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5.5 General Diabetes Self-Management and Education

Diabetes self-management education includes the ongoing processes of facilitating the knowledge, skill and ability necessary for diabetes self-care. It incorporates the needs, goals and life experiences of the person with diabetes. Education helps people with diabetes initiate effective self-management and cope with diabetes when they are first diagnosed. Ongoing diabetes education helps people with diabetes maintain effective self-management throughout a lifetime of diabetes (American Diabetes Association, 2014).

In the U.S., one option for self-management education is the Outpatient Diabetes Self-management and Training Program.  This is a service that educates patients on self-management of diabetes and includes education about self-monitoring of blood glucose, diet, exercise and sometimes medication (oral agents and/or insulin). The treatment plan is developed specifically for the patient, which helps engage and motivate patients to use the knowledge and skills in effective self-management. It follows the national standards for diabetes self-management education programs and American Diabetes Association (ADA) review criteria or the American Association of Diabetes Educators (AADE). Other countries have developed national standards that include many of the same components.

The evidence of the benefits of diabetes self-management education is substantial.  Diabetes education is associated with improved diabetes knowledge and improved self-care behavior (Norris, 2005) and improved clinical outcomes such as lower HgbA1c, lower self-reported weight, improved quality of life, healthy coping and lower costs (American Diabetes Association, 2014).  A recent meta-analysis suggested that educational and behavioral interventions in T2DM produced a moderate decline in HgbA1c of .43%, which was statistically significant. Larger sample size studies and those with better study quality scores had larger HgbA1c declines (Gary, 2003).

Better outcomes are reported when interventions are longer and include follow-up support; are culturally and age appropriate, and tailored to individual needs, address psychosocial issues and incorporate behavioral strategies. Those interventions that promote behavior change in turn improve clinical outcomes (Steinsbekk, 2012; Radhakrishnan, 2011).

Interventions that have psychosocial content (e.g., discuss quality of life with participants, and include empowerment or motivational interviewing) had a positive rate difference of 80% compared to diet outcomes. The relationship between diet and psychosocial issues is particularly relevant for women from high-risk ethnic groups living with T2DM. Interventions that focus on psychosocial support and self-management have proved successful in some studies among Hispanic and African American populations because they address emotions and beliefs about T2DM, deal with the question of how adjusting one's lifestyle may conflict with cultural norms, and demonstrate that incorporating psychosocial coping strategies may be effective in improving dietary behaviors.

The recent literature provides support for a variety of healthy coping interventions in diverse populations, including diabetes self-management education, support groups, problem-solving approaches, and coping skills interventions for improving a range of outcomes. Coping with an emphasis on problem-solving may benefit psychosocial outcomes in addition to self-care behavior and glycemic control, although more studies evaluating a common set of healthy coping outcomes are needed. There has been substantial interest in cognitive behavioral therapy (CBT), including several studies suggesting effectiveness of CBT-based interventions on depressive symptoms and diabetes-related stress, when delivered via novel formats, such as the Internet and/or telephone. However, evidence from recent trials is mixed (Thorpe, 2013).

A Cochrane review (Deakin, 2009) concluded group-based training for self-management strategies in people with T2DM is effective by improving fasting blood glucose levels, glycated hemoglobin and diabetes knowledge, and reducing systolic blood pressure levels, body weight and the requirement for diabetes medication. An anticipated benefit of diabetes education for patients is improved glycemic control as a consequence of better patient motivation, adherence to treatment and understanding of the disease. A number of recent systematic reviews and a meta-analysis highlight the effectiveness of nurses and dietitians in multiple studies in delivering effective diabetes education (Guicciardi, 2014; Steinsbekk, 2012; Tshiananga, 2012).

While the Diabetes Education and Self-management for Ongoing and Newly Diagnosed (DESMOND) randomized control trial demonstrated the HgbA1c level was not improved in the trial, this may have been because the major improvements in HgbA1c level achieved in the period after diagnosis of diabetes, as seen in both study arms, may have masked any effect of the intervention (Gillett, 2010).  A Cochrane review (Duke, 2009) found that individual diabetes education and self-management, compared to usual care, did not significantly improve glycemic control, although there was benefit for those with an A1c greater than 8.0%. Differences in patient characteristics and in education and self-management content and implementation may have contributed to the variability in outcomes. The review notes the impact may have been diluted by including a high number of participants who had a near normal HgbA1c at baseline. In a subgroup analysis focused on studies where participants had an average baseline HgbA1c of greater than 8%, there was a significant impact of individual education on glycemic control. The authors concluded the systematic review highlighted the benefits of individual education in lowering HgbA1c in a subgroup of patients with poorer control and a mean baseline HgbA1c greater than 8% (Duke, 2009).

The integrated chronic care model (CCM) is increasingly recommended as the preferred model of diabetes care in many countries. While focusing on organization of treatment so that care services are better integrated and more efficiently utilized, an integral component of CCM is support of patient management of patients' own care via diabetes self-management education (Siminero, 2006b).

Although a recent U.S. study based on commercial and Medicare claims databases revealed that patients using diabetes education have lower average medical costs than patients who do not (Duncan, 2011), due to a lack of large-scale population-based trials, the evidence documenting the clinical and economic impact of the CCM approach remains uncertain (Tshiananga, 2012).

A systematic review concluded computer-based diabetes self-management interventions currently have limited effectiveness (Pal, 2013).  They appear to have small benefits on glycemic control.  The effect size on HgbA1c was larger in the mobile phone subgroup. Current interventions do not show adequate evidence for improving depression, health-related quality of life or weight, but they do appear to be safe (Pal, 2013). Effective nutrition therapy interventions may be part of a comprehensive group education session or an individualized session. Interventions should also include recommendations for physical activity and utilize behavior change counseling to help sustained improved lifestyle modifications (Evert, 2014).