This meta-analysis assessed how successfully Diabetes Self-Management Education (DSME) interventions help people with type 2 diabetes achieve and maintain healthy blood glucose levels. We included 52 DSME programs with 9,631 participants that reported post-intervention A1c levels in randomized controlled trials. The training conditions resulted in significant reductions in A1c levels compared to control conditions. However, the impact of intervention was modest shifting of only 7.23% more participants from diabetic to pre-diabetic or normal status, relative to the control condition. Most intervention participants did not achieve healthy A1c levels. Further, few DSME studies assessed long-term maintenance of A1c gains. Past trends suggest that gains are difficult to sustain over time. Our results suggested that interventions delivered by nurses were more successful than those delivered by non-nursing personnel. We suggest that DSME programs might do better by going beyond procedural interventions. Most DSME programs relied heavily on rules and procedures to guide decisions about diet, exercise, and weight loss. Future DSME may need to include cognitive self-monitoring, diagnosis, and planning skills to help patients detect anomalies, identify possible causes, generate corrective action, and avoid future barriers to maintaining healthy A1c levels. Finally, comprehensive descriptions of DSME programs would advance future efforts. 1. Introduction Diabetes afflicts approximately 25.8 million people in the United States, or 8.3% of the population. Type 2 diabetes, or non-insulin dependent diabetes mellitus (NIDDM), accounts for 90 to 95% of all diagnosed cases of diabetes in adults [1]. The problem is growing, particularly among young people. Over their lifetime, patients experience increased risks of complications including blindness, kidney damage and failure, cardiovascular disease, nerve damage, and lower-limb amputation. A NIH study from 2011 estimated that costs related to the treatment of diabetes accounts for about $174 billion of the national health care annually [1]. Type 2 diabetes complications stem from the inability of the body to use insulin properly, resulting in heightened blood glucose levels [2]. This is measured with the HbA1c test, the percent of glycated hemoglobin in the blood. It is commonly called the A1c. The NIH criterion for diagnosing diabetes is an A1c of 6.5 or higher although this varies somewhat with the individual. Pre-diabetes is between 5.7 and 6.4. A reading below 5.7 is normal [3]. The U.K. Prospective Diabetes Study
References
[1]
National Diabetes Education Program, “Snapshot of diabetes,” 2011, http://ndep.nih.gov/media/fs_gensnapshot.pdf.
[2]
National Institute of Health, “National diabetes statistics, 2011,” 2011, http://diabetes.niddk.nih.gov/dm/pubs/statistics/index.aspx.
[3]
National Institute of Health, “The A1c test and diabetes,” 2011, http://diabetes.niddk.nih.gov/dm/pubs/A1CTest/A1C_Test_DM_508.pdf.
[4]
I. M. Stratton, A. I. Adler, H. A. W. Neil et al., “Association of glycaemia with macrovascular and microvascular complications of type 2 diabetes (UKPDS 35): prospective observational study,” British Medical Journal, vol. 321, no. 7258, pp. 405–412, 2000.
[5]
National Institute of Health, 2012, http://www.nih.gov/.
[6]
American Diabetes Association, 2012, http://www.diabetes.org/.
[7]
American Association of The Diabetes Educators, 2012, http://www.diabeteseducator.org/.
[8]
K. Bunker and Diabetes Forecast, “Blood glucose meters,” 2010, http://forecast.diabetes.org/magazine/features/blood-glucose-meters.
[9]
T. Neithercott and Diabetes Forecast, “New products,” 2009, http://forecast.diabetes.org/magazine/resource-guide/new-products.
[10]
S. E. Ellis, T. Speroff, R. S. Dittus, A. Brown, J. W. Pichert, and T. A. Elasy, “Diabetes patient education: a meta-analysis and meta-regression,” Patient Education and Counseling, vol. 52, no. 1, pp. 97–105, 2004.
[11]
T. L. Gary, J. M. Genkinger, E. Guallar, M. Peyrot, and F. L. Brancati, “Meta-analysis of randomized educational and behavioral interventions in type 2 diabetes,” The Diabetes Educator, vol. 29, no. 3, pp. 488–501, 2003.
[12]
S. L. Norris, J. Lau, S. J. Smith, C. H. Schmid, and M. M. Engelgau, “Self-management education for adults with type 2 diabetes. A meta-analysis of the effect on glycemic control,” Diabetes Care, vol. 25, no. 7, pp. 1159–1171, 2002.
[13]
S. L. Norris, M. M. Engelgau, and K. M. V. Narayan, “Effectiveness of self-management training in type 2 diabetes: a systematic review of randomized controlled trials,” Diabetes Care, vol. 24, no. 3, pp. 561–587, 2001.
[14]
K. Ismail, K. Winkley, and S. Rabe-Hesketh, “Systematic review and meta-analysis of randomised controlled trials of psychological interventions to improve glycaemic control in patients with type 2 diabetes,” The Lancet, vol. 363, no. 9421, pp. 1589–1597, 2004.
[15]
A. K. Sigurdardottir, H. Jonsdottir, and R. Benediktsson, “Outcomes of educational interventions in type 2 diabetes: WEKA data-mining analysis,” Patient Education and Counseling, vol. 67, no. 1-2, pp. 21–31, 2007.
[16]
G. A. D'Eramo-Melkus, J. Wylie-Rosett, and J. A. Hagan, “Metabolic impact of education in NIDDM,” Diabetes Care, vol. 15, no. 7, pp. 864–869, 1992.
[17]
C. Abraham and S. Michie, “A taxonomy of behavior change techniques used in interventions,” Health Psychology, vol. 27, no. 3, pp. 379–387, 2008.
[18]
C. A. Sarkisian, A. F. Brown, K. C. Norris, R. L. Wintz, and C. M. Mangione, “A systematic review of diabetes self-care interventions for older, African American, or Latino adults,” The Diabetes Educator, vol. 29, no. 3, pp. 467–479, 2003.
[19]
E. T. Adolfsson, M. L. Walker-Engstr？m, B. Smide, and K. Wikblad, “Patient education in type 2 diabetes—a randomized controlled 1-year follow-up study,” Diabetes Research and Clinical Practice, vol. 76, no. 3, pp. 341–350, 2007.
[20]
T. D. Agurs-Collins, S. K. Kumanyika, T. R. T. Have, and L. L. Adams-Campbell, “A randomized controlled trial of weight reduction and exercise for diabetes management in older African-American subjects,” Diabetes Care, vol. 20, no. 10, pp. 1503–1511, 1997.
[21]
Y. Amano, M. Sugiyama, J. S. Lee et al., “Glycemic index-based nutritional education improves blood glucose control in Japanese adults: a randomized controlled trial,” Diabetes Care, vol. 30, no. 7, pp. 1874–1876, 2007.
[22]
W. Anderson-Loftin, S. Barnett, P. Bunn, P. Sullivan, J. Hussey, and A. Tavakoli, “Soul food light: Culturally competent diabetes education,” The Diabetes Educator, vol. 31, no. 4, pp. 555–563, 2005.
[23]
D. L. Arseneau, A. C. Mason, O. B. Wood, E. Schwab, and D. Green, “A comparison of learning activity packages and classroom instruction for diet management of patients with non-insulin-dependent diabetes mellitus,” The Diabetes Educator, vol. 20, no. 6, pp. 509–514, 1994.
[24]
N. D. Barnard, J. Cohen, D. J. A. Jenkins et al., “A low-fat vegan diet improves glycemic control and cardiovascular risk factors in a randomized clinical trial in individuals with type 2 diabetes,” Diabetes Care, vol. 29, no. 8, pp. 1777–1783, 2006.
[25]
S. A. Brown, A. A. Garcia, K. Kouzekanani, and C. L. Hanis, “Culturally competent diabetes self-management education for Mexican Americans: the Starr County border health initiative,” Diabetes Care, vol. 25, no. 2, pp. 259–268, 2002.
[26]
E. M. Campbell, S. Redman, P. S. Moffitt, and R. W. Sanson-Fisher, “The relative effectiveness of educational and behavioral instruction programs for patients with NIDDM: a randomized trial,” The Diabetes Educator, vol. 22, no. 4, pp. 379–386, 1996.
[27]
L. J. Cheskin, A. M. Mitchell, A. D. Jhaveri et al., “Efficacy of meal replacements versus a standard food-based diet for weight loss in type 2 diabetes: a controlled clinical trial,” The Diabetes Educator, vol. 34, no. 1, pp. 118–127, 2008.
[28]
J. G. Christian, D. H. Bessesen, T. E. Byers, K. K. Christian, M. G. Goldstein, and B. C. Bock, “Clinic-based support to help overweight patients with type 2 diabetes increase physical activity and lose weight,” Archives of Internal Medicine, vol. 168, no. 2, pp. 141–146, 2008.
[29]
T. A. Deakin, J. E. Cade, R. Williams, and D. C. Greenwood, “Structured patient education: the diabetes X-PERT programme makes a difference,” Diabetic Medicine, vol. 23, no. 9, pp. 944–954, 2006.
[30]
L. Engl and H. Lindner, “Impact of using a pedometer on time spent walking in older adults with type 2 diabetes,” The Diabetes Educator, vol. 32, no. 1, pp. 98–107, 2006.
[31]
Z. Faridi, L. Liberti, K. Shuval, V. Northrup, A. Ali, and D. L. Katz, “Evaluating the impact of mobile telephone technology on type 2 diabetic patients' self-management: the NICHE pilot study,” Journal of Evaluation in Clinical Practice, vol. 14, no. 3, pp. 465–469, 2008.
[32]
J. A. Fornos, N. F. Andrés, J. C. Andrés, M. M. Guerra, and B. Egea, “A pharmacotherapy follow-up program in patients with type-2 diabetes in community pharmacies in Spain,” Pharmacy World and Science, vol. 28, no. 2, pp. 65–72, 2006.
[33]
M. J. Franz, A. Monk, B. Barry et al., “Effectiveness of medical nutrition therapy provided by dietitians in the management of non-insulin-dependent diabetes mellitus: a randomized, controlled clinical trial,” Journal of the American Dietetic Association, vol. 95, no. 9, pp. 1009–1017, 1995.
[34]
R. A. Gabbay, I. Lendel, T. M. Saleem et al., “Nurse case management improves blood pressure, emotional distress and diabetes complication screening,” Diabetes Research and Clinical Practice, vol. 71, no. 1, pp. 28–35, 2006.
[35]
P. G？de, M. Beck, P. Vedel, and O. Pedersen, “Limited impact of lifestyle education in patients with type 2 diabetes mellitus and microalbuminuria: results from a randomized intervention study,” Diabetic Medicine, vol. 18, no. 2, pp. 104–108, 2001.
[36]
E. C. Gallegos, F. Ovalle-Berúmen, and M. V. Gomez-Meza, “Metabolic control of adults with type 2 diabetes mellitus through education and counseling,” Journal of Nursing Scholarship, vol. 38, no. 4, pp. 344–351, 2006.
[37]
R. E. Glasgow and D. J. Toobert, “Brief, computer-assisted diabetes dietary self-management counseling: effects on behavior, physiologic outcomes, and quality of life,” Medical Care, vol. 38, no. 11, pp. 1062–1073, 2000.
[38]
R. E. Glasgow, D. J. Toobert, S. E. Hampson, J. E. Brown, P. M. Lewinsohn, and J. Donnelly, “Improving self-care among older patients with type II diabetes: the “sixty something...” study,” Patient Education and Counseling, vol. 19, no. 1, pp. 61–74, 1992.
[39]
A. N. Goudswaard, R. P. Stolk, N. P. A. Zuithoff, H. W. de Valk, and G. E. H. M. Rutten, “Long-term effects of self-management education for patients with type 2 diabetes taking maximal oral hypoglycaemic therapy: a randomized trial in primary care,” Diabetic Medicine, vol. 21, no. 5, pp. 491–496, 2004.
[40]
E. Gucciardi, M. DeMelo, R. N. Lee, and S. L. Grace, “Assessment of two culturally competent diabetes education methods: individual versus individual plus group education in Canadian Portuguese adults with type 2 diabetes,” Ethnicity and Health, vol. 12, no. 2, pp. 163–187, 2007.
[41]
P. G. H. Janssen, K. J. Gorter, R. P. Stolk, and G. E. H. M. Rutten, “Randomised controlled trial of intensive multifactorial treatment for cardiovascular risk in patients with screen-detected type 2 diabetes: 1-year data from the ADDITION Netherlands study,” British Journal of General Practice, vol. 59, no. 558, pp. 43–48, 2009.
[42]
H. S. Kim and H. S. Jeong, “A nurse short message service by cellular phone in type-2 diabetic patients for six months,” Journal of Clinical Nursing, vol. 16, no. 6, pp. 1082–1087, 2007.
[43]
H. S. Kim and M. S. Song, “Technological intervention for obese patients with type 2 diabetes,” Applied Nursing Research, vol. 21, no. 2, pp. 84–89, 2008.
[44]
S. H. Ko, K. H. Song, S. R. Kim et al., “Long-term effects of a structured intensive diabetes education programme (SIDEP) in patients with type 2 diabetes mellitus—a 4-year follow-up study,” Diabetic Medicine, vol. 24, no. 1, pp. 55–62, 2007.
[45]
M. A. Krousel-Wood, L. Berger, X. Jiang, L. Blonde, L. Myers, and L. Webber, “Does home-based exercise improve body mass index in patients with type 2 diabetes? Results of a feasibility trial,” Diabetes Research and Clinical Practice, vol. 79, no. 2, pp. 230–236, 2008.
[46]
B. Kulzer, N. Hermanns, H. Reinecker, and T. Haak, “Effects of self-management training in type 2 diabetes: a randomized, prospective trial,” Diabetic Medicine, vol. 24, no. 4, pp. 415–423, 2007.
[47]
P. C. Ligtenberg, J. B. L. Hoekstra, E. Bol, M. L. Zonderland, and D. W. Erkelens, “Effects of physical training on metabolic control in elderly type 2 diabetes mellitus patients,” Clinical Science, vol. 93, no. 2, pp. 127–135, 1997.
[48]
J. Lujan, S. K. Ostwald, and M. Ortiz, “Promotora diabetes intervention for Mexican Americans,” The Diabetes Educator, vol. 33, no. 4, pp. 660–670, 2007.
[49]
C. L. McKibbin, T. L. Patterson, G. Norman et al., “A lifestyle intervention for older schizophrenia patients with diabetes mellitus: a randomized controlled trial,” Schizophrenia Research, vol. 86, no. 1–3, pp. 36–44, 2006.
[50]
J. Ménard, H. Payette, J. P. Baillargeon et al., “Efficacy of intensive multitherapy for patients with type 2 diabetes mellitus: a randomized controlled trial,” Canadian Medical Association Journal, vol. 173, no. 12, pp. 1457–1466, 2005.
[51]
M. J. O'Kane, B. Bunting, M. Copeland, and V. E. Coates, “Efficacy of self monitoring of blood glucose in patients with newly diagnosed type 2 diabetes (ESMON study): randomised controlled trial,” British Medical Journal, vol. 336, no. 7654, pp. 1174–1177, 2008.
[52]
S. D. Pedersen, J. Kang, and G. A. Kline, “Portion control plate for weight loss in obese patients with type 2 diabetes mellitus: a controlled clinical trial,” Archives of Internal Medicine, vol. 167, no. 12, pp. 1277–1283, 2007.
[53]
M. Pibernik-Okanovic, M. Prasek, T. Poljicanin-Filipovic, I. Pavlic-Renar, and Z. Metelko, “Effects of an empowerment-based psychosocial intervention on quality of life and metabolic control in type 2 diabetic patients,” Patient Education and Counseling, vol. 52, no. 2, pp. 193–199, 2004.
[54]
J. D. Piette, M. Weinberger, and S. J. McPhee, “The effect of automated calls with telephone nurse follow-up on patient-centered outcomes of diabetes care: a randomized, controlled trial,” Medical Care, vol. 38, no. 2, pp. 218–230, 2000.
[55]
R. Rachmani, I. Slavacheski, M. Berla, R. Frommer-Shapira, and M. Ravid, “Treatment of high-risk patients with diabetes: motivation and teaching intervention: a randomized, prospective 8-year follow-up study,” Journal of the American Society of Nephrology, vol. 16, no. 3, supplement 1, pp. S22–S26, 2005.
[56]
M. C. Rosal, B. Olendzki, G. W. Reed, O. Gumieniak, J. Scavron, and I. Ockene, “Diabetes self-management among low-income Spanish-speaking patients: a pilot study,” Annals of Behavioral Medicine, vol. 29, no. 3, pp. 225–235, 2005.
[57]
U. Schwedes, M. Siebolds, and G. Mertes, “Meal-related structured self-monitoring of blood glucose: effect on diabetes control in non-insulin-treated type 2 diabetic patients,” Diabetes Care, vol. 25, no. 11, pp. 1928–1932, 2002.
[58]
S. Shea, “The informatics for diabetes and education telemedicine (IDEATel) project,” Transactions of the American Clinical and Climatological Association, vol. 118, pp. 289–304, 2007.
[59]
H. Sone, A. Katagiri, S. Ishibashi et al., “Effects of lifestyle modifications on patients with type 2 diabetes: the Japan diabetes complications study (JDCS) study design, baseline analysis and three year-interim report,” Hormone and Metabolic Research, vol. 34, no. 9, pp. 509–515, 2002.
[60]
L. Steed, J. Lankester, M. Barnard, K. Earle, S. Hurel, and S. Newman, “Evaluation of the UCL diabetes self-management programme (UCL-DSMP): a randomized controlled trial,” Journal of Health Psychology, vol. 10, no. 2, pp. 261–276, 2005.
[61]
J. A. Sturt, S. Whitlock, C. Fox et al., “Effects of the diabetes manual 1:1 structured education in primary care,” Diabetic Medicine, vol. 25, no. 6, pp. 722–731, 2008.
[62]
J. Sun, Y. Wang, X. Chen et al., “An integrated intervention program to control diabetes in overweight Chinese women and men with type 2 diabetes,” Asia Pacific Journal of Clinical Nutrition, vol. 17, no. 3, pp. 514–524, 2008.
[63]
M. Trento, P. Passera, M. Bajardi et al., “Lifestyle intervention by group care prevents deterioration of Type II diabetes: a 4-year randomized controlled clinical trial,” Diabetologia, vol. 45, no. 9, pp. 1231–1239, 2002.
[64]
M. Trento, P. Passera, M. Tomalino et al., “Therapeutic group education in the follow-up of patients with non-insulin treated, non-insulin dependent diabetes mellitus,” Diabetes, Nutrition and Metabolism, vol. 11, no. 3, pp. 212–216, 1998.
[65]
T. Tsujiuchi, H. Kumano, K. Yoshiuchi et al., “The effect of Qi-gong relaxation exercise on the control of type 2 diabetes mellitus: a randomized controlled trial,” Diabetes Care, vol. 25, no. 1, pp. 241–242, 2002.
[66]
M. Uusitupa, J. Laitinen, O. Siitonen, E. Vanninen, and K. Py？r？l？, “The maintenance of improved metabolic control after intensified diet therapy in recent type 2 diabetes,” Diabetes Research and Clinical Practice, vol. 19, no. 3, pp. 227–238, 1993.
[67]
C. Wattana, W. Srisuphan, L. Pothiban, and S. L. Upchurch, “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,” Nursing and Health Sciences, vol. 9, no. 2, pp. 135–141, 2007.
[68]
H. J. Yoo, H. G. An, S. Y. Park et al., “Use of a real time continuous glucose monitoring system as a motivational device for poorly controlled type 2 diabetes,” Diabetes Research and Clinical Practice, vol. 82, no. 1, pp. 73–79, 2008.
[69]
K. H. Yoon and H. S. Kim, “A short message service by cellular phone in type 2 diabetic patients for 12 months,” Diabetes Research and Clinical Practice, vol. 79, no. 2, pp. 256–261, 2008.
[70]
K. D. Lippa, H. A. Klein, and V. L. Shalin, “Everyday expertise: cognitive demands in diabetes self-management,” Human Factors, vol. 50, no. 1, pp. 112–120, 2008.
[71]
H. A. Klein and K. Lippa, “Type 2 diabetes self-management: controlling a dynamic system,” Cognitive Engineering and Decision Making, vol. 2, no. 1, pp. 48–62, 2008.
[72]
APA Publications and Communications Board, “Reporting standards for research in psychology: why do we need them? What might they be?” American Psychologist, vol. 63, no. 9, pp. 839–851, 2008.
[73]
M. Espeland, X. Pi-Sunyer, G. Blackburn et al., “Reduction in weight and cardiovascular disease risk factors in individuals with type 2 diabetes one-year results of the look AHEAD trial,” Diabetes Care, vol. 30, no. 6, pp. 1374–1383, 2007.
[74]
P. Craig, P. Dieppe, S. Macintyre, S. Michie, I. Nazareth, and M. Petticrew, “Developing and evaluating complex interventions: the new medical research council guidance,” British Medical Journal, vol. 337, article a1655, 2008.
