Two patient education interventions improved poorly controlled diabetes modestly in separate studies reported online Oct. 10 in Archives of Internal Medicine.
The first clinical trial compared a "highly structured" group behavioral diabetes education intervention against one group and one individual control education condition in adults who had longstanding, poorly controlled type 1 or type 2 diabetes. The 222 study subjects (110 with type 1 and 112 with type 2 disease) had baseline hemoglobin A1c levels of 7.5% or higher.
Diabetes nurses or dietitians who were certified diabetes educators ran each program, said Katie Weinger, Ed.D., of the Joslin Diabetes Center and Harvard Medical School, Boston, and her associates.
The highly structured group intervention involved five 2-hour sessions during a 6-week period in which a small group of patients reviewed daily glucose logs and discussed food choices and physical activity. The educators used a structured cognitive-behavioral curriculum to facilitate self-care goal-setting and to help patients identify and overcome barriers to self-care.
The investigators hoped that this intervention would provide "a scaffold that [would] allow participants to integrate specific dietary and physical activity behaviors into their busy schedules."
The group control condition involved the same length of time and the same amount of contact with health professionals but didn’t include any of the cognitive behavior strategies or structured goal-setting activities. The individual control condition gave patients unlimited access to one-on-one appointments with the diabetes educators for 6 months, but did not require that they attend appointments.
"Patients with type 1 diabetes who struggle with achieving glycemic targets [may] need more help with emotional and psychological issues than support with diabetes self-management skills."
The primary outcome measure was improvement in HbA1c level to a target of less than 7% at 3-, 6-, and 12-month follow-up.
Patients in all three study groups showed statistically significant but modest improvement in glycemic control. Most did not achieve their HbA1c target level of less than 7%.
Study subjects who received the highly structured group intervention showed the most improvement, with a mean decrease of 0.8 percentage points in HbA1c at 3 months, compared with mean decreases of 0.4 percentage points in both control groups, the investigators said (Arch. Intern. Med. 2011 Oct. 10 [doi:10.1001/archinternmed.2011.502]).
Glycemic control deteriorated slightly but "was basically maintained at 12 months" for both group interventions but not for the individual control condition.
Patients with type 2 diabetes showed more improvement with the structured intervention than did those with type 1 diabetes, with a reduction in HbA1c of 0.7 percentage points at 3 months, compared with only 0.3 for type 1 diabetes. It may be that patients with type 1 diabetes receive more educational and behavioral support at diagnosis and throughout the course of their disease, and thus do not benefit as much from this intervention, compared with those with type 2 diabetes, Dr. Weinger and her colleagues said.
"Another explanation may be that patients with type 1 diabetes who struggle with achieving glycemic targets need more help with emotional and psychological issues than support with diabetes self-management skills," they added.
Neither the highly structured intervention nor the control conditions significantly improved diabetes-related quality of life, the number of daily meter checks, or the frequency of self-care behaviors.
"Although our participants did not achieve glycemic targets of less than 7% ... we believe that a 0.67% reduction in HbA1c level observed at 12 months, if sustained over the long term, should by itself result in about a 20% reduction in microvascular end points and about a 10% reduction in cardiovascular end points," Dr. Weinger and her associates wrote.
In the second clinical trial, Dr. JoAnn Sperl-Hillen of HealthPartners Research Foundation, Minneapolis, and her associates also studied patients with poorly controlled type 2 diabetes (HbA1c levels of 7% or higher). The study subjects were 337 adults residing in Minnesota and 286 in New Mexico. The mean age was 62 years, and the mean duration of diabetes was 12 years.
The researchers assessed a group education program endorsed by the American Diabetes Association that included "Conversation Maps" – a highly interactive group approach using large, laminated tabletop visual aids to facilitate discussions. Topics covered during the 8 hours of the program included healthy eating, monitoring blood sugar, taking medications, problem solving, risk reduction, healthy coping, and increasing physical activity.
This intervention was compared against standard individual diabetes education – three 1-hour sessions with a certified diabetes educator at 1-month intervals – and usual care (no specific diabetes education).
At 6-month follow-up, HbA1c levels decreased more, by 0.51 percentage points, with the individual diabetes education than with the group intervention (0.24%) or usual care (0.27%). Scores on measures of physical health, nutrition, and physical activity also improved significantly with the individual education but not with group education, compared with usual care, Dr. Sperl-Hillen and her colleagues said (Arch. Intern. Med. 2011 Oct. 10 [doi:10.1001/archinternmed.2011.507]).