Meta-analysis of the effects of educational and psychosocial interventions on management of diabetes mellitus

The effect of a structured behavioral intervention on poorly controlled diabetes: a randomized controlled trial

BACKGROUND

Although maintaining nearly normal glycemia delays onset and slows progression of diabetes complications, many patients with diabetes and their physicians struggle to achieve glycemic targets. The best methods to support patients as they follow diabetes prescriptions and recommendations are unclear.

METHODS

To test the efficacy of a behavioral diabetes intervention in improving glycemia in long-duration, poorly controlled diabetes, we randomized 222 adults with diabetes (49% type 1) (mean [SD] age, 53 [12] years; mean [SD] disease duration 18 [12] years; mean [SD] hemoglobin A(1c) [HbA(1c)] concentration, 9.0% [1.1%]) to attend (1) a 5-session manual-based, educator-led structured group intervention with cognitive behavioral strategies (structured behavioral arm); (2) an educator-led attention control group education program (group attention control); or (3) unlimited individual nurse and dietitian education sessions for 6 months (individual control). Outcomes were baseline and 3-, 6-, and 12-month postintervention HbA(1c) levels (primary) and frequency of diabetes self-care, 3-day pedometer readings, 24-hour diet recalls, average number of glucose checks, physical fitness, depression, coping style, self-efficacy, and quality of life (secondary).

RESULTS

Linear mixed modeling found that all groups showed improved HbA(1c) levels (P < .001). However, the structured behavioral arm showed greater improvements than the group and individual control arms (3-month HbA(1c) concentration changes: -0.8% vs -0.4% and -0.4%, respectively (P = .04 for group × time interaction). Furthermore, participants with type 2 disease showed greater improvement than those with type 1 (P = .04 for type of diabetes × time interaction). Quality of life, glucose monitoring, and frequency of diabetes self-care did not differ by intervention over time.

CONCLUSIONS

A structured, cognitive behavioral program is more effective than 2 control interventions in improving glycemia in adults with long-duration diabetes. Educators can successfully use modified psychological and behavioral strategies.

TRIAL REGISTRATION

clinicaltrials.gov Identifier: NCT000142922.

Protocol for the ADDITION-Plus study: a randomised controlled trial of an individually-tailored behaviour change intervention among people with recently diagnosed type 2 diabetes under intensive UK general practice care

BACKGROUND

The increasing prevalence of type 2 diabetes poses both clinical and public health challenges. Cost-effective approaches to prevent progression of the disease in primary care are needed. Evidence suggests that intensive multifactorial interventions including medication and behaviour change can significantly reduce cardiovascular morbidity and mortality among patients with established type 2 diabetes, and that patient education in self-management can improve short-term outcomes. However, existing studies cannot isolate the effects of behavioural interventions promoting self-care from other aspects of intensive primary care management. The ADDITION-Plus trial was designed to address these issues among recently diagnosed patients in primary care over one year.

METHODS/DESIGN

ADDITION-Plus is an explanatory randomised controlled trial of a facilitator-led, theory-based behaviour change intervention tailored to individuals with recently diagnosed type 2 diabetes. 34 practices in the East Anglia region participated. 478 patients with diabetes were individually randomised to receive (i) intensive treatment alone (n = 239), or (ii) intensive treatment plus the facilitator-led individual behaviour change intervention (n = 239). Facilitators taught patients key skills to facilitate change and maintenance of key behaviours (physical activity, dietary change, medication adherence and smoking), including goal setting, action planning, self-monitoring and building habits. The intervention was delivered over one year at the participant's surgery and included a one-hour introductory meeting followed by six 30-minute meetings and four brief telephone calls. Primary endpoints are physical activity energy expenditure (assessed by individually calibrated heart rate monitoring and movement sensing), change in objectively measured dietary intake (plasma vitamin C), medication adherence (plasma drug levels), and smoking status (plasma cotinine levels) at one year. We will undertake an intention-to-treat analysis of the effect of the intervention on these measures, an assessment of cost-effectiveness, and analyse predictors of behaviour change in the cohort.

DISCUSSION

The ADDITION-Plus trial will establish the medium-term effectiveness and cost-effectiveness of adding an externally facilitated intervention tailored to support change in multiple behaviours among intensively-treated individuals with recently diagnosed type 2 diabetes in primary care. Results will inform policy recommendations concerning the management of patients early in the course of diabetes. Findings will also improve understanding of the factors influencing change in multiple behaviours, and their association with health outcomes.

Monitoring in diabetes self-management: issues and recommendations for improvement

The American Association of Diabetes Educators hosted a Monitoring Symposium during which 18 invited participants considered pre-set questions regarding how diabetes education can more effectively address barriers to monitoring for people with diabetes and related conditions. This report provides a summary of the moderated discussion and highlights the key points that apply to diabetes educators and other providers involved with diabetes care. The participating thought leaders reviewed findings from published literature and participated in a moderated discussion with the aim of providing practical advice for health care practitioners regarding monitoring for people with diabetes so that the overall health of this population can be enhanced. The discussants also defined monitoring for diabetes as including that done by the clinician or laboratory, as well as self-monitoring. The discussion was distilled into key points that apply to diabetes educators and other providers involved with diabetes care. Participants developed specific recommendations for a self-monitoring behavior and monitoring framework. People with diabetes benefit from instruction and guidance about self-monitoring and decision making that is based on monitored results and informed interactions with providers. Importantly, collaboration among the entire diabetes care community is needed to ensure that monitoring is performed and utilized to its fullest advantage. Going forward, it will be critical to mitigate barriers to diabetes self-management and training and to identify linkages and partnerships to address barriers to self-monitoring.

Testing covariates of Type 2 diabetes-cognition associations in older adults: moderating or mediating effects?

OBJECTIVE

The general goal of this study was to advance our understanding of Type 2 diabetes (T2D)-cognition relationships in older adults by linking and testing comprehensive sets of potential moderators, potential mediators, and multiple cognitive outcomes.

METHOD

We identified in the literature 13 health-related (but T2D-distal) potential covariates, representing four informal domains (i.e., biological vitality, personal affect, subjective health, lifestyle activities). Cross-sectional data from the Victoria Longitudinal Study (age range = 53-90 years; n = 41 T2D and n = 458 control participants) were used. We first examined whether any of the 13 potential covariates influenced T2D-cognition associations, as measured by a comprehensive neuropsychological battery (15 measures). Next, using standard regression-based moderator and mediator analyses, we systematically tested whether the identified covariates would significantly alter observed T2D-cognition relationships.

RESULTS

Six potential covariates were found to be sensitive to T2D associations with performance on seven cognitive measures. Three factors (systolic blood pressure, gait-balance composite, subjective health) were significant mediators. Each mediated multiple cognitive outcomes, especially measures of neurocognitive speed, executive functioning, and episodic memory.

CONCLUSIONS

Our findings offer a relatively comprehensive perspective of T2D-related cognitive deficits, comorbidities, and modulating influences. The implications for future research reach across several fields of study and application. These include (1) neuropsychological research on neural and biological bases of T2D-related cognitive decline, (2) clinical research on intervention and treatment strategies, and (3) larger-scale longitudinal studies examining the potential multilateral and dynamic relationships among T2D status, related comorbidities, and cognitive outcomes.

Culturally appropriate health education for Type 2 diabetes in ethnic minority groups: a systematic and narrative review of randomized controlled trials

To determine if culturally appropriate health education is more effective than 'usual' health education for people with diabetes from ethnic minority groups living in high- and upper-middle-income countries. A systematic review with meta-analysis, following the methodology of the Cochrane Collaboration. Electronic literature searches of nine databases were made, with hand searching of three journals and 16 author contacts. The criteria for inclusion into the analysis were randomized controlled trials of a specified diabetes health education intervention, and a named ethnic minority group with Type 2 diabetes. Data were collected on HbA(1c), blood pressure, and quality-of-life measures. A narrative review was also performed. Few studies fitted the selection criteria, and were heterogeneous in methodologies and outcome measures, making meta-analysis difficult. HbA(1c) showed an improvement at 3 months [weighted mean difference (WMD) -0.32%, 95% confidence interval (CI) -0.63, -0.01] and 6 months post intervention (WMD -0.60%, 95% CI -0.85, -0.35). Knowledge scores also improved in the intervention groups at 6 months (standardized mean difference 0.46, 95% CI 0.27, 0.65). There was only one longer-term follow-up study, and one formal cost-effectiveness analysis. Culturally appropriate health education was more effective than 'usual' health education in improving HbA(1c) and knowledge in the short to medium term. Due to poor standardization between studies, the data did not allow determination of the key elements of interventions across countries, ethnic groups and health systems, or a broad view of their cost-effectiveness. The narrative review identifies learning points to direct future research.

Effectiveness of diabetes educational interventions in Iran: a systematic review

BACKGROUND

Education of patients with diabetes is considered a fundamental aspect of diabetes care and aims to empower patients by improving knowledge and skills. The aim of this study was to conduct a systematic review of reports published about educational interventions on Iranian patients with diabetes.

METHODS

All published articles in Iranian and international journals and those presented in relevant congresses were reviewed using standard key words. Studies published from April 2002 to December 2008 that met the eligibility criteria were included for this systematic review.

RESULTS

A total of 18 discrete studies were identified. These studies were heterogeneous with respect to patient population, educational intervention, outcomes assessed, study quality, and generalizability. However, positive effects of self-management training on knowledge, frequency, and accuracy of self-monitoring of blood glucose and glycemic control were demonstrated in studies with short follow-up (less than 6 months). Effects of interventions on lipids, nutritional diet, weight, blood pressure, and quality of life were variable.

CONCLUSIONS

There are insufficient and conflicting findings to obtain any firm conclusions regarding diabetes education in Iran. However, the appropriate diabetes health education appears to have short-term effects on glycemic control and knowledge of diabetes. The heterogeneity of studies made subgroup comparisons difficult to interpret with confidence. There is a need for long-term, more rigorous methodology. It is also highly recommended to health policy makers in Iran that a special course for training diabetes educators be designed because it would enable them to tailor appropriate education intervention for people with diabetes.

Psychological factors that promote behavior modification by obese patients

Background

The weight-loss effect of team medical care in which counseling is provided by clinical psychologists was investigated in an university hospital obesity (OB) clinic. Nutritional and exercise therapy were also studied. In our previous study, we conducted a randomized, controlled trial with obese patients and confirmed that subjects who received counseling lost significantly more weight than those in a non-counseling group. The purpose of this study was to identify the psychological characteristics assessed by ego states that promote behavior modification by obese patients.

Methods

147 obese patients (116 females, 31 males; mean age: 45.9 ± 15.4 years) participated in a 6-month weight-loss program in our OB clinic. Their psychosocial characteristics were assessed using the Tokyo University Egogram (TEG) before and after intervention. The Wilcoxon signed rank test was used to compare weight and psychological factors before and after intervention. Multiple regression analysis was used to identify factors affecting weight loss.

Results

Overall, 101 subjects (68.7%) completed the program, and their data was analyzed. The subjects mean weight loss was 6.2 ± 7.3 kg (Z = 7.72, p < 0.01), and their mean BMI decreased by 2.4 ± 2.7 kg/m² (Z = 7.65, p < 0.01). Significant differences were observed for the Adult (A) ego state (0.68 ± 3.56, Z = 1.95, p < 0.05) and the Free Child (FC) ego state (0.59 ± 2.74, Z = 2.46, p < 0.01). The pre-FC ego state had a significant effect on weight loss (β = 0.33, p < 0.01), and a tendency for changes in the A ego state scores to affect weight loss (β = - 0.20, p = 0.06) was observed.

Conclusion

This study of a 6-month weight-loss program that included counseling by clinical psychologists confirmed that the A ego state of obese patients, which is related to their self-monitoring skill, and the FC ego state of them, which is related to their autonomy, were increased. Furthermore, the negative aspects of the FC ego state related to optimistic and instinctive characteristics inhibited the behavior modification, while the A ego state represented objective self-monitoring skills that may have contributed to weight loss.

The ADDITION-Cambridge trial protocol: a cluster -- randomised controlled trial of screening for type 2 diabetes and intensive treatment for screen-detected patients

BACKGROUND

The increasing prevalence of type 2 diabetes poses a major public health challenge. Population-based screening and early treatment for type 2 diabetes could reduce this growing burden. However, the benefits of such a strategy remain uncertain.

METHODS AND DESIGN

The ADDITION-Cambridge study aims to evaluate the effectiveness and cost-effectiveness of (i) a stepwise screening strategy for type 2 diabetes; and (ii) intensive multifactorial treatment for people with screen-detected diabetes in primary care. 63 practices in the East Anglia region participated. Three undertook the pilot study, 33 were allocated to three groups: no screening (control), screening followed by intensive treatment (IT) and screening plus routine care (RC) in an unbalanced (1:3:3) randomisation. The remaining 27 practices were randomly allocated to IT and RC. A risk score incorporating routine practice data was used to identify people aged 40-69 years at high-risk of undiagnosed diabetes. In the screening practices, high-risk individuals were invited to take part in a stepwise screening programme. In the IT group, diabetes treatment is optimised through guidelines, target-led multifactorial treatment, audit, feedback, and academic detailing for practice teams, alongside provision of educational materials for newly diagnosed participants. Primary endpoints are modelled cardiovascular risk at one year, and cardiovascular mortality and morbidity at five years after diagnosis of diabetes. Secondary endpoints include all-cause mortality, development of renal and visual impairment, peripheral neuropathy, health service costs, self-reported quality of life, functional status and health utility. Impact of the screening programme at the population level is also assessed through measures of mortality, cardiovascular morbidity, health status and health service use among high-risk individuals.

DISCUSSION

ADDITION-Cambridge is conducted in a defined high-risk group accessible through primary care. It addresses the feasibility of population-based screening for diabetes, as well as the benefits and costs of screening and intensive multifactorial treatment early in the disease trajectory. The intensive treatment algorithm is based on evidence from studies including individuals with clinically diagnosed diabetes and the education materials are informed by psychological theory. ADDITION-Cambridge will provide timely evidence concerning the benefits of early intensive treatment and will inform policy decisions concerning screening for type 2 diabetes.

TRIAL REGISTRATION

Current Controlled trials ISRCTN86769081.

Development of a diabetes education program for youth with type 2 diabetes

PURPOSE

The purpose of this article is to present the Treatment Options for Type 2 Diabetes in Adolescents and Youth (TOD2AY) study and a description of the implementation of the standard diabetes education (SDE) program.

METHODS

A total of 218 participants (one third of the eventual sample of 750) were initially enrolled in the study. To date, the mean age of participants was 14.3 + 2.1 years, with 63% being female. Families of study participants were largely low or middle income (more than half report family income <$35 000) and about three-quarters were minority.

RESULTS

More than three-quarters (79%) of families achieved full mastery of the entire SDE program. Mastery required on average 5.5 + 1.3 sessions. In addition, 62% of the families were able to achieve mastery of the session topic in a single visit.

CONCLUSIONS

In summary, the TOD2AY study SDE program fills the need for effective, engaging materials for youth and their families to use in mastering essential type 2 diabetes skills and knowledge.

Access to diabetes self-management education: results of national surveys of patients, educators, and physicians

PURPOSE

To examine factors related to access to diabetes self-management education (DSME), including services delivered and sought; patient, physician, and program barriers to access; educator outreach and expansion efforts; and perceptions of alternative DSME delivery strategies.

METHODS

Internet surveys were completed by 1169 adults with diabetes (661 with prior DSME, 508 with no prior DSME) from a national community survey panel, 1871 educators who were AADE members, and 629 physicians (212 diabetes specialists, 417 primary care practitioners) from a national physician survey panel.

RESULTS

Physicians want patients to receive more self-management support, but some report that patients are told to do things with which the physician does not agree. Provider (physician and educator)-delivered DSME is more highly regarded among those who have received it than among those who have not received it. Physicians generally have positive perceptions of provider-delivered DSME, and educators see physicians as key to encouraging DSME use in patients. Some physicians are concerned about losing patients sent to DSME, and 11% of patients report changing physicians as a result of DSME. Most DSME programs have grown recently as a result of recruiting efforts and adding new programs/services; most programs plan more such efforts. Patients prefer traditional DSME sources/settings and are moderately accepting of media sources.

CONCLUSIONS

Additional efforts are required to guarantee that all people with diabetes receive the DSME they need. This will require increased referral by physicians, increased follow-through by patients, and increased availability of DSME in forms that make it appealing to patients and physicians.

Integrating co-morbid depression and chronic physical disease management: identifying and resolving failures in self-regulation

Research suggests that treatments for depression among individuals with chronic physical disease do not improve disease outcomes significantly, and chronic disease management programs do not necessarily improve mood. For individuals experiencing co-morbid depression and chronic physical disease, demands on the self-regulation system are compounded, leading to a rapid depletion of self-regulatory resources. Because disease and depression management are not integrated, patients lack the understanding needed to prioritize self-regulatory goals in a way that makes disease and depression management synergistic. A framework in which the management of co-morbidity is considered alongside the management of either condition alone offers benefits to researchers and practitioners and may help improve clinical outcomes.

Predictors of Successful Diabetes Management in Low-Income Hispanic People

The specific aim of this predictive, correlational study was to test a culturally sensitive diabetes-specific health protection model to determine predictors of successful diabetes management in a newly diagnosed, type 2, low-income Hispanic population. Using a research-based Hispanic Health Protection Model (HHPM) as a framework, 240 adult participants with low levels of acculturation, strong beliefs about illness attribution and control of health, and low literacy levels were interviewed in a three-phase process over 4 to 6 months. The data analysis resulted in support of the HHPM based on relationships between 11 variables in four partial structural equation models, including lifestyle profile, acculturation, health beliefs, professional and social support, self-efficacy, diabetes knowledge, quality of life (self-satisfaction and impact of diabetes), and changes in hemoglobin a1c and body mass index. The study established carefully translated measures that held up to strong psychometric criteria. There was support for the HHPM for this population, and the results suggest future intervention with strengthening enablers, such as professional support and diabetes self-efficacy, in relation to this group's health beliefs.

Analysis System for Self-Efficacy Training (ASSET). Assessing treatment fidelity of self-management interventions

OBJECTIVE

The paper presents the development of a coding tool for self-efficacy orientated interventions in diabetes self-management programmes (Analysis System for Self-Efficacy Training, ASSET) and explores its construct validity and clinical utility.

METHODS

Based on four sources of self-efficacy (i.e., mastery experience, role modelling, verbal persuasion and physiological and affective states), published self-efficacy based interventions for diabetes care were analysed in order to identify specific verbal behavioural techniques. Video-recorded facilitating behaviours were evaluated using ASSET.

RESULTS

The reliability between four coders was high (K=0.71). ASSET enabled assessment of both self-efficacy based techniques and participants' response to those techniques. Individual patterns of delivery and shifts over time across facilitators were found. In the presented intervention we observed that self-efficacy utterances were followed by longer patient verbal responses than non-self-efficacy utterances.

CONCLUSION

These detailed analyses with ASSET provide rich data and give the researcher an insight into the underlying mechanism of the intervention process.

PRACTICE IMPLICATIONS

By providing a detailed description of self-efficacy strategies ASSET can be used by health care professionals to guide reflective practice and support training programmes.

Culturally appropriate health education for type 2 diabetes mellitus in ethnic minority groups

BACKGROUND

Ethnic minority groups in upper-middle and high income countries tend to be socio-economically disadvantaged and to have higher prevalence of type 2 diabetes than the majority population.

OBJECTIVES

To assess the effectiveness of culturally appropriate diabetes health education on important outcome measures in type 2 diabetes.

SEARCH STRATEGY

We searched the The Cochrane Library, MEDLINE, EMBASE, PsycINFO, CINAHL, ERIC, SIGLE and reference lists of articles. We also contacted authors in the field and handsearched commonly encountered journals.

SELECTION CRITERIA

RCTs of culturally appropriate diabetes health education for people over 16 years with type 2 diabetes mellitus from named ethnic minority groups resident in upper-middle or high income countries.

DATA COLLECTION AND ANALYSIS

Two authors independently assessed trial quality and extracted data. Where there were disagreements in selection of papers for inclusion, all four authors discussed the studies. We contacted study authors for additional information when data appeared to be missing or needed clarification.

MAIN RESULTS

Eleven trials involving 1603 people were included, with ten trials providing suitable data for entry into meta-analysis. Glycaemic control (HbA1c), showed an improvement following culturally appropriate health education at three months (weight mean difference (WMD) - 0.3%, 95% CI -0.6 to -0.01), and at six months (WMD -0.6%, 95% CI -0.9 to -0.4), compared with control groups who received 'usual care'. This effect was not significant at 12 months post intervention (WMD -0.1%, 95% CI -0.4 to 0.2). Knowledge scores also improved in the intervention groups at three months (standardised mean difference (SMD) 0.6, 95% CI 0.4 to 0.7), six months (SMD 0.5, 95% CI 0.3 to 0.7) and twelve months (SMD 0.4, 95% CI 0.1 to 0.6) post intervention. Other outcome measures both clinical (such as lipid levels, and blood pressure) and patient centred (quality of life measures, attitude scores and measures of patient empowerment and self-efficacy) showed no significant improvement compared with control groups.

AUTHORS' CONCLUSIONS

Culturally appropriate diabetes health education appears to have short term effects on glycaemic control and knowledge of diabetes and healthy lifestyles. None of the studies were long-term, and so clinically important long-term outcomes could not be studied. No studies included an economic analysis. The heterogeneity of studies made subgroup comparisons difficult to interpret with confidence. There is a need for long-term, standardised multi-centre RCTs that compare different types and intensities of culturally appropriate health education within defined ethnic minority groups.

Effects of a multifaceted psychiatric intervention targeted for the complex medically ill: a randomized controlled trial

BACKGROUND

This study evaluated a multifaceted psychiatric intervention targeted at the complex medically ill identified by means of the INTERMED, an instrument to assess case complexity.

METHODS

Of 885 rheumatology inpatients and diabetes outpatients who were assessed for eligibility, 247 were identified as complex (INTERMED score >20) and randomized to the intervention (n = 125, 84 rheumatology and 41 diabetes patients) or care as usual (n = 122, 78 rheumatology and 44 diabetes patients). For the majority of the cases the multifaceted intervention consisted of an intervention conducted by a psychiatric liaison nurse and/or of referral to a liaison psychiatrist, followed by advice to the treating physician or organization of a multidisciplinary case conference. Baseline and follow-up at months 3, 6, 9 and 12 measured prevalence of major depression (Mini-International Neuropsychiatric Interview), depressive symptoms (Center for Epidemiological Studies Depression Rating Scale), physical and mental health (SF-36), quality of life (EuroQol), health care utilization and HbA(1c) levels (diabetic patients).

RESULTS

Prevalence of major depression was reduced from 61% (T0) to 28% (T4) in the intervention group and remained stable in care as usual (57% at T0 to 50% at T4). Compared to care as usual, significant improvement over time was observed in the intervention group with regard to depressive symptoms (F = 11.9; p = 0.001), perception of physical (F = 5.7; p = 0.018) and mental health (F = 3.9; p = 0.047) and quality of life (F = 21.8; p < 0.001). Effects tended to be stronger in diabetes patients, in patients with baseline major depression and in patients with moderate INTERMED scores. Finally, hospital admissions occurred less often in the intervention group, reaching statistical significance for the period between 6 and 9 months of follow-up (p = 0.02).

CONCLUSIONS

The results suggest that a psychiatric intervention targeted for complex medical patients can improve health outcomes.

Access to diabetes self-management education

PURPOSE

The purpose of this study is to explore issues related to access to diabetes self-management education (DSME), including supply and demand, educator outreach and expansion efforts, patient and physician barriers to access, and acceptability of alternative DSME delivery strategies.

METHODS

Telephone focus groups were conducted with 17 diabetes educators, 18 primary care physicians who treat adults with diabetes, and 14 adults with type 1 or type 2 diabetes (8 in a group for those who had received diabetes education and 6 in a group for those who had not).

RESULTS

DSME programs develop new services to attract additional patients but do little outreach, and budget struggles are common. Some physicians establish good relationships with DSME programs, but others are critical of the available programs and experience conflicts over the role of educators vis-à-vis that of the physician. Physicians do not refer all patients to DSME and are perceived by educators and patients as not providing enough encouragement to attend DSME. Patients generally have positive experiences with DSME but do not discuss these experiences with their physicians. Patients are receptive to alternative strategies for DSME delivery (community settings, electronic media), but physicians are concerned about meeting standards, and educators want to make sure that they are available to support alternative education strategies.

CONCLUSIONS

Future advocacy efforts should seek implementation of policies to guarantee that all people with diabetes can receive the DSME they need.

Educational interventions aiming at improving adherence to treatment recommendations in type 2 diabetes: A sub-analysis of a systematic review of randomised controlled trials

OBJECTIVE

In the management of type 2 diabetes, a complex interaction takes place between medical professionals' treatment goals and patients' health beliefs about the disease and its treatment options. The contribution of self-management education to adherence in general or even more specifically to medicine taking is not known. We assessed educational interventions aimed at improving adherence to medical treatment recommendations, other than lifestyle advice.

STUDY DESIGN

Systematic literature review.

SETTING

This paper represents an analysis of eight articles describing an educational intervention as a subgroup of a Cochrane Review [E. Vermeire, J. Wens, P. Van Royen, Y. Biot, H. Hearnshaw, A. Lindenmeyer, Interventions for improving adherence to treatment recommendations in people with type 2 diabetes mellitus, Cochrane Database of Systematic Reviews 2005, Issue 2, Art. No.: CD003638, doi:10.1002/14651858.CD003638.pub2] on interventions to improve adherence to treatment recommendations in people with type 2 diabetes.

RESULTS

Four studies reported interventions using face-to-face education, two reported on the effects of group education and two on distance education by telemedicine. Due to poor quality of study designs, a variety of heterogeneous outcome measures in different time intervals, unclear definitions of adherence, and difficulties in evaluating different aspects of education performed, general conclusions could not be drawn.

CONCLUSION

Consistent conclusions about the effectiveness of educational interventions on adherence to treatment recommendations were hard to be drawn. There is an urgent need for well-designed intervention studies on the effect of different aspects of education on adherence to treatment recommendations.

Social support, quality of life, and self-care behaviors amongAfrican Americans with type 2 diabetes

PURPOSE

The purpose of this study was to examine social support and its relationship to diabetes-specific quality of life and self-care behaviors in African Americans with type 2 diabetes.

METHODS

The study followed a cross-sectional, observational design and recruited 89 African American adults, age 40 and older (mean = 60, SD = 10.5), diagnosed with type 2 diabetes. Participants completed measures assessing diabetes-specific quality of life, self-care behaviors (healthy eating, physical activity, self-monitoring of blood glucose, foot care, medication and/or insulin use), demographic background, and diabetes-related social support. Diabetes-related social support variables included amount of social support received, satisfaction with support, positive support behavior, negative support behavior, and primary source of support.

RESULTS

Stepwise regressions, controlling for demographic variables, were conducted to identify predictors of diabetes-specific quality of life and self-care behaviors from the diabetes-related social support variables. Satisfaction with support was a predictor for improved diabetes-specific quality of life (r = -.579, P < .001) and blood glucose monitoring (r = .258, P < .05). Positive support behavior was a predictor for following a healthy eating plan (r = .280, P < .05), spacing out carbohydrates evenly throughout the day (r = .367, P < .01), and performing physical activity at least 30 minutes per day (r = .296, P < .05). Negative support behavior was a predictor for not taking medication as recommended (r = -.348, P < .01).

CONCLUSIONS

Findings indicate that social support plays a role in diabetes-specific quality of life and self-management practices. Social support encompasses multiple dimensions that differentially influence specific diabetes health-related outcomes and behaviors.

Computerized learning technologies for diabetes: a systematic review

BACKGROUND

The objective of this study was to evaluate computerized learning technology interventions that can empower patients in the self-management of diabetes and support diabetes education over a distance.

METHODS

We searched Medline (1966-2006), CINAHL (1982-2006), and the Cochrane Central Register of Controlled Trials (first quarter 2007) databases. We also reviewed reference lists from included studies to identify additional studies. We included 25 articles representing 21 randomized controlled trials that evaluated a computerized learning technology and measured the outcome of patient care. We extracted patient sample, intervention, educational content topics, outcome measures, and statistical significance.

RESULTS

Of 21 eligible trials, 18 trials (85.7%) reported significant positive outcomes. Almost 44% (43.8%) of the outcomes demonstrated significant improvements (49 of 112 outcomes).

CONCLUSIONS

Patient self-management behaviors are important in chronic disease management, and initial evidence suggests that computerized learning technology interventions can play a significant role in the future.

Program design features that can improve participation in health education interventions

Background

Although there have been reported benefits of health education interventions across various health issues, the key to program effectiveness is participation and retention. Unfortunately, not everyone is willing to participate in health interventions upon invitation. In fact, health education interventions are vulnerable to low participation rates. The objective of this study was to identify design features that may increase participation in health education interventions and evaluation surveys, and to maximize recruitment and retention efforts in a general ambulatory population.

Methods

A cross-sectional questionnaire was administered to 175 individuals in waiting rooms of two hospitals diagnostic centres in Toronto, Canada. Subjects were asked about their willingness to participate, in principle, and the extent of their participation (frequency and duration) in health education interventions under various settings and in intervention evaluation surveys using various survey methods.

Results

The majority of respondents preferred to participate in one 30–60 minutes education intervention session a year, in hospital either with a group or one-on-one with an educator. Also, the majority of respondents preferred to spend 20–30 minutes each time, completing one to two evaluation surveys per year in hospital or by mail.

Conclusion

When designing interventions and their evaluation surveys, it is important to consider the preferences for setting, length of participation and survey method of your target population, in order to maximize recruitment and retention efforts. Study respondents preferred short and convenient health education interventions and surveys. Therefore, brevity, convenience and choice appear to be important when designing education interventions and evaluation surveys from the perspective of our target population.

Metabolic effects of interventions to increase exercise in adults with type 2 diabetes

AIMS/HYPOTHESIS

The aim of this meta-analysis was to integrate the results of primary research testing the effect of diabetes self-management interventions that included recommendations to increase exercise on metabolic outcomes among adults with type 2 diabetes.

MATERIALS AND METHODS

Extensive literature searching strategies were used to identify published and unpublished intervention studies that measured glycated haemoglobin outcomes. Primary study results were coded. Fixed- and random-effects meta-analytic procedures included moderator analyses.

RESULTS

Data were synthesised across 10,455 subjects from 103 research reports. The overall mean weighted effect size for two-group comparisons was 0.29 (higher mean for treatment than control). This effect size is consistent with a difference in HbA1c means of 0.45% (e.g. 7.38% for treatment subjects vs 7.83% for control subjects). For single-group studies, the overall mean weighted effect size was 0.32-0.34. Control group subjects experienced no improvement in metabolic control during participation in the studies. Interventions that targeted multiple health behaviours resulted in smaller effect size estimates (0.22) than interventions that focused only on exercise behaviours (0.45). Funded studies reported greater improvements in metabolic controls. Studies with a greater proportion of female subjects reported lower effect sizes. Baseline HbA1c and BMI were unrelated to metabolic outcomes.

CONCLUSIONS/INTERPRETATION

These findings suggest that self-management interventions that include exercise recommendations improve metabolic control, despite considerable heterogeneity in the magnitude of the intervention effect. Interventions that emphasise exercise may be especially effective in improving metabolic control. Primary research testing interventions in randomised trials to confirm causal relationships would be constructive.

Not lost in translation: nutrition education, a critical component of translational research

Translational research is an emerging field of science, embracing disciplines in medicine and public health to create a full-spectrum research agenda. Often described as science "from bench to bedside and back again," translational research may be better described as "from bench to behavior," as it strives to apply laboratory results to clinical settings. Because the demand for translational research has emerged, it is critical for nutrition educators to ensure that translational research includes community and policy areas and to recognize themselves as translation researchers. The purpose of this report is to provide a framework for nutrition educators to better understand translational research and to recognize their role in translational research, using type 2 diabetes as an example.

Effects of self-management training in Type 2 diabetes: a randomized, prospective trial

AIMS

The efficacy of three education programmes for Type 2 diabetic patients was tested in a randomized trial. A didactic-oriented training programme (treatment A) was compared with a self-management-oriented programme delivered in group sessions (treatment B). The latter programme was compared with a more individualized approach (treatment C).

METHODS

One hundred and eighty-one Type 2 diabetic patients (age 55.6 +/- 6.3 years, diabetes duration 6.6 +/- 6.2 years, HbA(1c) 7.8 +/- 1.6%, female 49.7%) took part. Efficacy was assessed 3 months (t1) after baseline (t0) and at a follow-up 15 months (t2) after baseline.

RESULTS

The fall in HbA(1c) in treatment B at t1 was sustained at t2 (t0 8.1 +/- 1.8%, t1 7.3 +/- 1.7%, t2 7.4 +/- 1.9%). In treatment A, HbA(1c) was unchanged throughout (t0 7.6 +/- 1.5%, t1 7.5 +/- 1.3%, t2 7.7 +/- 1.7%; treatment A vs. treatment B; P < 0.05). With the more individualized approach of treatment C, there was a fall in HbA(1c) at t1, but this was not sustained at t2 (t0 7.8 +/- 1.6%, t1 7.1 +/- 1.3%, t2 7.6 +/- 1.6%; treatment B vs. treatment C; P = 0.73). There were also significant benefits in treatment B subjects compared with treatment A in further medical (body mass index and fasting blood glucose), psychological (control, irritability and hunger dependency of eating behaviour, and trait anxiety) and behavioural (exercise) variables. There were no significant benefits of the more individualized treatment C compared with group treatment B. No significant differences were found regarding triglyceride levels, high-density lipoprotein, diabetes-related knowledge, negative well-being, urine or blood glucose levels or foot care.

CONCLUSION

Self-management training had a significantly higher medium-term efficacy than didactic diabetes education. The group sessions were more effective than a more individualized approach.

Long-term effects of a structured intensive diabetes education programme (SIDEP) in patients with Type 2 diabetes mellitus--a 4-year follow-up study

AIMS

Patient education is a very important part of diabetes care. However, until now, little data has been presented about the long-term effectiveness of structured intensive diabetes education programmes (SIDEP) for people with Type 2 diabetes mellitus.

METHODS

People with Type 2 diabetes (n = 547) hospitalized from December 1999 to December 2000 were randomly assigned to two groups. Two hundred and nineteen patients undertook an inpatient SIDEP and the remaining patients received conventional glycaemic control without intensive education. After discharge, all patients were monitored regularly. Laboratory data were obtained, and adherence to self-care behaviour was determined on a five-point scale by questionnaires completed annually.

RESULTS

Of the patients who completed the SIDEP, 160 (73.1%) were followed up for more than 4 years. The mean HbA(1c) (7.9 +/- 1.2 vs. 8.7 +/- 1.6%; P < 0.05) and the frequency of hospitalization related to diabetes per patient per year (0.3 +/- 0.6 vs. 0.8 +/- 0.9; P < 0.05) was significantly lower in the SIDEP group than in the control group. The SIDEP group adhered more closely to self-care behaviour than the control group over 4 years (P < 0.05). People with Type 2 diabetes mellitus of longer duration and those treated with insulin had poorer HbA(1c) at follow-up.

CONCLUSIONS

A well-designed, intensive patient education programme is necessary for people with diabetes. However, regular and sustained reinforcement with encouragement is also required to maintain optimal glycaemic control, especially in insulin-treated patients.

Behavioral Interventions for Diabetes Self-Management

This article synthesizes the research on behavioral interventions aimed at diabetes self-management, describes current trends in diabetes self-management, and proposes future directions for diabetes self-management care and research. Interventions that are multifaceted, tailored to the individual, and provided six months or longer demonstrate modest effects in improving diabetes-related outcomes. Improving access to behavioral interventions, maintaining the effects of behavioral interventions, and addressing the more complex social and environmental factors that contribute to behavior change are current challenges in diabetes self-management that warrant further attention and research.

Diabetes mellitus in older men

Most persons with diabetes mellitus are over the age of 60 years. Males develop diabetes more commonly than females. Older diabetics tend to have both impaired insulin release as well as insulin resistance. In older persons diabetes mellitus is associated with decreased functional status and cognitive dysfunction. In general, older persons with diabetes are inclined to be underdiagnosed and undertreated. Managing diabetes in older persons requires special considerations because of their differences in pathophysiology of diabetes and strong association with functional, cognitive impairments and comorbidities. The use of strict therapeutic diets is not recommended in older persons. Treatment of hypertension and hyperglycemia can improve outcomes in older persons. The interdisciplinary team approach is important for care of older diabetic persons.

Evaluation of a Diabetes Education Call Center Intervention

Patients require education and information as they engage in self-help, self-care, and disease management activities. The purpose of this study was to determine how effective voice technologies are in diabetes patient education. A pretest-posttest study was conducted to evaluate the effectiveness of prerecorded educational messages delivered via the telephone to participants with diabetes. The intervention consisted of 24 four-minute messages on the topics of knowledge and prevention, glucose level, diet and activity, and management and coping. Eighteen persons with diabetes participated in the pretest-posttest trial. A total of 324 educational messages were listened to over a 12-week intervention period. The pretest-posttest trial demonstrated that a brief telephone-based diabetes education intervention can have a significant impact on increasing frequency of checking blood for glucose (p = 0.017), improving general diabetes knowledge (p = 0.048), and improving insulin-specific knowledge (p = 0.020). Automated educational interventions should be based on scientifically sound evidence and can be effectively delivered by telephone. Automated telephone-based diabetes education may be used alone or as a supplement to existing diabetes education. Automated education is a viable solution when healthcare organizations and regions that as a result of a lack of human and financial resources cannot afford a diabetes educator.

Exploring patient perceptions of movement through the stages of change model within a diabetes tele-care intervention

Achieving strict control of diabetes is challenging for many patients and most need regularly to depend on ongoing support from health care professionals. One approach that might successfully provide this in a cost-effective and acceptable way is the delivery of advice and support over the telephone (tele-care). To date the process and effects of tele-care have however rarely been studied. This article explores the potential of one behavioural model, the trans-theoretical stages of change model (TTM), to understand and theorize about behaviour change for this chronic disease. Case study data are drawn from a wider randomized controlled trial (RCT) set up to assess the effectiveness of a pro-active call centre-based stepped treatment support to people with type 2 diabetes. The case study demonstrates the relevance and importance of the TTM model in this area. Different experiential and behavioural processes were of particular significance and held different meanings for the various change groups.

Implementing diabetes self-management training programs: breaking through the barriers in primary care

OBJECTIVE

To review issues, examples, and recommendations for the delivery of diabetes self-management training (DSMT) services in the primary care setting.

METHODS

Barriers to provision of DSMT at the point of care and strategies to overcome such challenges are discussed. In addition, new avenues to support continuing diabetes education are presented.

RESULTS

Diabetes is a complex disease that requires education, monitoring, and medication adjustment to achieve treatment goals. Unfortunately, adequate support is seldom available for the increased time and effort needed for optimal management of diabetes. Health-care delivery systems are designed to provide a response to acute illnesses and are poorly configured to meet the needs of patients with complex chronic illnesses. Although team care and DSMT have proved to be effective, they have infrequently been integrated in primary care offices, where most patients with diabetes receive treatment. It is encouraging that the studies conducted to date have generally found office-based counseling and educational strategies to be effective for the vast majority of patients with diabetes. Community-based programs that extend DSMT have also been successful.

CONCLUSION

Diabetes is a chronic disease that requires providers to deliver multifaceted care and patients to be proficient in many self-care skills. Team care and DSMT approaches have been found to yield beneficial results, yet such strategies are seldom used in the primary care office. Thus, models that support the team approach to delivery of diabetes care and self-management education interventions should be explored and encouraged.

The diabetes educator: trying hard, but must concentrate more on behaviour

Current guidelines state that education is fundamental to help people with diabetes modify their lifestyle and prevent ill health and early death. However, many people with diabetes are not receiving adequate education. There is a widespread assumption that transferring knowledge will improve health outcomes but there is little empirical support for this assertion. Indeed, knowledge and behaviour are poorly correlated. Knowledge may be a necessary condition but is rarely a sufficient condition for behaviour change. Single interventions, cognitive or behavioural, have had disappointing results, unsurprisingly given the complexity of human behaviour. The most effective interventions are multifaceted and include education, behavioural and psychosocial elements, and target lifestyle change and factors such as self-efficacy and empowerment. We advocate that educational interventions should have multiple components. They should aim to improve patients' sense of self-efficacy and empowerment, and build attitudes towards diabetes that will support the lifestyle changes needed for successful self-management. These conclusions have implications for future research and clinical practice.

Diabetes Management Among Low-Income African Americans

Incidence of type II diabetes is increasing in the United States and is most prevalent among low-income African Americans. Community health initiatives supported by partnerships of community leaders and health professionals can contribute to the elimination of inequalities in health status. The focus of Racial and Ethnic Approaches to Community Health (REACH) 2010, an initiative sponsored by the Centers for Disease Control and Prevention, is to facilitate the initiation of community-wide changes as well as increase individual empowerment to reduce disparities in diabetes, cardiovascular disease, and cancer. A pilot program developed by REACH health educators and community health partners to improve disease self-management among low-income African American diabetic patients was implemented at a community health center in Nashville, Tenn. The program's major components included health education, individual counseling, screenings, and outreach. The program shows promise of improving patient care and outcomes.

Outcome of one-year of specialist care of patients with type 2 diabetes: a multi-center prospective survey (JDDM 2)

OBJECTIVE

Specialist care is reportedly associated with favorable therapeutic results, although detailed outcomes of recent large-scale prospective surveys of specialist care have yet to be published. The goal of this study was to elucidate the effects of one year's specialist care on the management of type 2 diabetes.

PATIENTS AND METHODS

A multi-centered, prospective observational study was undertaken. 754 type 2 diabetes patients, who made their first visit to one of eleven participating outpatient clinics specializing in diabetes care, were enrolled. Routine structured diabetes care according to established guideline, including diabetes self-management education, was provided to all patients at each clinic visit. Parameters relating to glycemic control, serum lipids, blood pressure, patient follow-up status and others were followed for twelve months.

RESULTS

The HbA(1C) level had improved significantly from 8.4+/-2.2% at baseline to 6.8+/-1.2% after six months and was 7.0+/-1.3% after twelve months (mean+/-SD). The higher the baseline HbA(1C) level, the greater the subsequent improvement. Moreover, the most dramatic improvements in HbA(1C) levels were seen within the first three months. The proportion of patients satisfying all of the therapeutic goals was extremely low at baseline and remained at less than 10% after twelve months of specialist care.

CONCLUSIONS

Diabetic patients under specialist care experienced substantial improvement, especially in glycemic control, as early as a few months after the first visit. However, 35 percent of patients dropped out during the 12-month study period and this is one area that needs to be improved.

Improving students' diabetes management through school-based diabetes care

INTRODUCTION

The purpose of this pilot study was to conduct periodic diabetes care visits in school, with the goal of promoting optimal management of diabetes for high-risk youth.

METHOD

A convenience sample of 27 students receiving care at a university-affiliated children's diabetes center and enrolled in a large urban school district received the diabetes visit intervention. Intervention effect was measured by parent survey of home/school diabetes management practices, the Self-Efficacy for Diabetes Tool, and a diabetes care-provider survey of subjects' usual care, management competence, and glycemic control.

RESULTS

The frequency of diabetes care office visits, insulin adjustment, and home and school blood sugar monitoring all increased. The percentage of children receiving insulin in school doubled. Pre-intervention to post-intervention changes in glycemic control and student self-efficacy did not reach statistical significance. The response to the program was universally positive.

DISCUSSION

This study demonstrated that diabetes care visits in school are feasible and not disruptive to the students' educational program. The visits improved diabetes management at home and at school. School nurses' knowledge about diabetes and confidence in diabetes management was improved through a role-modeling approach.

Perspectives on clinic attendance, medication and foot-care among people with diabetes in the Torres Strait Islands and Northern Peninsula Area

OBJECTIVE

To achieve a better understanding of the perspectives and needs of Indigenous people with diabetes in the Torres Strait and to identify ways to promote successful self-management of diabetes.

DESIGN

Descriptive study collecting qualitative data in focus groups and in-depth interviews. Analysis of three key areas of diabetes self-care, namely attending appointments at the clinic, monitoring blood glucose levels and taking medication and foot-care.

SETTING

Informal settings in remote communities of the Torres Strait and Northern Peninsula Area of Far North Queensland.

SUBJECTS

Sixty-seven Torres Strait Islanders (26 men and 41 women) with diabetes from eight Torres Strait and Northern Peninsula Area communities.

MAIN OUTCOME MEASURES

A better understanding of the views, enabling factors and barriers that people experience when managing their diabetes in remote Torres Strait communities.

RESULTS

Participants who expressed satisfaction with clinical-initiated sessions when called highlighted positive relationships and encouraging feedback from doctors. People's attitudes and practices related to oral and injectable treatments varied widely, possibly linked to levels of understanding. Widespread knowledge of foot-care and fear of amputation in an environment highly conducive to foot sores and infection was evident. Generally, participants wanted more education and personal support in all areas of diabetes care. Service providers in health and other sectors need to place more emphasis on supporting self-management of diabetes within the family and community environment.

A 3-year prospective randomized controlled clinical trial of group care in type 1 diabetes

BACKGROUND AND AIMS

We showed that continuing education can be embedded into routine diabetes care by seeing patients in small groups rather than individually. Group care was cost-effective in improving quality of life, knowledge of diabetes, health behaviours and clinical outcomes in people with type 2 diabetes. The aim of this study was to verify if group care can also be applied to type 1 diabetes.

METHODS AND RESULTS

Randomized, controlled clinical trial comparing 31 patients managed by group care with 31 managed by traditional one-to-one care. A syllabus was built and later remodulated with the patients in a series of focus-group meetings. The primary end-point was changes in quality of life. Secondary end-points were: knowledge of diabetes, health behaviours, HbA1c and circulating lipids. Differential costs to the Italian National Health System and to the patients were also calculated. After 3 years, quality of life improved among patients on group care, along with knowledge and health behaviours (p<0.001, all). Knowledge added its effects to those of group care by independently influencing behaviours (p=0.004) while quality of life changed independently of either (p<0.001). Among controls, quality of life worsened (p<0.001) whereas knowledge and behaviours remained unchanged. HDL cholesterol increased among patients on group care (p=0.027) and total cholesterol decreased in the controls (p<0.05). HbA1c decreased, though not significantly, in both. Direct costs for group and one-to-one care were Euros 933.19 and Euros 697.10 per patient, respectively, giving a cost-effectiveness ratio of Euros 19.42 spent per point gained in the quality of life scale.

CONCLUSIONS

Group care is applicable and also cost-effective in type 1 diabetes. It improves quality of life, knowledge and behaviours. Future programme adjustments should strive to impact more on metabolic control.

Diabetes self-management among low-income spanish-speaking patients: A pilot study

BACKGROUND

The prevalence of type 2 diabetes and diabetes-related morbidity and mortality is higher among low-income Hispanics when compared to that of Whites. However, little is known about how to effectively promote self-management in this population.

PURPOSE

The objectives were first to determine the feasibility of conducting a randomized clinical trial of an innovative self-management intervention to improve metabolic control in low-income Spanish-speaking individuals with type 2 diabetes and second to obtain preliminary data of possible intervention effects.

METHODS

Participants for this pilot study were recruited from a community health center, an elder program, and a community-wide database developed by the community health center, in collaboration with other agencies serving the community, by surveying households in the entire community. Participants were randomly assigned to an intervention (n = 15) or a control (n = 10) condition. Assessments were conducted at baseline and at 3 months and 6 months postrandomization. The intervention consisted of 10 group sessions that targeted diabetes knowledge, attitudes, and self-management skills through culturally specific and literacy-sensitive strategies. The intervention used a cognitive-behavioral theoretical framework.

RESULTS

Recruitment rates at the community health center, elder program, and community registry were 48%, 69%, and 8%, respectively. Completion rates for baseline, 3-month, and 6-month assessments were 100%, 92%, and 92%, respectively. Each intervention participant attended an average of 7.8 out of 10 sessions, and as a group the participants showed high adherence to intervention activities (93% turned in daily logs, and 80% self-monitored glucose levels at least daily). There was an overall Group x Time interaction (p = .02) indicating group differences in glycosylated hemoglobin over time. The estimated glycosylated hemoglobin decrease at 3 months for the intervention group was -0.8% (95% confidence intervals = -1.1%, -0.5%) compared with the change in the control group (p = .02). At 6 months, the decrease in the intervention group remained significant, -0.85% (95% confidence intervals = -1.2, -0.5), and the decrease was still significantly different from that of the controls (p = .005). There was a trend toward increased physical activity in the intervention group as compared to that of the control group (p = .11) and some evidence (nonsignificant) of an increase in blood glucose self-monitoring in the intervention participants but not the control participants. Adjusting for baseline depressive scores, we observed a significant difference in depressive symptoms between intervention participants and control participants at the 3-month assessment (p = .02).

CONCLUSIONS

Low-income Spanish-speaking Hispanics are receptive to participate in diabetes-related research. This study shows that the pilot-tested diabetes self-management program is promising and warrants the conduct of a randomized clinical trial.

Group based training for self-management strategies in people with type 2 diabetes mellitus

BACKGROUND

It has been recognised that adoption of self-management skills by the person with diabetes is necessary in order to manage their diabetes. However, the most effective method for delivering education and teaching self-management skills is unclear.

OBJECTIVES

To assess the effects of group-based, patient-centred training on clinical, lifestyle and psychosocial outcomes in people with type 2 diabetes.

SEARCH STRATEGY

Studies were obtained from computerised searches of multiple electronic bibliographic databases, supplemented by hand searches of reference lists of articles, conference proceedings and consultation with experts in the field. Date of last search was February 2003.

SELECTION CRITERIA

Randomised controlled and controlled clinical trials which evaluated group-based education programmes for adults with type 2 diabetes compared with routine treatment, waiting list control or no intervention. Studies were only included if the length of follow-up was six months or more and the intervention was at least one session with the minimum of six participants.

DATA COLLECTION AND ANALYSIS

Two reviewers independently extracted data and assessed study quality. A meta-analysis was performed if there were enough homogeneous studies reporting an outcome at either four to six months, 12-14 months, or two years, otherwise the studies were summarised in a descriptive manner.

MAIN RESULTS

Fourteen publications describing 11 studies were included involving 1532 participants. The results of the meta-analyses in favour of group-based diabetes education programmes were reduced glycated haemoglobin at four to six months (1.4%; 95% confidence interval (CI) 0.8 to 1.9; P < 0.00001), at 12-14 months (0.8%; 95% CI 0.7 to 1.0; P < 0.00001) and two years (1.0%; 95% CI 0.5 to 1.4; P < 0.00001); reduced fasting blood glucose levels at 12 months (1.2 mmol/L; 95% CI 0.7 to 1.6; P < 0.00001); reduced body weight at 12-14 months (1.6 Kg; 95% CI 0.3 to 3.0; P = 0.02); improved diabetes knowledge at 12-14 months (SMD 1.0; 95% CI 0.7 to 1.2; P < 0.00001) and reduced systolic blood pressure at four to six months (5 mmHg: 95% CI 1 to 10; P = 0.01). There was also a reduced need for diabetes medication (odds ratio 11.8, 95% CI 5.2 to 26.9; P < 0.00001; RD = 0.2; NNT = 5). Therefore, for every five patients attending a group-based education programme we could expect one patient to reduce diabetes medication.

AUTHORS' CONCLUSIONS

Group-based training for self-management strategies in people with type 2 diabetes is effective by improving fasting blood glucose levels, glycated haemoglobin and diabetes knowledge and reducing systolic blood pressure levels, body weight and the requirement for diabetes medication.

Metabolic control, self-management and psychosocial adjustment in women with type 2 diabetes

AIMS

To examine factors associated with metabolic control, self-management (diet and exercise behaviour), and psychosocial adjustment (diabetes-related distress) in women with type 2 diabetes.

DESIGN

Cross-sectional design using baseline data of women with type 2 diabetes enrolled to participate in a pilot study of a nurse coaching intervention (n = 53).

ETHICAL ISSUES

Appropriate ethical review and approval was completed. Informed consent from participants was obtained.

OUTCOME MEASURES

Physiological measures included body mass index and glycosylated haemoglobin (HbA1c). Self-management measures included the Dietary Subscale of the Summary of Diabetes Self-Care Activities Questionnaire and a modified Paffenbarger Physical Activity Questionnaire. Psychosocial measures included the Problem Areas in Diabetes Survey (diabetes-related distress), the Diabetes Questionnaire, the Diabetes Self-Management Assessment Tool Support and Confidence Subscale, and the Social Functioning Scale. Descriptive, bivariate, and multivariate analyses were completed.

RESULTS

The most consistent predictor of metabolic control, dietary self-management, and diabetes-related distress was support and confidence in living with diabetes. Additionally, women had difficulty meeting optimal goals for exercise, yet reported higher levels of other physical activity.

LIMITATIONS

This study was an exploratory analysis with a homogeneous sample of women with type 2 diabetes enrolled in an intervention study and measurements included multiple self-report instruments.

CONCLUSIONS

Interventions to increase women's perceived self-confidence and support may contribute to positive health outcomes in women with type 2 diabetes.

RELEVANCE TO CLINICAL PRACTICE

Assessment of social support and self-confidence in diabetes self-management in women with type 2 diabetes may assist in determining individualized goals and strategies. Enhanced social support and self-confidence in diabetes self-management may subsequently improve metabolic control, self-management and psychosocial adjustment to diabetes.

Differences in food habits and cardiovascular disease risk factors among Native Americans with and without diabetes: the Inter-Tribal Heart Project

OBJECTIVE

To examine differences in food habits among Native Americans with and without diabetes.

DESIGN

A cross-sectional epidemiological study in which participants underwent a physical examination and answered an extensive interviewer-administered questionnaire to assess differences in food servings, preparation and eating habits.

SETTING/PARTICIPANTS

Participants aged >/=25 years were randomly selected from three reservations in Minnesota and Wisconsin. There were 990 persons without diabetes, 294 with a prior diagnosis of diabetes, and 80 with fasting glucose >125 mg dl(-1) but no prior diabetes diagnosis.

RESULTS

Persons with prior diabetes diagnosis were less likely than those without diabetes to report eating fast-food meals two or more times per week, eat visible fat on meat or the skin on poultry, eat fried chicken or fried fish, to add fat to cooked vegetables and drink whole milk. Persons with previously undiagnosed diabetes were more likely than previously diagnosed persons to report eating fast-food meals two or more times per week, eat visible fat on meat and the skin on poultry, drink whole milk and eat fried fish, but were less likely to drink low-fat milk. Previously undiagnosed persons were more likely than either diagnosed persons or persons without diabetes to consume lard from cooked foods and use it when cooking.

CONCLUSION

Persons with diagnosed diabetes showed healthier eating patterns than those without diabetes, while undiagnosed persons showed some less favourable patterns. Because virtually all persons with diabetes in these communities receive nutrition education, the results suggest that nutrition education programmes for diabetics may be associated with healthier eating patterns.

Is the relationship between adherence behaviours and glycaemic control bi-directional at adolescence? A longitudinal cohort study

AIM

To analyse the change in adherence to diabetes treatment and its association with metabolic control from childhood to adolescence. The Tanner pubertal staging model was selected as a marker of developmental maturity.

METHODS

In a multicentre, longitudinal cohort study, 142 children with Type 1 diabetes completed a scale that assessed adherence to treatment and a test of diabetes knowledge at the beginning of the study (T0) and four years later (T4). HbA1c and clinical data were collected at T0 and at T4.

RESULTS

From T0 to T4, the mean HbA1c increased from 8.2 +/- 1.6 to 9.1 +/- 1.4% (P < 0.001). Among patients at pubertal stages 1-4, adherence did not decline from T0 to T4, whereas the HbA1c level increased and a positive correlation between adherence and the knowledge score was noted (r = 0.32; P < 0.02). Among adolescents at pubertal stage 5, the level of adherence decreased (P < 0.01) from T0 to T4 and the HbA1c level increased despite an increase in the knowledge score (P < 0.001), a negative correlation between HbA1c and adherence was found (r = -0.37; P = 0.001) and adherence at T4 significantly added to the prediction of HbA1c at T4.

CONCLUSIONS

In this longitudinal study, an initial worsening of glycaemic control as a result of puberty preceded worsening of adherence behaviours. Low levels of adherence become predictive of HbA1c degradation among pubertal stage 5 adolescents. These results suggest a potential bi-directional relationship between glycaemic control and adherence.