Assessment of group versus individual diabetes education: a randomized study

The effect of group-based lifestyle interventions on risk factors and insulin resistance in subjects at risk for metabolic syndrome: the Tabaruzaka Study 1

AIM

The aim of this study was to evaluate the efficacy of two group-based lifestyle interventions in ameliorating the risk factors of metabolic syndrome (MS) and insulin resistance.

METHODS

Ninety-eight subjects who had at least one component of MS were randomized into standard intervention (SI) (4-month intervention; n = 50) and extended intervention (EI) (10-month intervention; n = 48) groups, and 39 subjects were followed up for a control group. The effects of intervention were evaluated after 10, 22 and 34 months.

RESULTS

At month 10, the standard and EI groups showed improved body mass index (BMI) (SI, -0.28; EI, -0.47; control, -0.09), high-density lipoprotein (HDL) cholesterol, fasting plasma glucose and A1c and a decreased mean number of components of MS (SI, -0.37; EI, -0.51; control, 0.08). At month 34, the effects on BMI (SI, -0.66; EI, -0.60; control, -0.05) and HDL-cholesterol were sustained for both the intervention groups. In controls, the increases in fasting plasma glucose and the mean number of components of MS from the baseline to month 34 were greater than those in the standard and EI groups. Whole body insulin sensitivity index and hepatic insulin resistance index were also improved at month 10.

CONCLUSIONS

Group-based lifestyle intervention could be an efficient way to prevent MS. Its effects were sustainable, at least in part, for 2 years. These effects may be mediated by an improvement in insulin sensitivity.

Adesão a um programa de aconselhamento nutricional para adultos com excesso de peso e comorbidades

OBJETIVO: Investigar adesão a programa de aconselhamento nutricional em grupo para indivíduos com excesso de peso e comorbidades. MÉTODOS: Estudo analítico de intervenção controlada e aberta. Oitenta adultos, de ambos os sexos, com índice de massa corporal entre 25 e 35kg/m², portadores de dois ou mais fatores de risco cardiovascular associados foram alocados aleatoriamente em dois grupos para acompanhamento por três meses. O grupo de intervenção com aconselhamento nutricional em grupo recebeu atendimento individual e participou de seis reuniões grupais para discussão sobre alimentação saudável e atividade física, com dinâmicas e método participativo. O grupo-controle, com atendimento padrão individual, foi assistido em três consultas ambulatoriais. Consideraram-se repercussões dietéticas antes e após a intervenção e assiduidade às reuniões como parâmetros de adesão ao tratamento. RESULTADOS: Trinta e três participantes concluíram o estudo. Do total inicial, 45,8% e 40,7% do grupo de intervenção com aconselhamento nutricional em grupo e do grupo-controle com atendimento padrão individual, respectiva-mente, atingiram nível ótimo de assiduidade. Os fatores mais citados como barreiras à adesão ao tratamento foram fazer refeições fora de casa (46,7% - grupo-controle com atendimento padrão individual) e dificuldade em aplicar os conhecimentos na prática, principalmente em eventos sociais (33,3% - grupo de intervenção com aconselhamento nutricional em grupo). Verificou-se aumento significativo do percentual médio do uso de temperos naturais e do número de refeições ao dia nos dois grupos após a intervenção. Porém, não houve diminuição significativa do consumo energético intra ou entre os grupos. CONCLUSÃO: Apesar da abrangência do conteúdo e do emprego de um método participativo no grupo de intervenção, a adesão foi insuficiente para alterar significativamente os principais parâmetros dietéticos estudados. O apro-fundamento da abordagem comportamental, continuada e multiprofissional deve ser objeto de mais investigações.

Comparing the processes: accreditation and recognition

Diabetes education programs are developed to serve the diabetes community by offering quality education that meets a set of standards and is then eligible for third-party insurance reimbursement. Three organizations are authorized by the U.S. Centers for Medicare and Medicaid Services to determine whether diabetes education programs meet required standards. Each of the three relies on the 2007 edition of the National Standards for Diabetes Self-Management Education. This article summarizes similarities among and unique qualities of each of the organization's approaches to assuring quality.

Effectiveness of a Psychoeducative Intervention in a Summer Camp for Children With Type 1 Diabetes Mellitus

Purpose

The purpose of this study was to evaluate the effectiveness of a psychoeducative intervention implemented in a summer camp for children with type 1 diabetes.

Methods

A prospective cohort study was conducted comparing 2 groups of children with type 1 diabetes. The intervention group (n = 34) received interventions that addressed knowledge, behaviors, skills, and psychological factors during a summer camp. The control group (n = 23) received the usual education and care. Evaluated measurements were glycosylated hemoglobin (A1C), diabetes knowledge, anxiety, psychological adaptation, and use of health care services.

Results

No significant changes in A1C annual average, body mass index (BMI), diabetes knowledge, anxiety, medical visits, or hospital admissions were observed after the intervention in comparison with before intervention. Only the adaptation to the school environment improved significantly. The control group significantly increased BMI and A1C.

Conclusions

No relevant variations in diabetes knowledge, anxiety, psychological adaptation, or use of health care services were found after the psychoeducative intervention implemented in the summer camp. Future studies with random allocation of subjects are necessary to confirm the intervention’s effectiveness.

Preferences and opinions of patients with Type 2 diabetes on education and self-care: a cross-sectional survey

OBJECTIVE

To assess the preferences of patients with Type 2 diabetes regarding self-care activities and diabetes education.

RESEARCH DESIGN AND METHODS

Questionnaire survey carried out in general practices and outpatient clinics across the Netherlands.

OUTCOMES

preferred setting for education, preferred educator, and preferred and most burdensome self-care activity. Multinomial logistic regression analysis assessed associations between outcomes and patient characteristics, preferences and opinions.

RESULTS

Data of 994 consecutive individuals were analysed (mean 65 years; 54% male; 97% Caucasian; 21% low education level; 80% primary care). Of these, 19% thought they had poor to average glycaemic control, 61% thought they were over-weight and 32% thought they took too little exercise. Eighty per cent of respondents preferred diabetes education during regular diabetes check-ups. Patients taking insulin preferred education to be given by nurses [odds ratio (OR) 2.45; 95% confidence interval (CI) 1.21-4.96]. Individuals who thought their health to be poor/average preferred education to be given by doctors (OR 1.65; 95% CI 1.08-2.53). Physical exercise was the preferred self-care activity of those who thought they took too little exercise (OR 1.97; 95% CI 1.32-2.93) but was preferred less by patients with mobility problems (OR 0.65; 95% CI 0.43-0.97). Patients with eating disinhibition reported keeping to a healthy diet (OR 4.63; 3.00-7.16) and taking medication (OR 1.66; 95% CI 1.09-2.52) as the most burdensome self-care activities. Age was not an independent determinant of any preference.

CONCLUSIONS

When providing education for patients with newly diagnosed Type 2 diabetes, healthcare providers should consider making a tailored education plan, irrespective of the patient's age.

Structured education in type 1 diabetes

The UK has been slow to promote effective intensive insulin therapy among those with type 1 diabetes. Although many adults use multiple injections, few self-manage their diabetes effectively and maintain tight glucose targets. However, in recent years reports from other countries that high-quality skills training in self- management can improve glycaemic control while lowering rates of hypoglycaemia have changed attitudes. The DAFNE (Dose Adjustment for Normal Eating) trial, which promotes a flexible approach to eating while maintaining tight glucose targets, demonstrated that patients require training to manage their diabetes successfully. Many centres now offer DAFNE, or similar structured education programmes, to adults with type 1 diabetes. Most patients have difficulty in sustaining the approach and the most appropriate ways of continuing support are unclear. A large number of units still provide no structured training depriving their patients of an essential component of their treatment. Formal diabetes education can no longer be regarded as an optional extra. It needs to be seen as essential to treatment as medication and therefore resourced, researched, evaluated and quality assured to a similar standard.

Hearing aid effectiveness after aural rehabilitation - individual versus group (HEARING) trial: RCT design and baseline characteristics

BACKGROUND

Hearing impairment is the most common body system disability in veterans. In 2008, nearly 520,000 veterans had a disability for hearing loss through the Department of Veterans Affairs (VA). Changes in eligibility for hearing aid services, along with the aging population, contributed to a greater than 300% increase in the number of hearing aids dispensed from 1996 to 2006. In 2006, the VA committed to having no wait times for patient visits while providing quality clinically-appropriate care. One approach to achieving this goal is the use of group visits as an alternative to individual visits. We sought to determine: 1) if group hearing aid fitting and follow-up visits were at least as effective as individual visits, and 2) whether group visits lead to cost savings through the six month period after the hearing aid fitting. We describe the rationale, design, and characteristics of the baseline cohort of the first randomized clinical trial to study the impact of group versus individual hearing aid fitting and follow-up visits.

METHODS

Participants were recruited from the VA Puget Sound Health Care System Audiology Clinic. Eligible patients had no previous hearing aid use and monaural or binaural air-conduction hearing aids were ordered at the evaluation visit. Participants were randomized to receive the hearing aid fitting and the hearing aid follow-up in an individual or group visit. The primary outcomes were hearing-related function, measured with the first module of the Effectiveness of Aural Rehabilitation (Inner EAR), and hearing aid adherence. We tracked the total cost of planned and unplanned audiology visits over the 6-month interval after the hearing aid fitting.

DISCUSSION

A cohort of 659 participants was randomized to receive group or individual hearing aid fitting and follow-up visits. Baseline demographic and self-reported health status and hearing-related measures were evenly distributed across the treatment arms.Outcomes after the 6-month follow-up period are needed to determine if group visits were as least as good as those for individual visits and will be reported in subsequent publication.

TRIAL REGISTRATION

NCT00260663.

Continuous glucose monitoring technology for personal use: an educational program that educates and supports the patient

PURPOSE

The purpose of this article is to describe the development and implementation of an educational program for the initiation of real-time continuous glucose monitoring (CGM) technology for personal use, not 3-day CGMS diagnostic studies. The education program was designed to meet the needs of patients managing their diabetes with either diabetes medications or insulin pump therapy in an outpatient diabetes education center using a team-based approach.

METHODS

Observational research, complemented by literature review, was used to develop an educational program model and teaching strategies. Diabetes educators, endocrinologists, CGM manufacturer clinical specialists, and patients with diabetes were also interviewed for their clinical observations and experience.

RESULTS

The program follows a progressive educational model. First, patients learn in-depth about real-time CGM technology by attending a group presensor class that provides detailed information about CGM. This presensor class facilitates self-selection among patients concerning their readiness to use real-time CGM. If the patient decides to proceed with real-time CGM use, CGM initiation is scheduled, using a clinic-centered protocol for both start-up and follow-up.

CONCLUSIONS

Successful use of real-time CGM involves more than just patient enthusiasm or interest in a new technology. Channeling patient interest into a structured educational setting that includes the benefits and limitations of real-time CGM helps to manage patient expectations.

The effect of weight reduction interventions for persons with type 2 diabetes: a meta-analysis from a self-regulation perspective

PURPOSE

The main purpose of this article was to investigate the value of a self-regulation approach for weight reduction interventions in patients with type 2 diabetes. In addition, the potentially moderating effect of other intervention characteristics was explored.

METHODS

In a meta-analysis of 34 studies, overall effect sizes were calculated for weight and A1C. The focus of the analysis was, however, on the moderating effect of intervention characteristics, especially whether interventions that score high on self-regulation produce stronger effects.

RESULTS

The overall effect sizes (d) for weight loss in the short term (<6 months) were low and even lower in the longer term (>6 months). The overall effect sizes for A1C outcomes were higher and remained stable in the longer term. Interventions that scored high on self-regulation characteristics produced significantly better effects on both weight and A1C outcomes. Furthermore, "goal reformulation" increased the effect on weight outcomes whereas "emotion regulation" increased the effect on A1C. With respect to the other intervention characteristics, only the "inclusion of a patient's partner or relative" increased the effect on weight loss.

CONCLUSIONS

This meta-analysis underlines the importance of a self-regulation approach for weight reduction interventions in diabetes patients, in particular, for A1C outcomes. However, more research is needed to fully understand the relationship among self-regulation, weight, and A1C.

Group visits in the management of diabetes and hypertension: effect on glycemic and blood pressure control

Diabetes is a major public health problem that is reaching epidemic proportions in the United States and worldwide. Over 22 million Americans currently have diabetes and it is forecast that over 350 million people worldwide will be affected by 2030. Furthermore, the economic cost of diabetes care is enormous. Despite current efforts on the part of health care providers and their patients, outcomes of care remain largely suboptimal, with only 3% to 7% of the entire diabetes population meeting recommended treatment goals for glycemic, blood pressure, and lipid control. Therefore, alternative approaches to diabetes care are desperately needed. Group visits may provide a viable option for patients and health care providers, with the potential to improve outcomes and cost effectiveness. In this review, we highlight the magnitude of the diabetes epidemic, the barriers to optimal diabetes care, and the utility of the concept of group visits as a chronic disease management strategy for diabetes care.

A Structured Educational Program Improves Metabolic Control in Patients With Type 2 Diabetes

Purpose

To evaluate the effectiveness of a structured education group program in metabolic control in patients with type 2 diabetes.

Methods

A randomized controlled trial was conducted in a public teaching hospital and tertiary care center. Participants were 104 patients with type 2 diabetes not using insulin (aged 59 ± 9.5 years, diabetes duration of 10.5 ± 6.70 years, 53% women) randomized to attend an 8-hour structured group education program (delivered in 4 sessions, for 4 weeks, by a trained nurse educator) or to usual care. A pretest and posttest assessed the patients' knowledge before and after the course. The main outcome measures were A1C, weight, blood pressure, and lipids at 4-month intervals, up to 12 months.

Results

A1C levels decreased significantly in the intervention group after the 4th month and remained lower than in the control group until the 12th month (multivariate analysis of covariance, with baseline A1C as a covariate). Weight, blood pressure levels, total cholesterol, and high-density lipoprotein levels improved significantly, and similarly, in both groups.

Conclusions

A structured education group program centered in self-management improves the glycemic control in patients with type 2 diabetes, reaching the peak effect at 4 months, and lasting for up to 12 months.

Assessing Diabetes Dietary Goals and Self-Management Based on In-Depth Interviews With Latino and Caucasian Clients With Type 2 Diabetes

Latino ( n = 10) and Caucasian ( n = 8) clients with type 2 diabetes receiving care at a community health clinic participated in individual in-depth interviews assessing diabetes dietary self-management goal behaviors. Themes from interviews were identified using content analysis, which revealed current and future goals, influencing factors, and motivators and barriers to dietary modification for diabetes management. Implications for practice include simplifying goal setting to those goals with the greatest potential clinical impact or the greatest significance to the patient, in a socially supportive environment. Results contribute to future survey development and understanding how to optimize diabetes education for these populations.

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.

A low-fat vegan diet elicits greater macronutrient changes, but is comparable in adherence and acceptability, compared with a more conventional diabetes diet among individuals with type 2 diabetes

BACKGROUND

Although therapeutic diets are critical to diabetes management, their acceptability to patients is largely unstudied.

OBJECTIVE

To quantify adherence and acceptability for two types of diets for diabetes.

DESIGN

Controlled trial conducted between 2004 and 2006.

SUBJECTS/SETTING

Individuals with type 2 diabetes (n=99) at a community-based research facility. Participants were randomly assigned to a diet following 2003 American Diabetes Association guidelines or a low-fat, vegan diet for 74 weeks.

MAIN OUTCOME MEASURES

Attrition, adherence, dietary behavior, diet acceptability, and cravings.

STATISTICAL ANALYSES

For nutrient intake and questionnaire scores, t tests determined between-group differences. For diet-acceptability measures, the related samples Wilcoxon sum rank test assessed within-group changes; the independent samples Mann-Whitney U test compared the diet groups. Changes in reported symptoms among the groups was compared using chi(2) for independent samples.

RESULTS

All participants completed the initial 22 weeks; 90% (45/50) of American Diabetes Association guidelines diet group and 86% (42/49) of the vegan diet group participants completed 74 weeks. Fat and cholesterol intake fell more and carbohydrate and fiber intake increased more in the vegan group. At 22 weeks, group-specific diet adherence criteria were met by 44% (22/50) of members of the American Diabetes Association diet group and 67% (33/49) of vegan-group participants (P=0.019); the American Diabetes Association guidelines diet group reported a greater increase in dietary restraint; this difference was not significant at 74 weeks. Both groups reported reduced hunger and reduced disinhibition. Questionnaire responses rated both diets as satisfactory, with no significant differences between groups, except for ease of preparation, for which the 22-week ratings marginally favored the American Diabetes Association guideline group. Cravings for fatty foods diminished more in the vegan group at 22 weeks, with no significant difference at 74 weeks.

CONCLUSIONS

Despite its greater influence on macronutrient intake, a low-fat, vegan diet has an acceptability similar to that of a more conventional diabetes diet. Acceptability appears to be no barrier to its use in medical nutrition therapy.

Individual patient education for people with type 2 diabetes mellitus

BACKGROUND

Type 2 diabetes is a common and costly chronic disease which is associated with significant premature mortality and morbidity. Although patient education is an integral component of diabetes care, there remain uncertainties regarding the effectiveness of different methods and modes of education.

OBJECTIVES

To evaluate the effectiveness of individual patient education on metabolic control, diabetes knowledge and psychosocial outcomes.

SEARCH STRATEGY

Multiple electronic bibliographic databases were searched, including The Cochrane Library, MEDLINE, Premedline, ERIC, Biosis, AMED, Psychinfo, EMBASE, CINAHL, APAIS-health, Australian Medical Index, Web of Science, dissertation abstracts and Biomed Central.

SELECTION CRITERIA

Randomized controlled and controlled clinical trials which evaluated individual education for adults with type 2 diabetes. The intervention was individual face-to-face patient education while control individuals received usual care, routine treatment or group education. Only studies that assessed outcome measures at least six months from baseline were included.

DATA COLLECTION AND ANALYSIS

Information was extracted by two reviewers who summarized both study characteristics and outcome statistics. A meta-analysis using a fixed-effect model was performed if there were adequate studies with a specified outcome of sufficient homogeneity. For outcomes where there were too few studies or the assessment measurements were not standardized or variable, the results were summarised qualitatively.

MAIN RESULTS

Nine studies involving 1359 participants met the inclusion criteria. Six studies compared individual education to usual care and three compared individual education to group education (361 participants). There were no long-term studies and overall the quality of the studies was not high. In the six studies comparing individual face-to-face education to usual care, individual education did not significantly improve glycaemic control (weighted mean difference (WMD) in HbA1c -0.1% (95% confidence interval (CI) -0.3 to 0.1, P = 0.33) over a 12 to 18 month period. However, there did appear to be a significant benefit of individual education on glycaemic control in a subgroup analysis of three studies involving participants with a higher mean baseline HbA1c greater than 8% (WMD -0.3% (95% CI -0.5 to -0.1, P = 0.007). In the two studies comparing individual to group education, there was no significant difference in glycaemic control between individual or group education at 12 to 18 months with a WMD in HbA1c of 0.03% (95% CI -0.02 to 0.1, P = 0.22). There was no significant difference in the impact of individual versus usual care or group education on body mass index systolic or diastolic blood pressure. There were too few studies to perform a meta-analysis on the effect of individual education on dietary self management, diabetes knowledge, psychosocial outcomes and smoking habits. No data were available on the other main outcome measures of diabetes complications or health service utilization and cost analysis in these studies.

AUTHORS' CONCLUSIONS

This systematic review suggests a benefit of individual education on glycaemic control when compared with usual care in a subgroup of those with a baseline HbA1c greater than 8%. However, overall there did not appear to be a significant difference between individual education and usual care. In the small number of studies comparing group and individual education, there was an equal impact on HbA1c at 12 to 18 months. Additional studies are needed to delineate these findings further.

Influence of diabetic education on patient metabolic control

This study was conducted for the purpose of examining the effect of planned education given to persons with type 2 diabetes mellitus (DM) on their metabolic control. The method of the study was a randomly controlled clinical trial. A sample of 50 individuals participated, of which 25 were in the Experimental group (E), and 25 were in the Control group (C). The educational program consisted of three sessions between the educator and persons with diabetes. Before the education program, there was no statistically important significance between the metabolic control parameters of the E group and the C group. In the analysis of the difference between means of the E and C groups, after the third education program, statistically significant differences were found between fasting blood sugar, postparandial blood sugar, urine glucose, hemoglobin A1c, triglyceride, total cholesterol, and low-density lipoprotein cholesterol levels. In the study, regular and repetitive education provided by the nurses had a positive effect on the metabolic values of persons with DM.

The importance of health belief models in determining self-care behaviour in diabetes

Patients' self-care behaviours have a major role in diabetes management. Diabetes education provides the required knowledge, but despite this, self-care is often suboptimal. The degree to which patients follow advice as regards the various self-care behaviours is determined by their health beliefs (Illness Representations or Personal Models) of diabetes. Psychometric studies have tried to categorize and measure the beliefs about illness that influence patients to adhere to treatment recommendations in diabetes. Various models have been proposed to explain the relationship between beliefs and behaviour. Leventhal's Self-Regulatory Model, which takes account of the emotional as well as the objective rational response to illness, currently seems to offer the best system for identifying the determinants of patient self-care behaviour. A review of interventions indicates those based on psychological theory offer professionals the best chance of maximizing their patients' contribution to diabetes self-management and achieving improved outcomes, both glycaemic and psychosocial. Studies designed specifically to modify illness representations are now being undertaken. This brief review aims to summarize developments in this area of psychological theory over the last 20 years and the implications for promoting better self-care behaviour in diabetes.

Culturally tailored intervention for rural African Americans with type 2 diabetes

PURPOSE

The purpose of this pilot study was to evaluate a culturally tailored intervention for rural African Americans. Social Cognitive Theory provided the framework for the study.

METHODS

Twenty-two participants were recruited and randomly assigned to either Group or Individual diabetes self-management (DSME). Group DSME included story-telling, hands-on activities, and problem-solving exercises. Individual DSME sessions focused on goal-setting and problem-solving strategies. Sessions were offered in an accessible community center over a 10-week period.

RESULTS

Outcomes included glycosylated hemoglobin (A1C), self-care actions, self-efficacy level, goal attainment, and satisfaction with DSME. Participants in both Group and Individual DSME improved slightly over the 3-month period in self-care activities, A1C level, and goal attainment. Although differences were not statistically significant, trends indicate improved scores on dietary actions, foot care, goal attainment, and empowerment for those experiencing Group DSME.

CONCLUSIONS

The culturally tailored approach was well received by all participants. Improvements among those receiving Individual DSME may indicate that brief sessions usinga culturally tailored approach could enhance self-care and glycemic control. Additional testing among more participants over a longer time period is recommended.

Evidence-based nutrition practice guidelines for diabetes and scope and standards of practice

In the 1990s, the American Dietetic Association (ADA) began developing nutrition practice guidelines for registered dietitians (RDs) and evaluating how their use affected clinical outcomes. Clinical trials and outcomes research report that diabetes medical nutrition therapy, delivered using a variety of nutrition interventions and multiple encounters, is effective in improving glycemic and other metabolic outcomes. The process of developing nutrition practice guidelines has evolved into evidence-based nutrition practice guidelines, which are disease/condition-specific recommendations and toolkits. An expert work group identified important clinical questions related to diabetes nutrition therapy. Research studies were analyzed and evidence summaries and conclusion statements written and graded for strength of research design. Based on the research conclusions, evidence-based nutrition recommendations and guidelines for adults with type 1 and type 2 diabetes were formulated. The ADA evidence-based nutrition practice guidelines for diabetes are published in the Web-based evidence analysis library. The recommendations are similar to those of the American Diabetes Association, although developed using a different method. To define the RD's professional practice, the ADA has published the Scope of Dietetics Practice Framework, the Standards of Practice and Standards of Professional Performance, and specialized standards for the RD in diabetes nutrition care. The latter defines the knowledge, skills, and competencies required by RDs to provide diabetes care at the generalist, specialist, and advanced practice level.

Current strategies for evaluating, monitoring, and treating type 2 diabetes mellitus

Diabetes mellitus is a chronic progressive disease that has profound consequences for individuals, families, and society. Despite clear glycemic control targets articulated by the major medical societies, patients and physicians still struggle to meet and maintain these goals, leading to shortfalls in delivery of care. Recent advances in the treatment of type 2 diabetes seek to address these shortfalls: Modern oral hypoglycemic agents may be used with or in place of traditional therapies. Analogue insulins, whose pharmacokinetic and pharmacodynamic properties allow patients improved lifestyle flexibility compared with regular insulins, have done much to improve glycemic control. Using these new classes of therapy, physicians should strive to help patients understand and reach the targets for control that we know to be beneficial for the majority of individuals. Such targets include those for glycosylated hemoglobin (HbA1c), but increasingly we also realize the central importance of maintaining postprandial glucose levels within recommended limits, and it is likely that the recent introduction of a serum marker for this purpose, 1,5-anhydroglucitol, will help improve patient outcomes. By intensifying therapy early during the course of the disease process, using the most effective and acceptable therapies available, and maintaining the lowest and safest HbA1c levels for as long as possible, we will be serving our patients well and living up to our responsibilities as diabetes care physicians.

Evaluation of a structured educational programme for type 2 diabetes patients seen in private practice

AIM

Structured education is necessary in the management of a chronic disease such as diabetes and should be readily offered to patients in different settings. Our aim was to demonstrate the feasibility and advantages of a group education programme for type 2 diabetic patients in a private setting in France.

METHODS

A programme of group education for patients with type 2 diabetes was initiated by a multidisciplinary group of volunteer healthcare providers, including general practitioners, specialists in diabetology and non-medical members. All volunteers received one day of training, and physicians were instructed to organize several sessions of group education for the type 2 diabetic patients who regularly attended their practice. The first 427 patients entering the programme were included in the study, and asked to fill in a questionnaire to assess their knowledge, beliefs and behaviours with regard to diabetes. Their physician filled in a medical form. Six months later, the same questionnaire and form were sent for follow-up information.

RESULTS

At six months versus baseline, patients exhibited small, but consistent, improvements: (i) fasting glucose 142+/-42 mg/dL (P<0.04) vs 146+/-44 mg/dL (P<0.04); (ii) HbA(1c) 7.41+/-1.26% vs 7.57+/-1.33% (P<0.01); and (iii) all of the main parameters of diabetes self-management recorded in the study. The percentage of patients who inspected their feet at least once a week increased from 67 to 77% (P<0.001). Patients improved their knowledge of the disease and developed a more positive attitude towards their diabetes.

CONCLUSION

Our study demonstrates that it is possible to organize educational sessions for diabetic patients in a private-practice setting. At six months, patients receiving these sessions showed benefits in terms of blood glucose control and other important markers of self-management of their disease.

Interventions for enhancing medication adherence

BACKGROUND

People who are prescribed self-administered medications typically take less than half the prescribed doses. Efforts to assist patients with adherence to medications might improve the benefits of prescribed medications, but also might increase their adverse effects.

OBJECTIVES

To update a review summarizing the results of randomized controlled trials (RCTs) of interventions to help patients follow prescriptions for medications for medical problems, including mental disorders but not addictions.

SEARCH STRATEGY

We updated searches of The Cochrane Library, MEDLINE, CINAHL, EMBASE, International Pharmaceutical Abstracts (IPA), PsycINFO (all via OVID) and Sociological Abstracts (via CSA) in January 2007 with no language restriction. We also reviewed bibliographies in articles on patient adherence and articles in our personal collections, and contacted authors of relevant original and review articles.

SELECTION CRITERIA

Articles were selected if they reported an unconfounded RCT of an intervention to improve adherence with prescribed medications, measuring both medication adherence and treatment outcome, with at least 80% follow-up of each group studied and, for long-term treatments, at least six months follow-up for studies with positive initial findings.

DATA COLLECTION AND ANALYSIS

Study design features, interventions and controls, and results were extracted by one review author and confirmed by at least one other review author. We extracted adherence rates and their measures of variance for all methods of measuring adherence in each study, and all outcome rates and their measures of variance for each study group, as well as levels of statistical significance for differences between study groups, consulting authors and verifying or correcting analyses as needed. The studies differed widely according to medical condition, patient population, intervention, measures of adherence, and clinical outcomes. Therefore, we did not feel that quantitative analysis was scientifically justified; rather, we conducted a qualitative analysis.

MAIN RESULTS

For short-term treatments, four of ten interventions reported in nine RCTs showed an effect on both adherence and at least one clinical outcome, while one intervention reported in one RCT significantly improved patient adherence, but did not enhance the clinical outcome. For long-term treatments, 36 of 81 interventions reported in 69 RCTs were associated with improvements in adherence, but only 25 interventions led to improvement in at least one treatment outcome. Almost all of the interventions that were effective for long-term care were complex, including combinations of more convenient care, information, reminders, self-monitoring, reinforcement, counseling, family therapy, psychological therapy, crisis intervention, manual telephone follow-up, and supportive care. Even the most effective interventions did not lead to large improvements in adherence and treatment outcomes.

AUTHORS' CONCLUSIONS

For short-term treatments several quite simple interventions increased adherence and improved patient outcomes, but the effects were inconsistent from study to study with less than half of studies showing benefits. Current methods of improving adherence for chronic health problems are mostly complex and not very effective, so that the full benefits of treatment cannot be realized. High priority should be given to fundamental and applied research concerning innovations to assist patients to follow medication prescriptions for long-term medical disorders.

Nutritionist visits, diabetes classes, and hospitalization rates and charges: the Urban Diabetes Study

OBJECTIVE

We evaluated the association of different types of educational visits for diabetic patients of the eight Philadelphia Health Care Centers (PHCCs) (public safety-net primary care clinics), with hospital admission rates and charges reported to the Pennsylvania Health Care Cost Containment Council.

RESEARCH DESIGN AND METHODS

The study population included 18,404 patients who had a PHCC visit with a diabetes diagnosis recorded between 1 March 1993 and 31 December 2001 and had at least 1 month follow-up time.

RESULTS

A total of 31,657 hospitalizations were recorded for 7,839 (42.6%) patients in the cohort. After adjustment for demographic variables, baseline comorbid conditions, hospitalizations before the diabetes diagnosis, and number of other primary care visits, having had any type of educational visit was associated with 9.18 (95% CI 5.02-13.33) fewer hospitalizations per 100 person-years and $11,571 ($6,377 to $16,765) less in hospital charges per person. Each nutritionist visit was associated with 4.70 (2.23-7.16) fewer hospitalizations per 100 person-years and a $6,503 ($3,421 to $9,586) reduction in total hospital charges.

CONCLUSIONS

Any type of educational visit was associated with lower hospitalization rates and charges. Nutritionist visits were more strongly associated with reduced hospitalizations than diabetes classes. Each nutritionist visit was associated with a substantial reduction in hospital charges, suggesting that providing these services in the primary care setting may be highly cost-effective for the health care system.

Knowledge of diabetic patients about their disease before and after implementing a diabetes education program

The purpose of this quasi-experimental, prospective and comparative study is to evaluate the knowledge that diabetic patients have about their disease before and after implementing a Diabetes Education Program. Fifty-four diabetic patients participated in the study, which occurred from April 2004 to April 2005. Data collection was performed using a questionnaire. The study population was characterized as adult and elderly subjects, with ages between 29 and 78 years; 60 years, on the average; Most participants were female 40/54 (74.1%); white 32/54 (59.3%); married 37/54 (68.5%); retired 23/54 (42.6%); with incomplete primary education 32/54 (59.3%); and an income of one to two minimum wages 16/54 (29.6%). The patients' knowledge regarding their disease increased significantly (p<0.05); especially considering the general topics concerning diabetes mellitus: concept of the disease, physiopathology and treatments; other topics that stood out were physical activity and nutrition.

Education and self-management for people newly diagnosed with type 2 diabetes: a qualitative study of patients' views

OBJECTIVES

We explored the perceptions, views and experiences of diabetes education in people with type 2 diabetes who were participating in a UK randomized controlled trial of methods of education. The intervention arm of the trial was based on DESMOND, a structured programme of group education sessions aimed at enabling self-management of diabetes, while the standard arm was usual care from general practices.

METHODS

Individual semi-structured interviews were conducted with 36 adult patients, of whom 19 had attended DESMOND education sessions and 17 had been randomized to receive usual care. Data analysis was based on the constant comparative method.

RESULTS

Four principal orientations towards diabetes and its management were identified: 'resisters', 'identity resisters, consequence accepters', 'identity accepters, consequence resisters' and 'accepters'. Participants offered varying accounts of the degree of personal responsibility that needed to be assumed in response to the diagnosis. Preferences for different styles of education were also expressed, with many reporting that they enjoyed and benefited from group education, although some reported ambivalence or disappointment with their experiences of education. It was difficult to identify striking thematic differences between accounts of people on different arms of the trial, although there was some very tentative evidence that those who attended DESMOND were more accepting of a changed identity and its implications for their management of diabetes.

DISCUSSION

No one single approach to education is likely to suit all people newly diagnosed with diabetes, although structured group education may suit many. This paper identifies varying orientations and preferences of people with diabetes towards forms of both education and self-management, which should be taken into account when planning approaches to education.

Pontos básicos de um programa de educação ao paciente com diabetes melito tipo 1

O número de portadores de diabetes melito tipo 1 (DM1) está aumentando globalmente, entretanto, a maior parte dos pacientes apresenta controle glicêmico insatisfatório. Esta revisão na literatura foi realizada com três questões de pesquisa: Quais as recomendações e diretrizes de educação em diabetes existentes? Existem evidências para recomendar a adaptação de determinado programa segundo a faixa etária dos pacientes? Os programas de educação são efetivos na melhora dos níveis de HbA1c? Foram revisados 40 artigos, publicados entre 2000 e 2007, sobre educação em DM1 em crianças, adolescentes, adultos e usuários de bomba de infusão contínua de insulina, além de incluir o resumo das diretrizes da IDF, da ADA, da SBD, da AADE, do IDC, e outras peculiaridades para o contexto de saúde pública e privada. O portador de diabetes e sua família devem ser treinados a fazer decisões efetivas de autocuidado em sua rotina diária. O aprimoramento do paciente no automanejo aproxima o valor da HbA1c ao adequado para sua faixa etária. A educação individual e a em grupo apresentam equivalência na melhora do controle metabólico. Existe uma correlação positiva entre o tempo de educação e o controle da glicemia.

Opportunities and challenges for diabetes prevention at two community health centers

OBJECTIVE

Translating evidence-based diabetes prevention interventions to disadvantaged groups is a public health priority that poses unique challenges. Community health centers (CHCs) provide unequaled opportunities to prevent diabetes among poor and minority high-risk groups. This formative study sought to assess structural, processes-of-care (health care quality domains), and patient factors that need to be considered for diabetes prevention at CHCs.

RESEARCH DESIGN AND METHODS

A multimethod approach was implemented to assess system-, provider-, and patient-level factors at two large CHCs serving diverse urban communities.

RESULTS

Medical chart audits (n = 303) showed limited documentation of risks. Provider surveys (n = 74) evidenced knowledge gaps regarding factors associated with increased diabetes risk, efficacy of pharmacological interventions, and low perceived efficacy in promoting patient behavior change. Patient focus groups (two groups) with at-risk Hispanics and African Americans suggested mixed knowledge regarding whether diabetes can be prevented, some knowledge gaps regarding factors related to risk, and multiple challenges for lifestyle change.

CONCLUSIONS

Multiple and multilevel challenges to translating diabetes prevention interventions for the benefit of at-risk populations who seek care at CHCs were observed.

Impact of education on disease knowledge and glycaemic control among type 2 diabetic patients in family practice

In patients with diabetes type 2, good knowledge about disease often doesn't follow appropriate behavior in their life. Therefore, we wanted to find out basic level of disease knowledge and glycemic control among type 2 diabetic patients, and after that impact of passive and intensive education on knowledge and glycemic control. Starting with 130 participants, 91 patients with type 2 diabetes, from four family medicine services in Tuzla Canton, completed six months education about their disease. Disease Knowledge Test of Michigan Diabetes Training and Research Center was used to evaluate knowledge about diabetes and glycaemic control was assessed by HbA1c. Participants were tested at the beginning of survey, after 3 months of passive education and additional 3 months of intensive one. Basic test showed good knowledge of participants (score 8,3 out of 15), improved knowledge after passive education (score 9,23) and intensive one (11,19) (P<0,0001). Demographic characteristics of patients (age, sex, living area, level of education, duration of disease and type of treatment) had no influence on disease knowledge and glycaemic control during education. Generally, patient education improved significantly glycaemic control by HbA1c reduction 0,45% (P=0,011) without significant differences between passive and intensive one. Education of patients improves both disease knowledge and glycaemic control among type 2 diabetic patients.

Self-management education programmes by lay leaders for people with chronic conditions

BACKGROUND

Lay-led self-management programmes are becoming widespread in the attempt to promote self-care for people with chronic conditions.

OBJECTIVES

To assess systematically the effectiveness of lay-led self-management programmes for people with chronic conditions.

SEARCH STRATEGY

We searched: the Cochrane Central Register of Controlled Trials (CENTRAL, The Cochrane Library 2005, Issue 1), MEDLINE (January 1986 to May 2006), EMBASE (January 1986 to June 2006), AMED (January 1986 to June 2006), CINAHL (January 1986 to June 2006), DARE (1994 to July 2006, National Research Register (2000 to July 2006), NHS Economic Evaluations Database (1994 to July 2006), PsycINFO (January 1986 to June 2006), Science Citation Index (January 1986 to July 2006), reference lists and forward citation tracking of included studies. We contacted principal investigators and experts in the field. There were no language restrictions.

SELECTION CRITERIA

Randomised controlled trials (RCTs) comparing structured lay-led self-management education programmes for chronic conditions against no intervention or clinician-led programmes.

DATA COLLECTION AND ANALYSIS

Two authors independently assessed trial quality and extracted data. We contacted study authors for additional information. Results of RCTs were pooled using a random-effects model with standardised mean differences (SMDs) or weighted mean differences (WMDs) for continuous outcomes.

MAIN RESULTS

We included seventeen trials involving 7442 participants. The interventions shared similar structures and components but studies showed heterogeneity in conditions studied, outcomes collected and effects. There were no studies of children and adolescents, only one study provided data on outcomes beyond six months, and only two studies reported clinical outcomes.

PRIMARY OUTCOMES

Health status: There was a small, statistically-significant reduction in: pain (11 studies, SMD -0.10 (95% confidence interval (CI) -0.17 to -0.04)); disability (8 studies, SMD -0.15 (95% CI -0.25 to -0.05); and fatigue (7 studies, SMD -0.16 (95% CI -0.23 to -0.09); and small, statistically-significant improvement in depression (6 studies, SMD -0.16 95% CI -0.24 to -0.07). There was a small (but not statistically- or clinically-significant) improvement in psychological well-being (5 studies; SMD -0.12 (95% CI -0.33 to 0.09)); but no difference between groups for health-related quality of life (3 studies; WMD -0.03 (95% CI -0.09 to 0.02). Six studies showed a statistically-significant improvement in self-rated general health (WMD -0.20 (95% CI -0.31 to -0.10). Health behaviours: 7 studies showed a small, statistically-significant increase in self-reported aerobic exercise (SMD -0.20 (95% CI -0.27 to -0.12)) and a moderate increase in cognitive symptom management (4 studies, WMD -0.55 ( 95% CI -0.85 to -0.26)). Healthcare use: There were no statistically-significant differences between groups in physician or general practitioner attendance (9 studies; SMD -0.03 (95% CI -0.09 to 0.04)). There were also no statistically-significant differences between groups for days/nights spent in hospital (6 studies; WMD -0.32 (95% CI -0.71 to 0.07)). Self-efficacy: (confidence to manage condition) showed a small statistically-significant improvement (10 studies): SMD -0.30, 95% CI -0.41 to -0.19. No adverse events were reported in any of the studies.

AUTHORS' CONCLUSIONS

Lay-led self-management education programmes may lead to small, short-term improvements in participants' self-efficacy, self-rated health, cognitive symptom management, and frequency of aerobic exercise. There is currently no evidence to suggest that such programmes improve psychological health, symptoms or health-related quality of life, or that they significantly alter healthcare use. Future research on such interventions should explore longer term outcomes, their effect on clinical measures of disease and their potential role in children and adolescents.

Type 2 diabetic patients attending a nurse educator have improved metabolic control

To investigate if routine education by nurses is associated with improved metabolic control in type 2 diabetic (DM2) outpatients, we randomly selected 143 patients (81 women), not using insulin, at the Endocrine or Internal Medicine clinics, to be interviewed and submitted to a clinical and laboratory evaluation. Age was 59.1+/-10.1 years; duration of DM2 7.5+/-6.3 years; BMI 29.7+/-5.2 kg/m(2). Patients were grouped according to HbA(1c) (<7.0% or > or =7.0%). Age, gender, DM2 duration, BMI, and lipid profile were not different. Patients with HbA(1c)> or =7.0% (n=49) were more likely to be taking oral agents, and to be treated by internists rather than endocrinologists (P=0.04). Nurse education was associated with a greater proportion of patients with HbA(1c)<7.0%, especially among those attending the Internal Medicine clinic. In logistic regression, education by nurses remained associated to HbA(1c)<7.0% (OR: 3.29, P=0.005), after controlling for use of oral agents (OR 0.067, P=0.01), attending the Endocrine clinic (OR 4.11, P=0.002), self-reported adherence to diet ("yes" or "no"), known DM duration, and instruction level (NS). Nurse education contributes significantly and independently for better metabolic control in DM2 outpatients in a teaching hospital.

Planning and Implementing an Interdisciplinary Diabetes Workshop for Healthcare Professionals

A diabetes education program for healthcare professionals evolved out of a series of discussions among healthcare providers. This group realized the importance and the necessity of developing a current knowledge base for themselves, their clients, and their clients' families. The target audiences for this program were physicians, nurses, pharmacists, and dietitians who could be eligible to work toward becoming a certified diabetes educator. This article discusses the process used to develop and conduct these workshops. The lessons learned during this project are provided for consideration by others seeking to address common concerns and challenges in other areas of clinical practice.

The Effects of Interventions on Health-Related Quality of Life Among Persons With Diabetes

BACKGROUND

Health-related quality of life (HRQL) is increasingly used to measure the outcomes of interventions among people with chronic diseases.

OBJECTIVES

To assess the effect of interventions for adults with diabetes on HRQL, as measured by the Short Form (SF)-36 questionnaire.

RESEARCH DESIGN

The systematic review was conducted using the methods of the Cochrane Collaboration. Studies reporting SF-36 scores before and after an intervention focused on adults with diabetes were obtained from searches of multiple bibliographic databases. The mean changes and standardized mean differences between pre- and post-intervention were reported as outcome measures. Pooled estimates were obtained using random effects models.

RESULTS

: We identified 33 studies examining a wide range of interventions, including diabetes education and behavioral modifications (15 studies), pharmacotherapy (11 studies), and surgery (7 studies). Interventions generally demonstrated improvement in HRQL. When all available profile scores were examined together, the ranges of mean changes in scores were as follows: surgery for treating diabetes comorbidities, 15.0 to 42.0 point improvement; surgery for treating diabetes complications, -13.0 to 37.9; pharmacotherapy using insulin to optimize glycemic control, -4.6 to 27.6; pharmacotherapy for treating comorbidities, 3.8 to 33.2; pharmacotherapy for treating complications, -2.6 to 14.6. Pooled effects from 5 randomized controlled trials of educational interventions demonstrated significantly improved physical function [3.4 (95% CI, 0.1-6.6)] and mental health [4.2 (95% CI, 1.8-6.6)], and a decrease in bodily pain [3.6 (95% CI, 0.6-6.7)].

CONCLUSIONS

A variety of interventions can improve HRQL among adults with diabetes, but the magnitude of effects varied with the interventions. The mechanism of these changes needs to be further examined in the future research.

Effects of a diabetes self-management program on glycemic control, coronary heart disease risk, and quality of life among Thai patients with type 2 diabetes

Uncontrolled diabetes is a major health problem in Thailand. The objective of this study was to determine the effects of a diabetes self-management program on glycemic control, coronary heart disease (CHD) risk, and quality of life in 147 diabetic patients (aged 56.8 +/- 10.2 years). Type 2 diabetic patients who met the research criteria were randomized into two groups for a period of 6 months: the experimental group received the diabetes self-management program and the control group received the usual nursing care. The findings indicated that the experimental group demonstrated a significant decrease in the hemoglobin A(1c) level and CHD risk, with an increase in quality of life (QOL) compared to the control group. The diabetes self-management program was effective for improving metabolic control and the QOL for individuals with diabetes. Further studies should be replicated using larger groups over a longer time frame.

Outcomes of educational interventions in type 2 diabetes: WEKA data-mining analysis

OBJECTIVE

To analyze which factors contribute to improvement in glycemic control in educational interventions in type 2 diabetes reported in randomized controlled trials (RCT) published in 2001-2005.

METHODS

Papers were extracted from Medline and Scopus using educational intervention and adults with type 2 diabetes as keywords. Inclusion criteria were RCT design. Data were analyzed with a data-mining program.

RESULTS

Of 464 titles extracted, 21 articles reporting 18 studies met the inclusion criteria. Data mining showed that for initial glycosylated hemoglobin (HbA1c) level < or = 7.9% the diabetes education intervention achieved a small change in HbA1c level, or from +0.1 to -0.7%. For initial HbA1c > or = 8.0%, a significant drop in HbA1c level of 0.8-2.5% was found. Data mining indicated that duration, educational content and intensity of education did not predict changes in HbA1c levels.

CONCLUSION

Initial HbA1c level is the single most important factor affecting improvements in glycemic control in response to patient education. Data mining is an appropriate and sufficiently sensitive method to analyze outcomes of educational interventions. Diversity in conceptualization of interventions and diversity of instruments used for outcome measurements could have hampered actual discovery of effective educational practices.

PRACTICE IMPLICATIONS

Participation in educational interventions generally seems to benefit people with type 2 diabetes. Use of standardized instruments is encouraged as it gives better opportunities to identify conclusive results with consequent development of clinical guidelines.

Assessment of two culturally competent diabetes education methods: individual versus individual plus group education in Canadian Portuguese adults with type 2 diabetes

OBJECTIVE

To examine the impact of two culturally competent diabetes education methods, individual counselling and individual counselling in conjunction with group education, on nutrition adherence and glycemic control in Portuguese Canadian adults with type 2 diabetes over a three-month period.

DESIGN

The Diabetes Education Centre is located in the urban multicultural city of Toronto, Ontario, Canada. We used a three-month randomized controlled trial design. Eligible Portuguese-speaking adults with type 2 diabetes were randomly assigned to receive either diabetes education counselling only (control group) or counselling in conjunction with group education (intervention group). Of the 61 patients who completed the study, 36 were in the counselling only and 25 in the counselling with group education intervention. We used a per-protocol analysis to examine the efficacy of the two educational approaches on nutrition adherence and glycemic control; paired t-tests to compare results within groups and analysis of covariance (ACOVA) to compare outcomes between groups adjusting for baseline measures. The Theory of Planned Behaviour was used to describe the behavioural mechanisms that influenced nutrition adherence.

RESULTS

Attitudes, subjective norms, perceived behaviour control, and intentions towards nutrition adherence, self-reported nutrition adherence and glycemic control significantly improved in both groups, over the three-month study period. Yet, those receiving individual counselling with group education showed greater improvement in all measures with the exception of glycemic control, where no significant difference was found between the two groups at three months.

CONCLUSIONS

Our study findings provide preliminary evidence that culturally competent group education in conjunction with individual counselling may be more efficacious in shaping eating behaviours than individual counselling alone for Canadian Portuguese adults with type 2 diabetes. However, larger longitudinal studies are needed to determine the most efficacious education method to sustain long-term nutrition adherence and glycemic control.