A randomised controlled clinical trial of nurse-, dietitian- and pedagogist-led Group Care for the management of Type 2 diabetes

Effectiveness of a dietician-led intervention in reducing glycated haemoglobin among people with type 2 diabetes in Nepal: a single centre, open-label, randomised controlled trial

Background

Nutrition education and counselling are considered a cornerstone for the management of type 2 diabetes (T2D). However, there is limited research related to the management of T2D through dietary approach, particularly in low-income and middle-income countries (LMICs) like Nepal. This study assessed the effectiveness of a dietician-led dietary intervention in reducing glycated haemoglobin (HbA1c) levels among people with T2D.

Methods

An open-label, two-armed, hospital-based, randomised controlled trial was conducted at Tribhuvan University Teaching Hospital, Kathmandu, Nepal. Participants were randomly assigned to either dietician-led dietary intervention group (n = 78) or usual care control group (n = 78). People with type 2 diabetes with HbA1c >6.5% and aged 24-64 years were included in the study. The primary outcome was a change in HbA1c level over six months, and secondary outcomes included changes in biochemical and clinical parameters, Problem Areas in Diabetes (PAID) score, diabetic knowledge, dietary adherence, and macronutrient intake level. Data were analysed using an intention-to-treat approach. This trial is registered with ClinicalTrials.gov, NCT04267367.

Findings

Between August 15, 2021 and February 25, 2022, 156 people with type 2 diabetes were recruited for the study, of which 136 participants completed the trial. At six months of follow-up, compared to baseline values, the mean HbA1c (%) level decreased in the intervention group by 0.48 (95% CI: -0.80 to -0.16), while it increased in the control group by 0.22 (95% CI: -0.21 to 0.66). In an adjusted model, the reduction in HbA1c (%) levels for the intervention was 0.61 (95% CI: -1.04 to -0.17; p = 0.006). In addition, fasting blood glucose was decreased by 18.96 mg/dL (95% CI: -36.12 to -1.81; p = 0.031) after the intervention. The intervention resulted in the reduction of BMI, waist and hip circumference, PAID score, dietary adherence, and macronutrient intake in the intervention group compared to the control group.

Interpretation

The dietician-led intervention improved glycaemic control, improved macronutrient intake, and clinical outcomes among people with type 2 diabetes. The dietician-led intervention may be considered for diabetes management in LMICs.

Funding

The research was funded by the University Grants Commission (UGC), Nepal.

Quality improvement strategies for diabetes care: Effects on outcomes for adults living with diabetes

BACKGROUND

There is a large body of evidence evaluating quality improvement (QI) programmes to improve care for adults living with diabetes. These programmes are often comprised of multiple QI strategies, which may be implemented in various combinations. Decision-makers planning to implement or evaluate a new QI programme, or both, need reliable evidence on the relative effectiveness of different QI strategies (individually and in combination) for different patient populations.

OBJECTIVES

To update existing systematic reviews of diabetes QI programmes and apply novel meta-analytical techniques to estimate the effectiveness of QI strategies (individually and in combination) on diabetes quality of care.

SEARCH METHODS

We searched databases (CENTRAL, MEDLINE, Embase and CINAHL) and trials registers (ClinicalTrials.gov and WHO ICTRP) to 4 June 2019. We conducted a top-up search to 23 September 2021; we screened these search results and 42 studies meeting our eligibility criteria are available in the awaiting classification section.

SELECTION CRITERIA

We included randomised trials that assessed a QI programme to improve care in outpatient settings for people living with diabetes. QI programmes needed to evaluate at least one system- or provider-targeted QI strategy alone or in combination with a patient-targeted strategy. - System-targeted: case management (CM); team changes (TC); electronic patient registry (EPR); facilitated relay of clinical information (FR); continuous quality improvement (CQI). - Provider-targeted: audit and feedback (AF); clinician education (CE); clinician reminders (CR); financial incentives (FI). - Patient-targeted: patient education (PE); promotion of self-management (PSM); patient reminders (PR). Patient-targeted QI strategies needed to occur with a minimum of one provider or system-targeted strategy.

DATA COLLECTION AND ANALYSIS

We dual-screened search results and abstracted data on study design, study population and QI strategies. We assessed the impact of the programmes on 13 measures of diabetes care, including: glycaemic control (e.g. mean glycated haemoglobin (HbA1c)); cardiovascular risk factor management (e.g. mean systolic blood pressure (SBP), low-density lipoprotein cholesterol (LDL-C), proportion of people living with diabetes that quit smoking or receiving cardiovascular medications); and screening/prevention of microvascular complications (e.g. proportion of patients receiving retinopathy or foot screening); and harms (e.g. proportion of patients experiencing adverse hypoglycaemia or hyperglycaemia). We modelled the association of each QI strategy with outcomes using a series of hierarchical multivariable meta-regression models in a Bayesian framework. The previous version of this review identified that different strategies were more or less effective depending on baseline levels of outcomes. To explore this further, we extended the main additive model for continuous outcomes (HbA1c, SBP and LDL-C) to include an interaction term between each strategy and average baseline risk for each study (baseline thresholds were based on a data-driven approach; we used the median of all baseline values reported in the trials). Based on model diagnostics, the baseline interaction models for HbA1c, SBP and LDL-C performed better than the main model and are therefore presented as the primary analyses for these outcomes. Based on the model results, we qualitatively ordered each QI strategy within three tiers (Top, Middle, Bottom) based on its magnitude of effect relative to the other QI strategies, where 'Top' indicates that the QI strategy was likely one of the most effective strategies for that specific outcome. Secondary analyses explored the sensitivity of results to choices in model specification and priors.  Additional information about the methods and results of the review are available as Appendices in an online repository. This review will be maintained as a living systematic review; we will update our syntheses as more data become available.

MAIN RESULTS

We identified 553 trials (428 patient-randomised and 125 cluster-randomised trials), including a total of 412,161 participants. Of the included studies, 66% involved people living with type 2 diabetes only. Participants were 50% female and the median age of participants was 58.4 years. The mean duration of follow-up was 12.5 months. HbA1c was the commonest reported outcome; screening outcomes and outcomes related to cardiovascular medications, smoking and harms were reported infrequently. The most frequently evaluated QI strategies across all study arms were PE, PSM and CM, while the least frequently evaluated QI strategies included AF, FI and CQI. Our confidence in the evidence is limited due to a lack of information on how studies were conducted.  Four QI strategies (CM, TC, PE, PSM) were consistently identified as 'Top' across the majority of outcomes. All QI strategies were ranked as 'Top' for at least one key outcome. The majority of effects of individual QI strategies were modest, but when used in combination could result in meaningful population-level improvements across the majority of outcomes. The median number of QI strategies in multicomponent QI programmes was three.  Combinations of the three most effective QI strategies were estimated to lead to the below effects:  - PR + PSM + CE: decrease in HbA1c by 0.41% (credibility interval (CrI) -0.61 to -0.22) when baseline HbA1c < 8.3%; - CM + PE + EPR: decrease in HbA1c by 0.62% (CrI -0.84 to -0.39) when baseline HbA1c > 8.3%;  - PE + TC + PSM: reduction in SBP by 2.14 mmHg (CrI -3.80 to -0.52) when baseline SBP < 136 mmHg; - CM + TC + PSM: reduction in SBP by 4.39 mmHg (CrI -6.20 to -2.56) when baseline SBP > 136 mmHg;  - TC + PE + CM: LDL-C lowering of 5.73 mg/dL (CrI -7.93 to -3.61) when baseline LDL < 107 mg/dL; - TC + CM + CR: LDL-C lowering by 5.52 mg/dL (CrI -9.24 to -1.89) when baseline LDL > 107 mg/dL. Assuming a baseline screening rate of 50%, the three most effective QI strategies were estimated to lead to an absolute improvement of 33% in retinopathy screening (PE + PR + TC) and 38% absolute increase in foot screening (PE + TC + Other).

AUTHORS' CONCLUSIONS

There is a significant body of evidence about QI programmes to improve the management of diabetes. Multicomponent QI programmes for diabetes care (comprised of effective QI strategies) may achieve meaningful population-level improvements across the majority of outcomes. For health system decision-makers, the evidence summarised in this review can be used to identify strategies to include in QI programmes. For researchers, this synthesis identifies higher-priority QI strategies to examine in further research regarding how to optimise their evaluation and effects. We will maintain this as a living systematic review.

Cost-effectiveness of multicomponent interventions in type 2 diabetes mellitus in a cluster randomised controlled trial: the INDICA study

OBJECTIVE

To analyse the cost-effectiveness of multicomponent interventions designed to improve outcomes in type 2 diabetes mellitus (T2DM) in primary care in the Canary Islands, Spain, within the INDICA randomised clinical trial, from the public health system perspective.

DESIGN

An economic evaluation was conducted for the within-trial period (2 years) comparing the four arms of the INDICA study.

SETTING

Primary care in the Canary Islands, Spain.

PARTICIPANTS

2334 patients with T2DM without complications were included.

INTERVENTIONS

Interventions for patients (PTI), for primary care professionals (PFI), for both (combined intervention arm for patients and professionals, CBI) and usual care (UC) as a control group.

OUTCOMES

The main outcome was the incremental cost per quality-adjusted life-years (QALY). Only the intervention and the healthcare costs were included.

ANALYSIS

Multilevel models were used to estimate results, and to measure the size and significance of incremental changes. Missed values were treated by means of multiple imputations procedure.

RESULTS

There were no differences between arms in terms of costs (p=0.093), while some differences were observed in terms of QALYs after 2 years of follow-up (p=0.028). PFI and CBI arms were dominated by the other two arms, PTI and UC. The differences between the PTI and the UC arms were very small in terms of QALYs, but significant in terms of healthcare costs (p=0.045). The total cost of the PTI arm (€2571, 95% CI €2317 to €2826) was lower than the cost in the UC arm (€2750, 95% CI €2506 to €2995), but this difference did not reach statistical significance. Base case estimates of the incremental cost per QALY indicate that the PTI strategy was the cost-effective option.

CONCLUSIONS

The INDICA intervention designed for patients with T2DM and families is likely to be cost-effective from the public healthcare perspective. A cost-effectiveness model should explore this in the long term.

TRIAL REGISTRATION NUMBER

NCT01657227.

Self-management in patients with type 2 diabetes: Group-based versus individual education. A systematic review with meta-analysis of randomized trails

AIM

Patient education is an essential component of the treatment of type 2 diabetes mellitus (T2DM). The present meta-analysis was aimed at verifying the efficacy of group-based versus individual education for self-management in patients with T2DM.

DATA SYNTHESIS

A Medline and Embase search up to January 1st, 2021, was performed, including Randomized Controlled Trials (RCT) with duration>6 months, enrolling patients with T2DM and comparing individual-based with group-based educational programs. The primary outcome was endpoint HbA1c; secondary endpoints were lipid profile, body weight, blood pressure, patients' adherence/knowledge, and quality of life. The weighed difference in means (WMD) and Mantel-Haenzel Odds Ratio (MH-OR), with 95% Confidence Interval (CI), were calculated. We retrieved 14 RCT. No significant between-group difference in HbA1c (WMD -0.39[-0.89; 0.09] mmol/mol, p = 0.11) was observed. At metaregression analyses, longer trial duration, higher baseline mean age and duration of diabetes, and lower baseline HbA1c were correlated with greater efficacy of group-based programs in reducing HbA1c. When analyzed separately, trials excluding insulin-treated patients showed a significant reduction of HbA1c in favor of group education.

CONCLUSIONS

In patients with T2DM, group education has similar efficacy as individual education on glucose control. Group programs are associated with an improved quality of life and patients' knowledge.

PROSPERO AND OSF REGISTRATION

ID243149.

Dietary Management of Type 2 Diabetes in the MENA Region: A Review of the Evidence

The alarmingly rising trend of type 2 diabetes constitutes a major global public health challenge particularly in the Middle Eastern and North African (MENA) region where the prevalence is among the highest in the world with a projection to increase by 96% by 2045. The economic boom in the MENA region over the past decades has brought exceptionally rapid shifts in eating habits characterized by divergence from the traditional Mediterranean diet towards a more westernized unhealthy dietary pattern, thought to be leading to the dramatic rises in obesity and non-communicable diseases. Research efforts have brought a greater understanding of the different pathways through which diet and obesity may affect diabetes clinical outcomes, emphasizing the crucial role of dietary interventions and weight loss in the prevention and management of diabetes. The purpose of this review is to explore the mechanistic pathways linking obesity with diabetes and to summarize the most recent evidence on the association of the intake of different macronutrients and food groups with the risk of type 2 diabetes. We also summarize the most recent evidence on the effectiveness of different macronutrient manipulations in the prevention and management of diabetes while highlighting the possible underlying mechanisms of action and latest evidence-based recommendations. We finally discuss the need to adequately integrate dietetic services in diabetes care specific to the MENA region and conclude with recommendations to improve dietetic care for diabetes in the region.

Self-management education may improve blood pressure in people with type 2 diabetes. A randomized controlled clinical trial

BACKGROUND AND AIMS

Diabetes is a suitable model to evaluate intervention programmes aimed at chronic diseases, because of its well-defined and measurable process and outcome indicators. In this study, we aimed at investigating the effects of group based self-management education on clinical and psychological variables in type 2 diabetes.

METHODS AND RESULTS

Four-year randomized controlled clinical trial (ISRCTN14558376) comparing Group Care and traditional one-to-one care. Clinical and psychological variables were monitored at baseline, 2 and 4 years. Although differences between groups appear to be non-significant at univariate analysis, body weight, BMI and HbA1c, systolic and diastolic blood pressure improved in the patients followed by Group Care but not among Controls. Prescription of lipid-lowering and anti-hypertensive agents did not change among the patients on Group Care, whereas anti-hypertensives were stepped up among Controls without improving their blood pressure. Multivariable analysis suggests that blood pressure improvement among patients on Group Care was independent of BMI, duration of diabetes and antihypertensive medication, suggesting a direct effect of education, presumably by increasing adherence. The "Powerful Others" dimension of the Locus of Control worsened and fear of complications decreased among Controls.

CONCLUSIONS

The results confirm that a multidisciplinary structured group educational approach improves blood pressure, presumably through better adherence to healthy lifestyle and medication, in people with type 2 diabetes.

CLINICAL TRIAL REGISTRATION NUMBER

ISRCTN14558376.

Replicating group-based education interventions for the management of type 2 diabetes: a review of intervention reporting

AIMS

To assess the completeness of reporting of group-based education interventions for the management of type 2 diabetes.

METHODS

A previous systematic review of group-based education programmes for adults with type 2 diabetes identified eligible intervention studies. Data were extracted and assessed using the Template for Intervention Description and Replication ('TIDieR') checklist. Missing data were sourced from other published material, or by contacting authors.

RESULTS

Fifty-three publications describing 47 studies were included. No publications sufficiently described all items. Authors of 43 of the 47 included studies (91%) were contacted via e-mail to obtain missing data in order to complete the TIDieR checklist. Seven (16%) did not respond. Additional data were obtained for 33/47 studies (70%). Most studies (45/47, 96%) described the intervention duration and frequency, detailed the procedures and rationale (40/47, 85%), provided a brief intervention name and explained any individual tailoring (38/47, 81%), defined whether providers received training and adequately described how the programme was delivered (37/47, 79%). However, few described any modifications (28/47, 60%), whether the intervention was delivered as planned (27/47, 57%), where it was delivered (21/47, 45%), whether materials were provided (19/47, 40%), and who delivered the intervention (13/47, 28%).

CONCLUSIONS

Group-based education interventions for the management of type 2 diabetes are poorly reported. To translate effective research into practice, practitioners need sufficient detail to implement evidence-based interventions. Researcher adoption of the TIDieR checklist will assist the translation and replication of published interventions.

Dietitians' experiences and perspectives regarding access to and delivery of dietetic services for people with type 2 diabetes mellitus

AIMS

Dietetic intervention improves glycaemic control of type 2 diabetes mellitus (T2DM). The aim of this study was to explore the views of Australian dietitians with respect to the nutritional management of people with T2DM, patient access to dietitians and any suggested improvements for access to and delivery of dietetic services.

METHODS

Semi-structured interviews were conducted via telephone with 31 dietitians counselling people with T2DM and consulting a minimum of two sessions per week in private and/or non-private practice.

RESULTS

Participants came from urban and rural areas, public and private practice and with a range of years of practice. Themes that emerged from the interviews included the importance of dietetic services for people with T2DM; the referral pathways and beliefs about lack of referrals to dietitians; the perceptions on adequacy of the current dietetic services available for people with T2DM; and the recommendations on services available for people with T2DM.

CONCLUSION

Considering the evidence that diet is key in the prevention and management of T2DM, it is suggested current funding and service provision be reviewed with a focus on treating the aetiology of diabetes.

The dietetic workforce distribution geographic atlas provides insight into the inequitable access for dietetic services for people with type 2 diabetes in Australia

AIM

Dietetic intervention delivered by Accredited Practising Dietitians is demonstrated to improve clinical outcomes of type 2 diabetes. The aim of the present study was to assess the accessibility to dietetic intervention for people with type 2 diabetes in Australia.

METHODS

Prevalence data and dietitian workforce distribution data were sourced from Diabetes Australia and Dietitians Association of Australia, respectively. Geographical information system mapping and statistical analysis were used to compare the ratios of dietitians to people with type 2 diabetes across the states of Australia and by index of socio-economic advantage and disadvantage in each state.

RESULTS

An inequitable distribution of the dietetic workforce and that of the people with type 2 diabetes across Australia was demonstrated. An uneven distribution of the workforce is evidenced across states when compared to the distribution of type 2 diabetes prevalence; with New South Wales having a better ratio than Victoria and South Australia. Maps and prevalence data revealed the dietetic workforce was mostly concentrated in affluent urban centres whereas the type 2 diabetes prevalence rates were higher in rural and remote areas and in areas of lower socio-economic status.

CONCLUSIONS

This research highlights the need to address the limited access to dietetic intervention for those in rural, remote and disadvantaged areas which also have the greatest need. The financial burden of treating diabetic complications on the national health budget necessitates government initiatives. These should include better use of telehealth dietetic consultations and incentives for dietitians to work in rural, remote and disadvantaged areas.

Brief Report: Integration of PrEP Services Into Routine Antenatal and Postnatal Care: Experiences From an Implementation Program in Western Kenya

BACKGROUND

Programmatic approaches for delivering pre-exposure prophylaxis (PrEP) to pregnant and postpartum women in settings with high HIV burden are undefined. The PrEP Implementation for Young Women and Adolescents (PrIYA) Program developed approaches for delivering PrEP in maternal child health (MCH) clinics.

METHODS

Under the PrIYA Program, nurse-led teams worked with MCH staff at 16 public, faith-based, and private facilities in Kisumu, Kenya, to determine optimal clinic flow for PrEP integration into antenatal care (ANC) and postnatal care (PNC). A program-dedicated nurse facilitated integration. HIV-uninfected women were screened for behavioral risk factors; same-day PrEP was provided to interested and medically eligible women. PrEP and MCH services were evaluated using standardized flow mapping and time-and-motion surveys.

RESULTS

Clinics developed 2 approaches for integrating PrEP delivery within ANC/PNC: (1) co-delivery: ANC/PNC and PrEP services delivered by same MCH nurse or (2) sequential services: PrEP services after ANC/PNC by a PrEP-specialized nurse. Three clinics selected co-delivery and 13 sequential services, based on patient volume and space availability. Overall, 86 ANC/PNC visits were observed. Clients who initiated PrEP took a median of 18 minutes (interquartile range 15-26) for PrEP-related activities (risk assessment, PrEP counseling, creatinine testing, dispensation, and documentation) in addition to other routine ANC/PNC activities. For clients who declined PrEP, an additional 13 minutes (interquartile range 7-15) was spent on PrEP-related risk assessment and counseling.

CONCLUSIONS

PrEP delivery within MCH used co-delivery or sequential approaches. The moderate additional time burden for PrEP initiation in MCH would likely decline with community awareness and innovations such as group/peer counseling or expedited dispensing.

The health effects of medical nutrition therapy by dietitians in patients with diabetes: A systematic review and meta-analysis: Nutrition therapy and diabetes

AIMS

Intensive lifestyle, dietary interventions and patient education have been recommended as key milestones in to facilitate the management of Diabetes and contain the growing incidence. We performed a systematic review and meta-analysis to assess the health benefits of medical nutrition therapy among patients with diabetes.

DESIGN

A systematic search was performed in MEDLINE/PubMed, SCOPUS, and Cochrane library from onset up to February 2019 to identify trials investigating the health effect of Medical nutrition (MNT) in patients with diabetes. Random-effects models were used to calculate the effect sizes as weighted mean difference (WMD) and 95% confidence intervals (CI).

RESULTS

Eleven studies containing 1227 participants were included in the meta-analysis. Pooled results showed a significant reduction in Fasting blood sugar (FBS) (WMD= -8.85mg/dl, 95% CI: -14.41, -3.28), HbA1c (WMD: -0.43%, 95% CI: -0.69, -0.17), weight (WMD: -1.54kg, 95% CI: -2.44, -0.64), Body mass index (BMI) (WMD: -0.34 Kg/m2, 95% CI: -0.52, -0.17), waist circumference (WMD: -2.16cm, 95% CI: -4.09, -0.23), cholesterol (WMD: -4.06mg/dl, 95% CI: -7.31, -0.81), Systolic blood pressure (SBP) (WMD: -7.90mmHg, 95% CI: -13.03, -2.77). Results of meta-regression analysis based on age of participants and duration of intervention were not significant.

CONCLUSIONS

Patients with diabetes who received medical nutrition therapy showed significant improvements in outcome measures of FBS, HbA1c, weight, BMI, waist circumference, cholesterol, and SBP.

Feasibility and efficacy of nurse-led team management intervention for improving the self-management of type 2 diabetes patients in a Chinese community: a randomized controlled trial

AIM

The aim of this study was to examine the feasibility and efficacy of nurse-led team management (NLTM) intervention at improving the self-management of patients with type 2 diabetes (T2D) at community settings in Changsha, Hunan, China.

BACKGROUND

China has become the country with the largest number of patients with diabetes, and that number is growing, causing increasing pressure on the health care system. At present, the main diabetes management model in China is teamwork guided by general practitioners. However, the number of general practitioners is insufficient, and their work is overloaded, which leads to poor outcomes of diabetes management. Therefore, it is important to explore alternative methods of diabetes management, such as NLTM.

PATIENTS AND METHODS

In a randomized controlled trial, 171 T2D patients were randomized into the control or intervention arm. Participants in the control group received routine management from the community health service center, whereas the intervention group received 12 months NLTM intervention in addition to the standard care. The diabetes self-management scale, fasting blood sugar, and glycosylated hemoglobin A1c (HbA1c) were assessed at baseline and at 6 and 12 months after the start of the intervention.

RESULTS

Baseline data were comparable between arms. Repeated-measurement analysis showed that self-management of the intervention group improved compared with the control group after the intervention (P<0.05). There were no significant differences in HbA1c at 6 months, whereas after 12 months of intervention, there was a significant difference in HbA1c between the two groups (F=10.114, P<0.05). The intervention had no significant effect on fasting blood sugar.

CONCLUSION

The NLTM intervention has resulted in an impact of practical significance on T2D self-management, and was beneficial for controlling the level of HbA1c. The study has demonstrated the feasibility and efficacy of using NLTM in the management of T2D in a Chinese community.

Effect of Medical Nutrition Therapy for Patients With Type 2 Diabetes in a Low-/No-Cost Clinic: A Propensity Score-Matched Cohort Study

BACKGROUND

Although many studies have been conducted regarding the effectiveness of medical nutrition therapy (MNT) for type 2 diabetes management, less is known about the effectiveness of MNT for low-income adults. This study evaluated the contribution of MNT in improving A1C and blood pressure in a population of low-income adults with type 2 diabetes.

METHODS

This was a population-based, propensity score-matched cohort study using provincial health data from Altoona, Blair County, Pa. Patients who had been diagnosed with type 2 diabetes for at least 6 months before March 2014 were selected from two separate clinics that serve low-income populations. Patients who received MNT (n = 81) from a registered dietitian were compared to a matched group of patients who received primary care alone (n = 143). Outcome measures were A1C and systolic and diastolic blood pressure. The follow-up period was 1 year.

RESULTS

Improvements in A1C and systolic and diastolic blood pressure were statistically significant for patients who received MNT at uniform 3-month intervals through 1 year. At the 1-year follow-up, A1C reduction was -0.8% (P <0.01), systolic blood pressure reduction was -8.2 mmHg (P <0.01), and diastolic blood pressure reduction was -4.3 mmHg (P <0.05).

CONCLUSION

Although low-income individuals encounter a variety of barriers that reduce their capacity for success with and adherence to MNT, provision of nutrition therapy services by a registered dietitian experienced in addressing these barriers can be an effective addition to the existing medical components of type 2 diabetes care.

Role of a registered dietitian in pediatric type 1 and type 2 diabetes

Type 1 and type 2 diabetes are complex, chronic diseases that are best managed by a multidisciplinary care team. Type 1 diabetes is most commonly diagnosed in the pediatric population, although the prevalence of type 2 diabetes in youth is increasing rapidly. A registered dietitian (RD) is a critical member of the diabetes team who provides focused nutrition education from diagnosis and throughout routine follow-up care. Specifically in the pediatric population, the RD also assesses growth and development, as well as eating behaviors, food choices and meal patterns. Based on a review of research, ongoing support from an RD improves glycemic control and delays onset of diabetes complications. In addition, dietitian-led nutrition education helps better manage lipid levels and aids in weight management. A sample model describing RD involvement in a pediatric diabetes care team is discussed in further detail.

WITHDRAWN: Group based diabetes self-management education compared to routine treatment, waiting list control or no intervention for people with type 2 diabetes mellitus

The review authors of this review update are unable to continue with their work. The Cochrane Metabolic and Endocrine Disorders Review Group is seeking very experienced new authors to perform an update on this complex intervention review.

At June 2015, this review has been withdrawn. This review is out of date although it is correct as the date of publication. The latest version is available in the 'Other versions' tab on the Cochrane Library, and may still be useful to readers.

The editorial group responsible for this previously published document have withdrawn it from publication.

Comparison of community health worker-led diabetes medication decision-making support for low-income Latino and African American adults with diabetes using e-health tools versus print materials: a randomized, controlled trial

BACKGROUND

Health care centers serving low-income communities have scarce resources to support medication decision making among patients with poorly controlled diabetes.

OBJECTIVE

To compare outcomes between community health worker use of a tailored, interactive, Web-based, tablet computer-delivered tool (iDecide) and use of print educational materials.

DESIGN

Randomized, 2-group trial conducted from 2011 to 2013 (ClinicalTrials.gov: NCT01427660).

SETTING

Community health center in Detroit, Michigan, serving a Latino and African American low-income population.

PARTICIPANTS

188 adults with a hemoglobin A1c value greater than 7.5% (55%) or those who reported questions, concerns, or difficulty taking diabetes medications.

INTERVENTION

Participants were randomly assigned to receive a 1- to 2-hour session with a community health worker who used iDecide or printed educational materials and 2 follow-up calls.

MEASUREMENTS

Primary outcomes were changes in knowledge about antihyperglycemic medications, patient-reported medication decisional conflict, and satisfaction with antihyperglycemic medication information. Also examined were changes in diabetes distress, self-efficacy, medication adherence, and hemoglobin A1c values.

RESULTS

Ninety-four percent of participants completed 3-month follow-up. Both groups improved across most measures. iDecide participants reported greater improvements in satisfaction with medication information (helpfulness, P = 0.007; clarity, P = 0.03) and in diabetes distress compared with the print materials group (P < 0.001). The other outcomes did not differ between the groups.

LIMITATIONS

The study was conducted at 1 health center during a short period. The community health workers were experienced in behavioral counseling, thereby possibly mitigating the need for additional support tools.

CONCLUSION

Most outcomes were similarly improved among participants receiving both types of decision-making support for diabetes medication. Longer-term evaluations are necessary to determine whether the greater improvements in satisfaction with medication information and diabetes distress achieved in the iDecide group at 3 months translate into better longer-term diabetes outcomes.

PRIMARY FUNDING SOURCE

Agency for Healthcare Research and Quality and National Institute of Diabetes and Digestive and Kidney Diseases.

CenteringPregnancy-Africa: a pilot of group antenatal care to address Millennium Development Goals

BACKGROUND

severe health worker shortages and resource limitations negatively affect quality of antenatal care (ANC) throughout sub-Saharan Africa. Group ANC, specifically CenteringPregnancy (CP), may offer an innovative approach to enable midwives to offer higher quality ANC.

OBJECTIVE

our overarching goal was to prepare to conduct a clinical trial of CenteringPregnancy-Africa (CP-Africa) in Malawi and Tanzania. In Phase 1, our goal was to determine the acceptability of CP as a model for ANC in both countries. In Phase 2, our objective was to develop CP-Africa session content consistent with the Essential Elements of CP model and with national standards in both Malawi and Tanzania. In Phase 3, our objective was to pilot CP-Africa in Malawi to determine whether sessions could be conducted with fidelity to the Centering process.

SETTING

Phases 1 and 2 took place in Malawi and Tanzania. Phase 3, the piloting of two sessions of CP-Africa, occurred at two sites in Malawi: a district hospital and a small clinic.

DESIGN

we used an Action Research approach to promote partnerships among university researchers, the Centering Healthcare Institute, health care administrators, health professionals and women attending ANC to develop CP-Africa session content and pilot this model of group ANC.

PARTICIPANTS

for Phases 1 and 2, members of the Ministries of Health, health professionals and pregnant women in Malawi and Tanzania were introduced to and interviewed about CP. In Phase 2, we finalised CP-Africa content and trained 13 health professionals in the Centering Healthcare model. In Phase 3, we conducted a small pilot with 24 pregnant women (12 at each site).

MEASUREMENTS AND FINDINGS

participants enthusiastically embraced CP-Africa as an acceptable model of ANC health care delivery. The CP-Africa content met both CP and national standards. The pilot established that the CP model could be implemented with process fidelity to the 13 Essential Elements. Several implementation challenges and strategies to address these challenges were identified.

KEY CONCLUSIONS

preliminary data suggest that CP-Africa is feasible in resource-constrained, low-literacy, high-HIV settings in sub-Saharan Africa. By improving the quality of ANC delivery, midwives have an opportunity to make a contribution towards Millennium Development Goals (MDG) targeting improvements in child, maternal and HIV-related health outcomes (MDGs 4, 5 and 6). A clinical trial is needed to establish efficacy.

IMPLICATIONS FOR PRACTICE

CP-Africa also has the potential to reduce job-related stress and enhance job satisfaction for midwives in low income countries. If CP can be transferred with fidelity to process in sub-Saharan Africa and retain similar results to those reported in clinical trials, it has the potential to benefit pregnant women and their infants and could make a positive contribution to MGDs 4, 5 and 6.

Randomized controlled effectiveness trial of reciprocal peer support in heart failure

BACKGROUND

Although disease management programs for patients hospitalized with heart failure (HF) are effective, they are, however, often resource intensive, limiting their uptake. Peer support programs have led to improved outcomes among patients with other chronic conditions and may result in similar improvements for patients with HF.

METHODS AND RESULTS

In this randomized controlled trial, reciprocal peer support (RPS) arm patients participated in a HF nurse practitioner-led goal setting group session, received brief training in peer communication skills, and were paired with another participant in their cohort with whom they were encouraged to talk weekly using a telephone platform. Participants were also encouraged to attend 3 nurse practitioner-facilitated peer support group sessions. Patients in the nurse care management arm attended a nurse practitioner-led session to address their HF care questions and receive HF educational materials and information on how to access care management services. The median age of the patients was 69 years; 51% were female and 26% were racial/ethnic minorities. Only 55% of RPS patients participated in peer calls or group sessions. In intention-to-treat analyses, the RPS and nurse care management groups did not differ in time-to-first all-cause rehospitalization or death or in mean numbers of rehospitalizations or deaths. There were no differences in improvements in 6-month measures of HF-specific quality of life or social support. Conclusions- Among patients recently hospitalized for HF, more than half of RPS participants had no or minimal engagement with the RPS program, and the program did not improve outcomes compared with usual HF nurse care management.

CLINICAL TRIAL REGISTRATION

URL: http://www.clinicaltrials.gov. UNIQUE IDENTIFIER: NCT00508508.

Dietitian-coached management in combination with annual endocrinologist follow up improves global metabolic and cardiovascular health in diabetic participants after 24 months

This 24 month study evaluated the effect of dietitian coaching combined with minimal endocrinologist follow up on the glycemic control and cardiovascular risks of diabetic participants, compared with conventional endocrinologist follow up. Participants with type 1 or type 2 diabetes were assigned to either the control group with conventional endocrinologist follow up (C; n = 50) or the dietitian-coached group (DC; n = 51) with on-site diabetes self-management education every 3 months combined with annual endocrinologist followup. Over the 24 month intervention, weight (–0.7 vs. +2.1 kg; p = 0.04), BMI (+0.3 vs. +0.7 kg/m2; p = 0.009), and waist circumference (–1.3 vs. +2.4 cm; p = 0.01) significantly differed between the DC and control groups. HbA1C dropped significantly in participants of the DC versus the control group (–0.6% vs.–0.3%; p = 0.04). This was accompanied by improved overall energy intake (–548 vs. –74 kcal/day; p = 0.04). However, no link associated glycemic control to nutrient intake or intensiveness of pharmacotherapy. Coaching by a dietitian improves glycemic control and reduces certain cardiovascular risk factors in diabetic subjects, demonstrating that a joint dietitian–endocrinologist model of care provides a convenient strategy for cardiovascular risk management in the diabetic population.

The effectiveness of group medical visits on diabetes mellitus type 2 (dm2) specific outcomes in adults: a systematic review

BACKGROUND

The prevalence of diabetes mellitus is ubiquitous. Complications and costs of diabetes are rising and are depleting limited resources. It is imperative for healthcare professionals and patients alike to confront this chronic condition by exploring new interventions. An innovative health care delivery model has emerged in the last 25 years in the form of the group medical visit. Group medical visits can range from of six to twenty patients scheduled together with time allotted for individual care as well as in the group setting.

OBJECTIVES

The review objective was to conduct a systematic review and meta-analysis to synthesize the best available evidence related to effectiveness of group medical visits on HbA1c, blood pressure and cholesterol measurements/levels for adult patients with type II diabetes in outpatient settings.

SEARCH STRATEGY

A three-step literature search for studies in English language from 1990 to 2010 was conducted utilising (a) a primary search of Medline, CINAHL, PsycINFO and Cochrane Central Register of Controlled Trials, (b) a secondary search of non-indexed databases, and (c) a search of the grey literature. In addition, a manual review of the reference lists of all identified reports and articles was performed to identify additional studies.

INCLUSION CRITERIA

All randomised and quasi-experimental studies of adult patients (>18) with type II diabetes mellitus seen in outpatient health settings were considered if they met one or more of the following diagnostic outcome measurements: haemoglobin A1c, systolic and diastolic blood pressure, and low density lipoprotein cholesterol.

CRITICAL APPRAISAL, DATA COLLECTION AND ANALYSIS

Each of the eligible articles was reviewed by two independent reviewers. Disagreements between the reviewers were resolved through discussion, or with a third reviewer. Studies that met the inclusion criteria were assessed for methodological quality using the JBI standardized critical appraisal tools. Data extraction was undertaken using the standardised data extraction tool from JBI-MAStARI.

MAIN RESULTS

The search strategy identified 2,040 articles in the published and unpublished literature. Of these, 11 randomised controlled trials and 4 quasi-experimental trials met the inclusion criteria and represented 2240 patients included in the final review.There are clear benefits of group medical visits for patients' HbA1c levels which are consistent in the post-intervention and change from baseline effect sizes. The most significant effect observed is with the change from baseline results. Some evidence suggests post-intervention and change from baseline systolic blood pressure improvement at the nine to twelve month interval and change from baseline improvement at the 4 year timeframe. There is no evidence that group visits improve LDL cholesterol values of the group visit participants.

CONCLUSIONS

Group medical visits should be considered by clinicians as an effective non-pharmacologic intervention that can have a positive impact on biologic markers such as haemoglobin A1c and systolic blood pressure.

IMPLICATIONS FOR PRACTICE

The evidence suggests that the most powerful model of Group medical visits (GMV) is when a clinician prescriber is present during or immediately after GMV sessions for medication reconciliation or individual patient needs.

IMPLICATIONS FOR RESEARCH

Future research should include this GMV intervention in randomised controlled trials across different health systems and socio-economic and ethnic groups.

Diabetes control with reciprocal peer support versus nurse care management: a randomized trial

BACKGROUND

Resource barriers complicate diabetes care management. Support from peers may help patients manage their diabetes.

OBJECTIVE

To compare a reciprocal peer-support (RPS) program with nurse care management (NCM).

DESIGN

Randomized, controlled trial. (ClinicalTrials.gov registration number: NCT00320112)

SETTING

2 U.S. Department of Veterans Affairs health care facilities.

PATIENTS

244 men with hemoglobin A(1c) (HbA(1c)) levels greater than 7.5% during the previous 6 months.

MEASUREMENTS

The primary outcome was 6-month change in HbA(1c) level. Secondary outcomes were changes in insulin therapy; blood pressure; and patient reports of medication adherence, diabetes-related support, and emotional distress.

INTERVENTION

Patients in the RPS group attended an initial group session to set diabetes-related behavioral goals, receive peer communication skills training, and be paired with another age-matched peer patient. Peers were encouraged to talk weekly using a telephone platform that recorded call occurrence and provided reminders to promote peer contact. These patients could also participate in optional group sessions at 1, 3, and 6 months. Patients in the NCM group attended a 1.5-hour educational session and were assigned to a nurse care manager.

RESULTS

Of the 244 patients enrolled, 216 (89%) completed the HbA(1c) assessments and 231 (95%) completed the survey assessments at 6 months. Mean HbA(1c) level decreased from 8.02% to 7.73% (change, -0.29%) in the RPS group and increased from 7.93% to 8.22% (change, 0.29%) in the NCM group. The difference in HbA(1c) change between groups was 0.58% (P = 0.004). Among patients with a baseline HbA(1c) level greater than 8.0%, those in the RPS group had a mean decrease of 0.88%, compared with a 0.07% decrease among those in the NCM group (between-group difference, 0.81%; P < 0.001). Eight patients in the RPS group started insulin therapy, compared with 1 patient in the NCM group (P = 0.020). Groups did not differ in blood pressure, self-reported medication adherence, or diabetes-specific distress, but the RPS group reported improvement in diabetes social support.

LIMITATION

The study included only male veterans and lasted only 6 months.

CONCLUSION

Reciprocal peer support holds promise as a method for diabetes care management.