Behavioral Programs for Type 2 Diabetes Mellitus: A Systematic Review and Network Meta-analysis

Diabetes self-management education reduces risk of all-cause mortality in type 2 diabetes patients: a systematic review and meta-analysis

BACKGROUND

Diabetes self-management education is an essential part of diabetes care, but its impact on all-cause mortality risk of type 2 diabetes patients is unclear. A systematic review and meta-analysis aiming to elucidate the impact of diabetes self-management education on all-cause mortality risk of type 2 diabetes patients was performed.

METHODS

Randomised controlled trials were identified though literature search in Medline, Embase, CENTRAL, conference abstracts, and reference lists. Only randomised controlled trials comparing diabetes self-management education with usual care in type 2 diabetes patients and reporting outcomes after a follow-up of at least 12 months were considered eligible. Risk ratios with 95 %CIs were pooled. This study was registered at PROSPERO with the number of CRD42016043911.

RESULTS

42 randomised controlled trials containing 13,017 participants were included. The mean time of follow-up was 1.5 years. There was no heterogeneity among those included studies (I ² = 0 %). Mortality occurred in 159 participants (2.3 %) in the diabetes self-management education group and in 187 (3.1 %) in the usual care group, and diabetes self-management education significantly reduced risk of all-cause mortality in type 2 diabetes patients (pooled risk ratios : 0.74, 95 %CI 0.60-0.90, P = 0.003; absolute risk difference: -0.8 %, 95 %CI -1.4 to -0.3). Both multidisciplinary team education and nurse-led education could significantly reduce mortality risk in type 2 diabetes patients, and the pooled risk ratios were 0.66 (95 %CI 0.46-0.96, P = 0.02; I ² = 0 %) and 0.64 (95 % CI 0.47- 0.88, P = 0.005; I ² = 0 %), respectively. Subgroup analyses of studies with longer duration of follow-up (≥1.5 years) or larger sample size (≥300) also found a significant effect of diabetes self-management education in reducing mortality risk among type 2 diabetes. Significant effect of diabetes self-management education in reducing mortality risk was also found in those patients receiving diabetes self-management education with contact hours more than 10 h (pooled risk ratio: 0.60, 95 %CI 0.44-0.82, P = 0.001; I ² = 0 %), those receiving repeated diabetes self-management education (pooled RR: 0.71, P = 0.001; I ² = 0 %), those receiving diabetes self-management education using structured curriculum (pooled risk ratio: 0.72, P = 0.01; I ² = 0 %) and those receiving diabetes self-management education using in-person communication (pooled risk ratio: 0.75, P = 0.02; I ² = 0 %). The quality of evidence for the effect of diabetes self-management education in reducing all-cause mortality risk among type 2 diabetes patients was rated as moderate according to the Grading of Recommendations Assessment, Development, and Evaluation method, and the absolute risk reduction of all-cause mortality of type 2 diabetic patients by diabetes self-management education was estimated to be 4 fewer per 1000 person-years (from 1 fewer to 6 fewer).

CONCLUSIONS

The available evidence suggests that diabetes self-management education can reduce all-cause mortality risk in type 2 diabetes patients. Further clinical trials with longer time of follow-up are needed to validate the finding above.

High Fasting Plasma Glucose, Diabetes, and Its Risk Factors in the Eastern Mediterranean Region, 1990-2013: Findings From the Global Burden of Disease Study 2013

OBJECTIVE

The prevalence of diabetes in the Eastern Mediterranean Region (EMR) is among the highest in the world. We used findings from the Global Burden of Disease 2013 study to calculate the burden of diabetes in the EMR.

RESEARCH DESIGN AND METHODS

The burden of diabetes and burden attributable to high fasting plasma glucose (HFPG) were calculated for each of the 22 countries in the EMR between 1990 and 2013. A systematic analysis was performed on mortality and morbidity data to estimate prevalence, deaths, and disability-adjusted life years (DALYs).

RESULTS

The diabetes death rate increased by 60.7%, from 12.1 per 100,000 population (95% uncertainty interval [UI]: 11.2-13.2) in 1990 to 19.5 per 100,000 population (95% UI: 17.4-21.5) in 2013. The diabetes DALY rate increased from 589.9 per 100,000 (95% UI: 498.0-698.0) in 1990 to 883.5 per 100,000 population (95% UI: 732.2-1,051.5) in 2013. In 2013, HFPG accounted for 4.9% (95% UI: 4.4-5.3) of DALYs from all causes. Total DALYs from diabetes increased by 148.6% during 1990-2013; population growth accounted for a 62.9% increase, and aging and increase in age-specific DALY rates accounted for 31.8% and 53.9%, respectively.

CONCLUSIONS

Our findings show that diabetes causes a major burden in the EMR, which is increasing. Aging and population growth do not fully explain this increase in the diabetes burden. Programs and policies are urgently needed to reduce risk factors for diabetes, increase awareness of the disease, and improve diagnosis and control of diabetes to reduce its burden.

Self-Monitoring of Blood Glucose: Impact of Quantity Limits in Public Drug Formularies on Provincial Costs Across Canada

OBJECTIVES

For most patients with diabetes, routine use of blood glucose test strips (BGTS) has not been shown to be beneficial, yet the economic implications of broad publicly funded reimbursement for BGTS are substantial. We assessed the potential impact of BGTS quantity limits on utilization and costs for 6 publicly funded drug plans across Canada.

METHODS

A cross-sectional analysis was conducted in 6 provinces (Alberta, Saskatchewan, Manitoba, Nova Scotia, Newfoundland and Labrador and Prince Edward Island) for patients who received at least 1 prescription for BGTS in 2014 through the public drug program. We determined the number of BGTS that would have exceeded the quantity limits and the associated costs to the provincial drug program.

RESULTS

A total of $38,051,026 was spent on BGTS reimbursed through public drug programs among the 6 provinces. In provinces where BGTS use is largely restricted to patients using insulin, the potential annual savings were minimal, ranging from 0.4% to 2.3%, whereas in provinces with more liberal listings, potential savings ranged from 12.4% to 19.8%. Combining these results with data from a previous analysis in Ontario and British Columbia, the cost savings associated with BGTS quantity limits for 8 provinces across Canada (capturing approximately three-quarters of the Canadian population) is estimated to be $30.3 million annually.

CONCLUSIONS

The national implementation of a quantity limit policy for BGTS that aligns with evidence of efficacy, optimal prescribing and patient safety can lead to considerable savings for most public drug plans across Canada.

PREVIEW Behavior Modification Intervention Toolbox (PREMIT): A Study Protocol for a Psychological Element of a Multicenter Project

BACKGROUND

Losing excess body weight and preventing weight regain by changing lifestyle is a challenging but promising task to prevent the incidence of type-2 diabetes. To be successful, it is necessary to use evidence-based and theory-driven interventions, which also contribute to the science of behavior modification by providing a deeper understanding of successful intervention components.

OBJECTIVE

To develop a physical activity and dietary behavior modification intervention toolbox (PREMIT) that fulfills current requirements of being theory-driven and evidence-based, comprehensively described and feasible to evaluate. PREMIT is part of an intervention trial, which aims to prevent the onset of type-2 diabetes in pre-diabetics in eight clinical centers across the world by guiding them in changing their physical activity and dietary behavior through a group counseling approach.

METHODS

The program development took five progressive steps, in line with the Public Health Action Cycle: (1) Summing-up the intervention goal(s), target group and the setting, (2) uncovering the generative psychological mechanisms, (3) identifying behavior change techniques and tools, (4) preparing for evaluation and (5) implementing the intervention and assuring quality.

RESULTS

PREMIT is based on a trans-theoretical approach referring to valid behavior modification theories, models and approaches. A major "product" of PREMIT is a matrix, constructed for use by onsite-instructors. The matrix includes objectives, tasks and activities ordered by periods. PREMIT is constructed to help instructors guide participants' behavior change. To ensure high fidelity and adherence of program-implementation across the eight intervention centers standardized operational procedures were defined and "train-the-trainer" workshops were held. In summary PREMIT is a theory-driven, evidence-based program carefully developed to change physical activity and dietary behaviors in pre-diabetic people.

Benefits of Diabetes Self-Management for Health Plan Members: A 6-Month Translation Study

Background

Diabetes self-management education has been shown to be effective in controlled trials. However, few programs that meet American Association of Diabetes Educators standards have been translated into widespread practice.

Objective

This study examined the translation of the evidence-based Better Choices, Better Health-Diabetes program in both Internet and face-to-face versions.

Methods

We administered the Internet program nationally in the United States (n=1010). We conducted face-to-face workshops in Atlanta, Georgia; Indianapolis, Indiana; and St. Louis, Missouri (n=232). Self-report questionnaires collected health indicator, health behavior, and health care utilization measures. Questionnaires were administered on the Web or by mail. We determined hemoglobin A_1c (HbA_1c) from blood samples collected via mailed kits. Paired t tests determined whether changes between baseline and 6 months differed significantly from no change. Subgroup analyses determined whether participants with specific conditions benefited (high HbA_1c, depression, hypoglycemia, nonadherence to medication taking, and no aerobic exercise). We calculated the percentage of participants with improvements of at least 0.4 effect size in at least one of the 5 above measures.

Results

Of the 1242 participants, 884 provided 6-month follow-up questionnaires. There were statistically significant improvements in 6 of 7 health indicators (including HbA_1c) and in 7 of 7 behaviors. For each of the 5 conditions, there were significant improvements among those with the condition (effect sizes 0.59–1.1). A total of 662 (75.0%) of study participants improved at least 0.4 effect size in at least one criterion, and 327 (37.1%) improved in 2 or more.

Conclusions

The Diabetes Self-Management Program, offered in two modes, was successfully disseminated to a heterogeneous national population of members of either insured or administered health plans. Participants had small but significant benefits in multiple measures. The program appears effective in improving diabetes management.

Educational attainment moderates the associations of diabetes education with health outcomes

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

The Italian Diabetes and Exercise Study 2 (IDES-2): a long-term behavioral intervention for adoption and maintenance of a physically active lifestyle

BACKGROUND

Physical activity (PA)/exercise have become an integral part of the management of type 2 diabetes mellitus (T2DM). However, current guidelines are difficult to put into action in this population due to a number of barriers, especially the lack of acceptable, feasible, and validated behavioral intervention strategies. The present manuscript reports the rationale, study design and methods, and design considerations of the Italian Diabetes and Exercise Study (IDES)-2, a randomized controlled trial testing the efficacy of a behavior change strategy in increasing total daily PA and reducing sedentary time (SED-time) in patients with T2DM.

METHODS/DESIGN

Starting 7 January 2014, the IDES_2 began enrolling 300 patients with known T2DM of at least 1-year duration in three tertiary referral outpatient Diabetes Clinics in Rome. Additional requirements are age 40 to 80 years, body mass index 27 to 40 kg/m(2), sedentary lifestyle, and physically inactive for at least 6 months, ability to walk 1.6 km without assistance, and eligibility after cardiovascular evaluation. Patients are randomized by center and within each center, by age and type of diabetes treatment to either the intervention or the control group. Patients in the intervention (INT) group (n = 150) receive theoretical and practical exercise counseling consisting of aggregated behavior change techniques (one individual theoretical counseling session plus eight twice-a-week individual theoretical and practical exercise counseling sessions) once a year for 3 years. Patients in the control (CON) group (n = 150), receive standard care, including general physician recommendations for daily PA. The primary outcomes are total daily PA and SED-time, as measured objectively by the use of an accelerometer. Secondary outcomes include physical fitness, modifiable cardiovascular risk factors, musculoskeletal disturbances, well-being/depression, and health-related quality of life.

DISCUSSION

The behavioral intervention strategy tested in the IDES_2 is based on solid theoretical grounds and uses several behavioral change techniques, two factors which were found to improve effectiveness of behavioral intervention. In addition, physicians and exercise specialists have been specifically trained for counselling/prescribing and supervising PA/exercise, respectively, in subjects suffering from metabolic disorders. Finally, the large sample size, the long study duration, and the objective measurement of PA allow statistically significant and scientifically robust conclusions to be drawn on the feasibility and efficacy of this intervention in T2DM patients.

TRIAL REGISTRATION

ClinicalTrials.gov; NCT01600937 ; 10 October 2012.