and eligible for the program were included in a single-blinded, 30-day centralized management of an education program in China. Participants in the program were randomly divided into a usual nutrition education group or an intensive nutrition education group. The usual nutrition education group was used as a control group and received only basic health advice and principles of diabetic diets at the beginning and the end of the study. Participants in the intensive nutrition education group were arranged to receive intensive nutritional lectures about diabetes for 30 days. The primary outcomes were the changes in weight, body mass index (BMI), fasting plasma glucose (FPG), 2-h postprandial plasma glucose (PG), glycosylated hemoglobin (HbA1c), total glycerin (TG), total cholesterol (TC), high-density lipoprotein cholesterol (HDL-c), and low-density lipoprotein cholesterol (LDL-c). Results: After 30 days of intervention, FPG, PG, and HbA1c in the treatment group decreased significantly than the control group (p < 0.05). HbA1c reduced significantly by 0.6% in the intervention group. No significant differences in the change of blood lipids were observed between groups. However, TG, TC, and HDL-c made improvements compared with the baseline in the experimental group. Both groups had a reduction in weight and BMI within groups, especially in intensive nutrition education group. However, there was no statistical significance between groups. Conclusions: Intensive nutrition education has significant effects on blood glucose control in late middle-aged adults with type 2 diabetes. Intensive education can cultivate good diet habits and increase physical activity, which are important for diabetes patients in the short and long terms. These findings may contribute to improving education methodology and nutrition therapy in patients with type 2 diabetes.

Educational attainment moderates the associations of diabetes education with health outcomes

Diabetes education is a critical element of care for people with diabetes. However, the associations between diabetes education and self-care or health outcomes have not been clearly demonstrated at a national level. The aims of this study were to examine the associations of attendance of diabetes education classes with health behaviours and glycaemic control, and to understand whether these associations were moderated by level of educational attainment. Data were analysed for 456 adults from the 2012 Korea National Health and Nutrition Examination Survey V, collected from January 2010 to December 2012. No significant differences were observed between patients who had attended diabetes education classes and those who had never attended for factors such as smoking, drinking, exercise, nutrition therapy or glycaemic control. There was a significant interaction effect between receiving diabetes education and level of educational attainment on obtaining optimal glycaemic control. Attending diabetes education was positively associated with optimal glycaemic control among patients with more than a high school education but was negatively associated with it among those with less than middle school education. Diabetes education programmes need to be tailored to the needs and cognitive capacities of the target population.

Knowledge of A1c Predicts Diabetes Self-Management and A1c Level among Chinese Patients with Type 2 Diabetes

This study was to identify current A1c understanding status among Chinese patients with type 2 diabetes, assess if knowledge of A1c affects their diabetes self-management and their glycemic control and recognize the factors influencing knowledge of A1c among patients with type 2 diabetes. A multi-center, cross-sectional survey was conducted between April and July 2010 in 50 medical centers in the Mainland China. Participants were recruited from inpatients and outpatients who were admitted to or visited those medical centers. The survey included core questions about their demographic characteristics, diabetes self-management behavior, and A1c knowledge. Overall, of 5957 patients, the percentage of patients with good understanding was 25.3%. In the multivariable logistic regression model, the variables related to the knowledge of A1c status are presented. We discovered that patients with longer diabetes duration (OR = 1.05; 95%CI = 1.04-1.06) and having received diabetes education (OR = 1.80; 95%CI = 1.49-2.17) were overrepresented in the good understanding of A1c group. In addition, compared to no education level, higher education level was statistically associated with good understanding of A1c (P<0.001). The percentage of patients with good understanding varied from region to region (P<0.001), with Eastern being highest (OR = 1.54; 95%CI = 1.32-1.80), followed by Central (OR = 1.25; 95%CI = 1.02-1.53), when referring to Western. Only a minority of patients with type 2 diabetes in China understood their A1c value. The patients who had a good understanding of their A1c demonstrated significantly better diabetes self-management behavior and had lower A1c levels than those who did not.

Adaptation and Feasibility Study of a Digital Health Program to Prevent Diabetes among Low-Income Patients: Results from a Partnership between a Digital Health Company and an Academic Research Team

Background. The feasibility of digital health programs to prevent and manage diabetes in low-income patients has not been adequately explored. Methods. Researchers collaborated with a digital health company to adapt a diabetes prevention program for low-income prediabetes patients at a large safety net clinic. We conducted focus groups to assess patient perspectives, revised lessons for improved readability and cultural relevance to low-income and Hispanic patients, conducted a feasibility study of the adapted program in English and Spanish speaking cohorts, and implemented real-time adaptations to the program for commercial use and for a larger trial of in multiple safety net clinics. Results. The majority of focus group participants were receptive to the program. We modified the curriculum to a 5th-grade reading level and adapted content based on patient feedback. In the feasibility study, 54% of eligible contacted patients expressed interest in enrolling (n = 23). Although some participants' computer access and literacy made registration challenging, they were highly satisfied and engaged (80% logged in at least once/week). Conclusions. Underserved prediabetic patients displayed high engagement and satisfaction with a digital diabetes prevention program despite lower digital literacy skills. The collaboration between researchers and a digital health company enabled iterative improvements in technology implementation to address challenges in low-income populations.