Tugas Pak Wid Judul Buku
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MAPPING TEORY DAN REVIEW JURNAL
Di Ajukan Guna Memenuhi Tugas Mata Kuliah Logika Sains dan Berfikir Sistem
Oleh :
HARIYONONIM 101317087303
UNIVERSITAS AIRLANGGAFAKULTAS KESEHATAN MASYARAKATPROGRAM DOKTOR PRODI ILMU KESEHATANSURABAYA2014BUKU Judul BukuIsi UtamaInformasi ilmiah/alur informasiGrand teory
Substansi teoryConclusion/
kesimpulan
Judul Buku :
Quality of Life and DiabetesPenulis :
Richard R. Rubin1Mark PeyrotTahun :
1999
Jenis :
Tex Book
1. Issue penting kualitas hidup penderita Diabetes Melitus
2. Bagaimana kualitas hidup dikonseptualisasikan dan diukur?3. Kualitas hidup dan lama diabetes
4. Kualitas hidup dan adanya komplikasi yang berhubungan dengan diabetesPasien diabetes sering merasa tertantang oleh penyakit mereka dan tuntutan sehari- hariuntuk manajemen hari. Dan tuntutan ini substansial. pasien harus menangani diabetes mereka sepanjang hari, membuat keputusan yang tak terhitung jumlahnya yang sering upaya tersebut sia-sia untuk mendekati keadaan metabolik non-diabetes. Diabetes, terapi seperti insulin, secara substansial dapat mempengaruhi kualitas hidup yang baikGrand teoryDibandingkan dengan orang-orang tanpa diabetes, kebanyakan studi melaporkan kualitas hidup yang lebih buruk bagi orang-orang dengan diabetes, terutama mengenai fungsi fisik dan kesejahteraan. Mereka dengan diabetes melaporkan kualitas hidup yang lebih baik daripada orang yang memiliki berbagai kondisi kronis lainnya (seperti masalah jantung, epilepsi dengan kejang, arthritis, multiple sclerosis, stroke dan masalah paru-paru) di beberapa atau sebagian besar domain fungsi dan kesejahteraan.
Judul buku :
Decision Making in the Transtheoretical
Model of Behavior ChangePengarang :
James O. ProchaskaTahun : 2008 Pengambilan keputusan merupakan bagian integral dari model transtheoretical perubahan perilaku. Tahap perubahan merupakan dimensi temporal untuk perubahan perilaku dan telah menjadi dimensi utama untuk mengintegrasikan prinsip-prinsip dan proses perubahan dari seluruh teori psikoterapi dan perubahan perilaku.. Implikasi dari pola-pola hubungan dibahas dalam konteks untuk membantu pasien membuat keputusan yang lebih efektif untuk mengurangi perilaku berisiko kesehatan dan meningkatkan perilaku kesehatan-menggambarkan bagaimana penelitian tentang pengambilan keputusan didorong oleh teori perubahan perilaku , seperti model transtheoretical ( TM ) , dapat memajukan perawatan berbasis ilmu pengetahuan untuk populasi pasien yang secara historiskarena mereka tidak patuh , tidak termotivasi , atau tidak siap TTM ini dirancang untuk mengintegrasikan prinsip-prinsip dan proses perubahan dari seluruh teori terkemuka psikoterapi dan perubahan perilaku intinya mengintegrasikan dimensi
Grand te0ryHal yang paling penting dalam konsep ini adalah bahwa penelitian tentang pengambilan keputusan didorong oleh teori perubahan perilaku, seperti TTM, dapat memajukan ilmu pengetahuan-pengobatan berbasis populasi pasien yang secara historis understudied dan terlayani karena mereka patuh, tidak termotivasi, tahan, atau tidak siap untuk ilmu kami dan layanan kami
Judul Buku :
Quality of life and pharmaeconomic in clinical trialsPengarang :
Bert Spilker
Tahun : 1996Instrument pengkajian Kualitas hidup menurut WHO, instrument ini mengkaji secara holistik dan seimbang, dimana aspek positif dan negatif dapat terkaji yang meliputi 6 domain yaitu fisik, psikologis,tingkat ketergantungan,hubungan sosial, dan spiritual atau religiusKualitas hidup dapat didefinisakan sebagai persepsi individu dalam hidupnya yang meliputi budaya dan nilai hidup yang berhubungan dengan tujuan hidupGrand teoryWHO berkomitment untuk mengembangkan pengkajian kualitas hidup secara inernasional yang di gunakan untuk mengembangkan pengukuran status kesehatan individu akibat dampak dari penyakit kronis
JURNAL ILMIAHJudul artikel Tujuan PenelitianInformasi ilmiah/alur informasi
Dasar teori/konsep ilmiahMateri and methodeGrand teory
Substansi teoryConclusion/
kesimpulan
Perkembangan dan validasi DMOS (Diabetes Management orientation Scale) :Pengkajian Budaya berhubungan dengan pendekatan diabetes self management
Penulis
Aaron K.Y Wong Andrew G.O Stewart
John S. FurlerTahun
2009Jenis
Jurnal
Internasional
Meningkatkan sefl efficacy dengan perilaku managemen diriPerilaku manajemen diri diabetes tipe 2 yang ditingkatkan dengan self-efficacy sementaraperan budaya belum dipahami dengan baik. Penelitian ini dieksplorasi individualis budaya danaspek kolektivis manajemen diri dan hubungannya dengan kontrol diabetes.
Skala Manajemen Diabetes Orientasi dirancang untukmengukur orientasi individu dan kelompok diabetes
Analisis statistik dilakukan dengan menggunakan SPSS 15.0 forwindows [20]. Analisis faktor eksploratori dengan maksimalekstraksi kemungkinan dan rotasi miring dilakukan untukmemeriksa struktur faktor dari DMOS dan pilih item untukskala inklusi. Item yang dipertahankan untuk skala akhir jika merekamemiliki lebih dari 0,45 pemuatan, memastikan khas kontribusi masing-masing item ke faktor masing-masing [21]. paralelanalisis dan minimum rata-rata parsial (MAP) tes Velicer inidigunakan untuk menentukan jumlah faktor untuk ekstraksi.
Substansi teoryStudi ini menunjukkan bahwa intervensi ini memiliki potensi positif berdampak pada kesehatan masyarakat luas individu dengan diabetes, bukan hanya minoritas yang siap untuk perubahan.
Judul :Perubahan perilaku perawatan diri Membuat Perbedaan di Control GlikemikPenulis : HELEN JONES
LYNN EDWARDS, PDT, MHSA2
T. MICHAEL VALLIS
LAURIE RUGGIERO,
SUSAN R. ROSSITahun
2003
Jenis jurnal
IntenationalPenelitian ini bertujuan untuk membandingkan pengobatan diabetes Treatment As Usual (TAU) dengan (PTC), intervensi yang dikembangkan dari Transtheoretical Model of Change (TTM), untukmenentukan apakah intervensi PTC akan menghasilkan kesiapan yang lebih besar untuk berubah, lebih besarmeningkat dalam perawatan diri, dan meningkatkan kontrol diabetes.
Model TranstheoreticalPerubahan ( TTM ) telah diterapkan untuk kesehatanintervensi perubahan perilaku menggunakansistem komputerisasi , PersiapanPerubahan ( PTC ) , yang menyediakan perawatan diriPeserta dikelompokkan berdasarkan pengobatan diabetes dan diacak untuk pengobatan dengan PTC atau TAU serta menjadi acak mengenai penerimaan strip tes darah gratis. PTC terdiri dari laporan tahap-cocok pribadi assessment, self-help manual, newsletter, dan konseling telepon individu yang dirancang untuk meningkatkan kesiapan untuk diri-monitor glukosa darah (SMBG), makan sehat, dan / atau berhenti merokok.Sebanyak 1.029 orang dengan tipe 1 dan diabetes tipe 2 yang berada di salah satu dari tigatahap pra tindakan baik untuk SMBG, makan sehat, atau merokok direkrut.Substansi teoryStudi ini menunjukkan bahwa intervensi ini memiliki potensidari positif berdampak pada kesehatan yang luaspopulasi individu dengan diabetes, tidakhanya minoritas yang siap untuk perubahan
Judul : pengalaman management diri penderita diabetes : fokus grup studi pada penderita diabetes tipe 2 di taiwan
Penulis : Chiu-Chu Lin Robert M Anderson Bonnie M Hagerty Bih-O LeeTahun :
2006
Jenis jurnal :
Internasional
Tujuan dari penelitian ini adalah untuk memahami dan mendokumentasikanperspektif pasien Taiwan dengan diabetes tipe 2 mengenai proses danstrategi yang digunakan untuk mengelola sendiri kondisi kronis mereka
tujuan utama pengelolaan penderita diabetes adalah membantu penderita dan keluarga untuk berpartisipasi aktif dalam pengelolaan penyakit. Pada awal setiap kelompok fokus, moderator memperkenalkan dirinya dan lain anggota tim peneliti yang mengambil catatan lapangan dan menggambarkan sesi kelompok fokus yang direncanakan. Selain itu, untuk mendorong diskusi aktif dari semua anggota kelompok fokus, peserta diminta untuk secara terbuka mendiskusikan pengalaman mereka dan memberikan tanggapan jujur, bahkan jika mereka berbeda dari tanggapan peserta lain. Semua sesi, yang berlangsung 90-120 menit, direkam oleh dua microcassette tape recorder untuk memastikan kejelasan dan keakuratan transkripsi.
Grand teoryProses self-regulation Data dari lima kelompok fokus menunjukkan bahwa pasien mempelajari strategi untuk mengelola penyakit mereka dari serangkaian proses mengatur diri sendiri termasuk perilaku biologisdan penyesuaian psikologis. Misalnya, melalui 'mengidentifikasi respon tubuh,' peserta belajar hubungan antara kadar gula darah dan kontrol diet dan relaksasi emosional.
Judul :Faktor Risiko Perilaku yang Berhubungan dengan Kadar Gula Darah pada Penderita
Diabetes Melitus Tipe 2 di RSUD Kabupaten KaranganyarPenulis :
Rosita Purnama DewiTahun :
2013
Jenis Jurnal :
Nasional
Tujuan penelitian :Tujuan
penelitian ini adalah untuk mengetahui hubungan antara perilaku (pengetahuan, sikap dan
praktik) dalam hal diet, olahraga dan pengobatan dengan kadar gula darah
Diabetes Melitus (DM) merupakan penyakit kronik yang tidak dapat disembuhkan, tetapi
dapat dikendalikan melalui pengelolaan DM. Orang dengan DM memiliki
peningkatan risiko mengembangkan
sejumlah masalah kesehatan akibat
komplikasi akut maupun kronik.Penelitian ini merupakan penelitian
analitik dengan desain cross sectional.
Populasi penelitian ini adalah pasien DM
tipe 2 yang berobat di Poliklinik Penyakit
Dalam RSUD Kabupaten Karanganyar.
Sampel diambil sebanyak 72 orang,
menggunakan teknik purposive sampling.
Variabel terikat adalah kadar glukosa
darah puasa. Variabel bebas terdiri dari
pengetahuan diet, pengetahuan olahraga,
pengetahuan pengobatan, sikap diet,
sikap olahraga, sikap pengobatan, praktik
diet, praktik olahraga dan praktik
pengobatan. Pengambilan data dengan
wawancara menggunakan kuesioner.
Data dianalisis menggunakan uiji chi-
square.Substansi teoryDari penelitian ini dapat disimpulkan
bahwa sebagian besar pasien DM tipe 2
yang menjalani rawat jalan di Poliklinik
Penyakit Dalam RSUD Kabupaten
Karanganyar sudah memiliki pengetahuan
dan sikap yang baik terhadap pengelolaan
DM yang meliputi diet, olahraga dan
pengobatan. Akan tetapi dalam praktiknya
masih banyak yang tidak melaksanakan
pengelolaan DM dengan benar sehingga
kadar gula darah sebagian besar pasien
berada pada kategori tidak normal.
Judul penelitian :UPAYA PENANGANAN DAN PERILAKU PASIEN PENDERITA DIABETES
MELITUS TIPE 2 DI PUSKESMAS MARADEKAYA KOTA MAKASSAR
TAHUN 2013
Penulis :
1. Dian Lestari
2. Citrakesumasari3. Sriah Alharini
Mengetahui PENANGANAN DAN PERILAKU PASIEN PENDERITA DIABETES
MELITUS TIPE 2 DI PUSKESMAS MARADEKAYA KOTA MAKASSARPenyakit diabetes melitus telah menjadi masalah kesehatan dunia. Prevalensi dan insiden
penyakit ini terus meningkat di negara-negara industri maupun negara berkembang termasuk
Indonesia. Kurang terkontrolnya kadar glukosa darah sangat dipengaruhi oleh perilaku hidup pasien,
oleh karena itu pengetahuan yang dapat mengubah perilaku merupakan domain yang sangat penting
untuk terbentuknya perilaku.Penelitian ini telah dilaksanakan di Puskesmas Maradekaya Kota Makassar. Jenis
penelitian ini adalah penelitian survei observasional deskriptif yaitu untuk mengamati dan
mendeskripsikan upaya penanganan yang dilakukan oleh petugas kesehatan dan perilaku 4
pasien penderita DM tipe 2. Populasi dalam penelitian ini adalah semua pasien DM tipe 2
yang datang memeriksakan kesehatan ke Puskesmas Maradekaya pada 11 Maret sampai 13
April 2013. Sampel dalam penelitian ini diambil dari rata-rata kunjungan pasien DM perbulan
sebanyak 29 orang yang memenuhi kriteria penelitian. Dimana kriteria inklusi dari penelitian
ini yaitu pasien DM tipe 2 yang berkunjung ke puskesmas Maradekaya pada bulan Maret-
April 2013, tidak mengalami komplikasi yang mempengaruhi pola makan, dapat
berkomunikasi secara sadar dan bersedia menjadi responden. Dan kriteria eksklusi yaitu
dalam keadaan hamil atau menyusui, menderita penyakit neurogeneratif (pikun, stroke) dan
tidak mengikuti protokol penelitian. Data penelitian diperoleh dengan mengumpulkan data
primer dan data sekunder.
Grand teoryUpaya penanganan pasien penderita DM Tipe 2 di Puskesmas Maradekaya tidak
berjalan sesuai dengan pilar penanganan DM. Pengetahuan responden lebih banyak termasuk
kategori kurang dan hanya sebagian kecil yang memiliki pengetahuan cukup. Responden
dengan pengetahuan cukup lebih banyak memiliki kadar GDS tidak terkontrol.
Judul artikel :Efektivitas pendidikan diabetes dan manajemen diri untuk program yang sedang berlangsung dan baru didiagnosis (DESMOND) bagi orang-orang yang baru didiagnosis diabetes tipe 2: cluster percobaan terkontrol acakPenulis :
1. M J Davies2. SHeller
3. T C Skinner, Tahun:
2008
Jenis :
InternasionalUntuk mengevaluasi efektivitas program pendidikan kelompok terstruktur pada langkah-langkah biomedis, psikososial, dan gaya hidup pada orang yang baru didiagnosis diabetes tipe 2.diabetes di hubungkan dengan peningkatan morbiditas dan kematian dini akibat penyakit jantung, termasuk stroke dan infark miokard. Dalam praktek klinis dalam tim perawatan primer di Inggris kini imbalan finansial untuk mencapai target glikemik dan metabolik ketat pada pasien di bawah perawatan mereka dan ini telah menyebabkan tingkat peningkatan kontrol glikemik, terutama pada pasien dengan tipe 2 diabetes diabetes.meskipun layanan nasional kerangka telah membuat rekomendasi untuk penyediaan lebih luas kelompok terstruktur pendidikan, saat ini tidak ada bukti yang mendukung keyakinan bahwa pendidikan terstruktur memberikan manfaat tambahan bagi pasien dari pokok diagnosis.Klaster multisenter percobaan terkontrol acak dalam perawatan primer dengan pengacakan pada tingkat praktek.Grand teorySebuah program pendidikan kelompok terstruktur untuk pasien dengan diabetes tipe 2 yang baru didiagnosa menghasilkan peningkatan yang lebih besar dalam penurunan berat badan dan berhenti merokok dan perbaikan positif dalam keyakinan tentang penyakit tetapi tidak ada perbedaan dalam tingkat hemoglobin A1c sampai 12 bulan setelah diagnosis.
Judul artikel :Factors that Inuence Diabetes Self-Management in Hispanics
Living in Low Socioeconomic Neighborhoods in San Bernardino,
CaliforniaPenulis :
Delweiss Ramal
Anne Berit Petersen
Kathie Marlene Ingram Andrea Marie ChamplinTahun :
2012Jenis :
Internasional
untuk mengidentifikasi faktor yang mempengaruhi pengelolaan diri penderita diabetes pada orang Hispanik, data kualitatif yang dikumpulkan melalui lima kelompok fokus wawancara telah diteliti dengan menggunakan metode teori dasar
Program yang bertujuan untuk meningkatkan praktek manajemen diri harus memasukkan konteks sosial budaya dan sosial ekonomi di yang Hispanik dengan diabetes hidup.
Grounded theory, metode penelitian induktif digunakan untuk mempelajari fenomena tanpa sebelumnya dirumuskan dengan baik teori, digunakan untuk mengumpulkan, menganalisis, dan menginterpretasikan data kualitatif. Kami melakukan lima diskusi kelompok terfokus dengan 13, 2, 4, 3, dan 5 masing-masing peserta di empat lokasi yang berbeda di sebagian besar rendah sosial ekonomi, lingkungan Hispanik di Kota San Bernardino. Data dikumpulkan melalui interaksi kelompok fokus di mana sekelompok kecil individu dari populasi sasaran mengungkapkan pendapat mereka tentang suatu topik tertentu. Peserta sendiri dipilih dari Hispanik, yang telah mengikuti program pendidikan diabetes antara Juni 2008 dan Maret 2010 bertempat di salah satu dari empat komunitas-Grand teory
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Effectiveness of Self-ManagementTraining in Type 2 DiabetesA systematic review of randomized controlled trials
SUSAN L. NORRIS, MD, MPHMICHAEL M. ENGELGAU, MD, MSCK.M. VENKAT NARAYAN, MD, MPH
OBJECTIVE To systematically review the effectiveness of self-management training in type2 diabetes.
RESEARCH DESIGN AND METHODS MEDLINE, Educational Resources Informa-tion Center (ERIC), and Nursing and Allied Health databases were searched for English-languagearticles published between 1980 and 1999. Studies were original articles reporting the results ofrandomized controlled trials of the effectiveness of self-management training in people with type2 diabetes. Relevant data on study design, population demographics, interventions, outcomes,methodological quality, and external validity were tabulated. Interventions were categorizedbased on educational focus (information, lifestyle behaviors, mechanical skills, and copingskills), and outcomes were classified as knowledge, attitudes, and self-care skills; lifestyle be-haviors, psychological outcomes, and quality of life; glycemic control; cardiovascular disease riskfactors; and economic measures and health service utilization.
RESULTS A total of 72 studies described in 84 articles were identified for this review.Positive effects of self-management training on knowledge, frequency and accuracy of self-monitoring of blood glucose, self-reported dietary habits, and glycemic control were demon-strated in studies with short follow-up (,6 months). Effects of interventions on lipids, physicalactivity, weight, and blood pressure were variable. With longer follow-up, interventions thatused regular reinforcement throughout follow-up were sometimes effective in improving glyce-mic control. Educational interventions that involved patient collaboration may be more effectivethan didactic interventions in improving glycemic control, weight, and lipid profiles. No studiesdemonstrated the effectiveness of self-management training on cardiovascular diseaserelatedevents or mortality; no economic analyses included indirect costs; few studies examined health-care utilization. Performance, selection, attrition, and detection bias were common in studiesreviewed, and external generalizability was often limited.
CONCLUSIONS Evidence supports the effectiveness of self-management training in type2 diabetes, particularly in the short term. Further research is needed to assess the effectiveness ofself-management interventions on sustained glycemic control, cardiovascular disease risk fac-tors, and ultimately, microvascular and cardiovascular disease and quality of life.
Diabetes Care 24:561587, 2001
D iabetes self-management training,the process of teaching individualsto manage their diabetes (1), hasbeen considered an important part of
clinical management since the 1930s (2).The goals of diabetes education are to op-timize metabolic control, prevent acuteand chronic complications, and optimize
quality of life while keeping costs accept-able (3). One of the goals of Healthy Peo-ple 2010 is to increase to 60% (from the1998 baseline of 40%) the proportion ofindividuals with diabetes who receive for-mal diabetes education (4). There are sig-nificant knowledge and skill deficits in5080% of individuals with diabetes (5),and ideal glycemic control (HbA1c ,7.0%) (6) is achieved in less than half ofpersons with type 2 diabetes (7). The di-rect and indirect costs of diabetes and itscomplications were estimated to be $98billion in 1997 (8), although the cost ofdiabetes education as a discrete compo-nent of care has not been defined.
A large body of literature exists on di-abetes education and its effectiveness, in-cluding several important quantitativereviews showing positive effects. How-ever, these reviews aggregated studies ofheterogeneous quality (911) and typesof interventions (9,10) and do not iden-tify the most effective form of diabetes ed-ucation for specific populations oroutcomes. Moreover, educational tech-niques have evolved since these reviews(911) and have shifted from didacticpresentations to interventions involvingpatient empowerment (12).
The objective of this study was to sys-tematically review reports of publishedrandomized controlled trials to ascertainthe effectiveness of self-managementtraining in type 2 diabetes, to providesummary information to guide diabetesself-management programs and futurequantitative analyses, and to identify fur-ther research needs.
RESEARCH DESIGN ANDMETHODS
Search methodsThe English-language medical literaturepublished between January 1980 and De-cember 1999 was searched using theMEDLINE database of the National Li-brary of Medicine, the Educational Re-sources Information Center (ERIC)database, and the Nursing and Allied
c c c c c c c c c c c c c c c c c c c c c c c c c c c c c c c c c c c c c c c c c c c c c c c c c
From the Division of Diabetes Translation, National Center for Chronic Disease Prevention and HealthPromotion, Centers for Disease Control and Prevention, Atlanta, Georgia.
Address correspondence and reprint requests to Susan L. Norris, MD, Centers for Disease Control andPrevention, MS K-10, 4770 Buford Highway NE, Atlanta, GA 30341. E-mail: [email protected].
Received for publication 11 April 2000 and accepted in final form 19 October 2000.Abbreviations: SMBG, self-monitoring of blood glucose.A table elsewhere in this issue shows conventional and Syste`me International (SI) units and conversion
factors for many substances.
R e v i e w s / C o m m e n t a r i e s / P o s i t i o n S t a t e m e n t sR E V I E W
DIABETES CARE, VOLUME 24, NUMBER 3, MARCH 2001 561
Health database (commenced in 1982).The medical subject headings (MeSH)searched were Health Education com-bined with Diabetes Mellitus, includingall subheadings. Abstracts were not in-cluded because they generally contain in-sufficient information to assess thevalidity of the study by the criteria de-scribed below. Dissertations were also ex-cluded because the available abstractscontained insufficient information forevaluation and the full text was frequentlyunavailable. Titles of articles extracted bythe search were reviewed for their rele-vance to the effectiveness of diabetes ed-ucation, and if potentially relevant, thefull-text article was retrieved. Because au-tomated databases are incomplete (1315), the following journals, believed tohave the highest relevance, were searchedmanually: Diabetes Care, Diabetes Educa-tor, Diabetes Research and Clinical Practice,Diabetologia, and Diabetic Medicine.
Study selectionOnly randomized, controlled trial reportswere selected because this type of studydesign generally supports maximum va-lidity and causal inference (16). We re-viewed only studies in which all or mostsubjects had type 2 diabetes. If the type ofdiabetes was unclear, then the study wasincluded when the mean age was .30years. It was believed that the educationaltechniques and social influences (espe-cially family and peers) relevant to chil-dren and adolescents with either type 1 ortype 2 diabetes were sufficiently differentto warrant a separate review. To examineas broadly as possible the effectiveness ofdiabetes education, we included studiesof subjects with type 2 diabetes .18 yearsof age, with any degree of disease severityand with any comorbidity. Interventionsin all settings were included. Educationcould be delivered by any provider type,could involve any medium (written, oral,video, computer), could be individual- orgroup-based, and could be of any dura-tion and intensity. Studies with multi-component interventions were includedonly if the effects of the educational com-ponent could be examined separately.
Self-management training interven-tions were classified into one of the fol-lowing categories by primary educationalfocus: knowledge or information; lifestylebehaviors, including diet and physical ac-tivity; skill development, including skillsto improve glycemic control such as self-
monitoring of blood glucose (SMBG), aswell as skills to prevent and identify com-plications (e.g., foot care); and copingskills (to improve psychosocial function),including interventions using empower-ment techniques or promoting relaxationor self-efficacy. Studies with a focus onknowledge or information were subclas-sified by primary type of educational ap-proach: didactic or collaborative. Didacticeducation occurred when the patient at-tended to the information but did not in-teract with the instructor or participateactively in teaching sessions. Collabora-tive education occurred when the patientparticipated actively in the learning pro-cess, including group discussions orhands-on practice, or when teachingtechniques included empowerment (17),individualized goal-setting, biofeedback,or modeling. The other three categories oflifestyle, skill development, and copingskills education were generally all collab-orative to some extent; therefore, thesetypes of interventions were not subclassi-fied.
Data extractionData extracted from eligible studies in-cluded descriptive information, analysismethods, and results. Extraction was notblinded, because there is no evidence thatblinding results in a decrease in bias in theconduct of systematic reviews and meta-analyses (18,19).
Validity assessmentQuality assessment was determined bywhat was reported in each article, and in-ternal validity was assessed using Co-chrane methodology (20) for four types ofbias (Table 1). These biases are believed tohave significant effects on measured out-comes in intervention studies (21), and ifpresent in an article, note was made in thetables.
These criteria for bias were modifiedfrom those used in Cochrane methodolo-gies, because not one study in the litera-ture reviewed fulfilled all definitions forthe absence of bias. To avoid selectionbias, ideally one requires concealment ofthe allocation schedule so that neither pa-tient nor researcher can influence assign-ment sequence (22). However, becausemost studies in this review did not com-ment on method of allocation, beyondstating that subjects were randomized, al-location concealment was not used as anecessary criteria for the absence of selec-tion bias. To avoid performance bias,blinding of patients to the intervention isrequired, which is impossible in diabeteseducation studies; therefore, patientblinding was not used as a validity crite-rion. Attrition was noted as a potentialbias when more than 20% of initially en-rolled subjects dropped out before datacollection, and dropouts were not com-pared or were not found equivalent tocompleters at baseline.
External validity was also assessed
Table 1Assessment of internal validity based on Cochrane Collaboration Criteria (20)
Type of bias Definition
Selection bias Systematic differences in control and intervention groups at baselineTo avoid requires randomization and no significant differences
between baseline variables in control and intervention groups,or adequate statistical consideration of potential confounders ifbaseline differences exist
Performance bias Systematic differences in care provided to control and interventiongroups, apart from the intervention being evaluated
To avoid requires no evidence of contamination or cointervention,including no additional contacts with researcher or providers forthe intervention group compared with the control group
Attrition bias Systematic differences between study groups in withdrawals from thestudy
To avoid requires attrition ,20% of total n, or dropouts mustresemble completers in baseline characteristics
Detection bias Systematic differences in outcomes assessment between study groupsTo avoid requires blinding for any outcome subject to assessor
interpretation
Self-management training in type 2 diabetes
562 DIABETES CARE, VOLUME 24, NUMBER 3, MARCH 2001
and was considered adequate if the acces-sible population reasonably representedthe target population and study subjectswere either a random sample of the acces-sible population or consecutively referredpatients, or if no significant differencesbetween participants and nonparticipantswere demonstrated at baseline. Studieswith populations that consisted of volun-teers, that were convenience samples, orwere otherwise selected by the research-ers may not be generalizable to targetpopulations; therefore, the nature of thesestudy populations is indicated in the ta-bles.
OutcomesOutcomes are summarized in a qualita-tive fashion to 1) aid in generating hy-potheses, 2) detail the categorization ofvariables for future quantitative syntheses(23), and 3) portray the heterogeneity ofthe populations, interventions, method-ology, study quality, and outcomes in thisliterature. It was believed that derivationof a single summary statistic would not bemeaningful in determining what inter-ventions are effective in what popula-tions. The power of statistical tests ofhomogeneity is low, and failure to reject ahypothesis of homogeneity does notprove that studies are sufficiently similarto be aggregated (24).
We classified outcomes as 1) processmeasures including knowledge, attitudes,and self-care skills; 2) lifestyle behaviors,psychological outcomes, and quality oflife; 3) glycemic control; 4) cardiovasculardisease risk factors; and 5) economicmeasures and health service utilization.Because a study can have multiple out-comes, each study can be listed one ormore times in the results tables, which areclassified by outcome. Glycated hemoglo-bin measures are presented as percentagechange in the text and the figure, due tothe measurement of different glycatedcomponents of hemoglobin in differentstudies as well as the variability of mea-surement between laboratories and overtime (25).
RESULTS A total of 72 discretestudies, published in 84 articles, wereidentified. These studies are heteroge-neous with respect to patient population,educational intervention, outcomes as-sessed, study quality, and generalizability(Tables 26). Review of this literature re-veals a number of important generaliza-
tions concerning the components anddeterminants of effective interventionsand the outcomes most conducive to im-provement.
Process measuresKnowledge. Most studies measuringchanges in diabetes knowledge demon-strate improvement with education (Ta-ble 2) (26 46), including those withfollow-up of 612 months after the lastintervention contact (2830,36,40,43).Seven studies demonstrated improvedknowledge for both the intervention andcontrol groups (4753), suggesting pos-sible contamination due to the infeasibil-ity of blinding participants. A number ofstudies demonstrated that regular rein-forcement or repetition of the interven-tion seemed to improve knowledge levelsat variable lengths of follow-up: Bloom-garden et al. (34) (nine visits in 18months), Korhonen et al. (35) (one visitevery 3 months for 12 months), Campbellet al. (29) (regular reinforcement with vis-its and telephone calls over 12 months),and Rettig et al. (46) (12 visits in 12months). Knowledge was measured usinga variety of instruments, often specificallydeveloped for the study and lacking indocumented reliability and validity(26,30,32,33,35,39,44,47,52,5456).Self-care. Several studies observed in-creased frequency of, or more accurateSMBG, demonstrated by a decreased dis-crepancy between measurement by thepatient and health-care personnel(40,45,5759) (Table 2). Several studiesexamined the relationship between skillsteaching and glycemic control. Althoughthree of these studies (40,57,60) noted anincrease in frequency of SMBG, no corre-sponding improvement in HbA1c wasfound. Wing et al. (61) taught adjustmentof diet and physical activity in conjunc-tion with SMBG, but the patients in thisstudy failed to show improved glycemiccontrol at 1 year.
Several studies examined interven-tions focusing on foot lesions with mixedresults. Litzelman et al. (62) noted a de-crease in serious foot lesions at 1 year af-ter an intervention consisting of groupeducation, with three follow-up visits, pro-vider guidelines, and chart remind-ers. Other studies failed to demonstrateimprovements with interventions(41,46,63). Malone et al. (64) found a sig-nificant decrease in foot ulcer and ampu-
tation rates, although this study hadsignificant methodological inadequacies.
Lifestyle behaviorsMost studies that examined dietarychanges were positive for self-reportedchanges, including improvements in di-etary carbohydrate or fat intake(38,39,6570) (Table 3), a decrease in ca-loric intake (39,67), and an increase inconsumption of lower glycemic-indexfoods (71). A few studies demonstratingimproved dietary changes found corre-sponding improvements in weight(38,66,72) or glycemic control (31). Onlytwo studies failed to show improvementin diet: one had an 18-month follow-upand an intervention delivered every 3months (35), and the other (73) notedimproved dietary habits during the inter-vention but no significant difference at 6months.
Studies measuring physical activityoutcomes had variable results. Hanefeldet al. (65) demonstrated an increase inactivity at 5 years with a didactic interven-tion. Among studies with shorter fol-low-up duration, Wood (54) noted anincrease in physical activity at 4 months,Glasgow et al. (74) found an increase inthe number of minutes of activity 3months after an intensive intervention,and Wierenga (75) found improved phys-ical activity after five intervention sessionsat 4 months. Five studies found nochanges in physical activity comparedwith control groups (30,40,69,76,77). Itis unclear what factors might account forsuccess in some studies and not in others.
Psychological and quality-of-lifeoutcomesFour studies examined psychological out-comes (Table 3) (33,40,74,78); improve-ments were noted in problem solving (74)and anxiety levels (33). Quality of life wasexamined in three studies. Kaplan et al.(79) noted an increase in quality of life at18 months for an intervention subgroupthat received intensive counseling onboth diet and physical activity. Two stud-ies of brief interventions failed to demon-strate improved quality of life (60,67).
Glycemic controlStudies that focused on glycemic controlare described in Table 4 and Fig. 1. Bothcontrol and intervention study groupstended to have improved glycated hemo-globin measures (29,31,32,36,48,49,60,
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DIABETES CARE, VOLUME 24, NUMBER 3, MARCH 2001 563
Table 2Effect of self-management training on knowledge, attitudes, and self-care skills
Referencen, F/U interval,and mean age Interventions Outcomes Comments
1. Didactic, knowledge, and information interventions33 n 5 60; F/U immediate, 4
weeks; ?ageI: Four weekly group sessions;
individual as neededC: Started same education 4 weeks
later
Increased knowledge I vs. C at 4weeks, P , 0.01
No BL statistics; I more visits than CAttrition 29%, dropouts not equal to
completers at BLLow participation rate, but NSD
participants and nonparticipants34 n 5 345; F/U immediate;
58 yearsI: Nine multimedia education classes
over 1.5 yearsC: Usual care
Increased knowledge I vs. C,P 5 0.0073
NSD behavior score;NSD foot lesions
No mention blinding assessorLow participation rate;
nonparticipants older, more males
35 n 5 77; F/U 618 monthsfrom BL; 33 years
I: 5-day IP teaching: didactic,individual F/U q3 months, phoneaccess; instruction in self-adjustment insulin
C: 5-day IP traditional education 1written information; 3 3 1.5-hsessions; q3 months F/U
Increased knowledge both C andI, I . C, P , 0.01 at 12 months
Increased urine testing I and C(NSD between groups)Knowledge not correlated with BS
control
No BL comparison statisticsNo attrition informationNo blinding for diet historyLow recruitment rate and no
information on nonparticipants
42 n 5 30; F/U immediate;59 years
I: 15-min video featuring local HCWin Spanish
Increased knowledge in I, effect sizemoderate (0.61)
No BL comparison of demographicsUnclear if assessor blinded
C: Pretest only, then viewed video Convenience sampleI had no pretest to avoid bias from
retesting47 n 5 51; F/U 12 months
from BL; 53 yearsI: Three weekly didactic, small group
sessions q4 months 1 q2 monthsvisit with doctor
NSD knowledge between groups I more visits than CNo information on participation rates
C: Visit with doctor q2 months51 n 5 40; F/U immediate;
60 yearsI: 1-h individual education based on
patients prioritiesC: 1 h individual education based on
educators priorities
Increased knowledge both groups,P , 0.0001, NSD between groups
Unclear if assessor blindedConsecutively referred patientsType of DM unclear
52 n 5 111; F/U 23 months;56 years
I: One-page drug information sheetgiven to patients attending clinic
Both groups increased knowledge;NSD between groups
C: Usual care57 n 5 31; F/U 1 week; HbA1c
F/U 2 months; 65 yearsI: Four weekly TC after hospital
discharge: identify deficits andteach
I more frequent SMBG and increasedhypoglycemic prevention,P , 0.05
I more contact than CUnclear if assessor blindedNo information on nonparticipants
C: No TC or other contact2. Collaborative, knowledge, and information interventions26 n 5 80; F/U 6 months from
BL; 53 yearsI: Group sessions: didactic and
discussions; no details of durationor frequency; F/U every 3 months
Increased knowledge in I vs. C,P , 0.01
Attrition 25%, no comparisondropouts to completers
C: Care at general medical clinicevery 3 months
27, 28 n 5 532; F/U 1214months; 57 years
I: Average 2.4 sessions 3 1.5 h over2 months 1 home visit, TC F/U,contracting, skill exercises, goal-setting; over 26 months
C: Usual care
Achievement of some knowledge,skill, and self-care objectives in Ivs. C, P , 0.05
I more visits than CAttrition 51%, differences dropouts
and completersNo blinding assessorLow participation rate
29 n 5 238; F/U 3, 6, 12months from BL; 56 years
I-1: 13 individual sessions in 12months
Increased knowledge I-3 at 3 and 6months, P , 0.05
BL differences: I-2 better educated,I-1 longer duration DM
I-2: Three-day interactive course 1F/U 3 and 9 months 1 twoindividual sessions
I-3: Six or more individual sessionsbased on cognitive behaviortheory, TC F/U over 12 months
I more visits than CDropouts longer duration DM than
completersUnclear if study population
represents target population
C: 2 3 1-hour group education30 n 5 46; F/U immediate, 6
months; 66 years1: 8 3 2-hour small group sessions
over 3 months; problem- andparticipant-focused
C: One-day didactic teaching
Increased knowledge at 6 months Ivs. C, P , 0.05
I more visits than CMore C excluded due to poor controlNo mention blinding assessorNonparticipants older and heavier
32 n 5 174; F/U 46 months;57 years
I-1: Computer knowledge assessmentprogram (KAP) 1 interactivecomputer teaching (60 min)
I-2: KAP (2040 min) 1 feedbackI-3: KAP only
Increased knowledge all I, P , 0.05(within group)
Randomization by year and birthmonth (no details given)
I more contact than CNIDDM results reported here (49%
of total study population IDDM)C: No intervention
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564 DIABETES CARE, VOLUME 24, NUMBER 3, MARCH 2001
Table 2Continued
Referencen, F/U interval,and mean age Interventions Outcomes Comments
40, 60 n 5 558; F/U 6 months;45 years
I-1: Collaborative education byHCW, 3 h/week 3 4 weeks
I-2: Same education, led by fellowpatient
C: No interventionI based on Fishbein and Ajzen Health
Belief Model
Increased knowledge both I,P , 0.001;
Increased DM locus of control,P , 0.001
Improved attitude and frequencySMBG both I, P , 0.05
Increased self-adjustment of insulinboth I, P , 0.01
Hospitals randomizedI more visits than CUncertain blinding assessor
44 n 5 24; F/U immediate;3565 years
I: 1-h computer-based drill withfeedback including explanation ofcorrect answer
Increased knowledge in I vs. C,P 5 0.005
NSD attitudes toward the drill
No BL comparisonsVolunteer study population
C: As for I, but right/wrong feedbackonly
I and C received 14-min instructivevideo before computer drill
46 n 5 471; F/U 6, 12 monthsfrom BL; 52 years
I: Home visits, teaching based onneeds assessment, maximum 12visits
C: Usual care
Increased knowledge at 6 months,P 5 0.001
NSD foot appearance score at 6months
Attrition 20%, no comparisondropouts to completers
70% of eligible participated
Increased medication skills at 6months, P 5 0.04 and urinetesting, P 5 0.01
48 n 5 82; F/U 6 months fromBL; 56 years
I-1: 11 3 2-h didactic weekly course1 1 individual session
Increased knowledge for all threegroups; NSD between groups
No BL statistics comparing groupsI more visits than C
I-2: 11-week course 1 threeindividual sessions: barriers andsupport
C: Usual care
NSD health locus of control Attrition 40%, no comparisondropouts to completers
Volunteer study population
50 n 5 40; F/U 3 months;57 years
I: CAI, 4 3 1-h sessions: didactic,some feedback and testing
C: Didactic group teaching; 4 3 3-h
Increased knowledge both groups;NSD between groups
No BL group comparison statisticsLow participation rate, no informa-
tion on nonparticipants or dropouts54 n 5 107; F/U 1, 4 months;
60 yearsI: 2 3 2-h group didactic 1 practice
1 feedback 1 usual careC: Usual care: individual education
based on perceived patient needBoth in IP setting
Increased compliance to insulininjection time for I at 4 months,P 5 0.05
Randomized by hospital numberNo blinding assessorNo information on participation rates
55 n 5 41; F/U 2 months;60 years
I-1: Three-day program 1 groupsession with pharmacist
NSD change in knowledge between Iand C or between I-1 and I-2
No BL comparisonI more contact than C
I-2: Three-day program 1 individualsession with pharmacist; TC F/U
Improved attitudes/perceptionstowards medications in
23% had unusable data for SMBG
C: Standard center 3-day educationprogram
I vs. C, P , 0.05NSD attitudes to SMBG
56 n 5 53; F/U 35 weeks;63 years
I: 2 3 5-min TC in 5 weeks; focusknowledge and skills
NSD overall knowledge Attrition 25%, no comparisondropouts to completers
C: 2 3 15-min individual visits in 5weeks, same content
Both groups individual educationimmediately before intervention
59 n 5 60; F/U 3 months fromBL; 55 years
I: Three-day group education, withF/U of four TC and one home visit;reinforce knowledge and skills
Frequency SMBG I . C,P , 0.0001
I more contact than CUnclear if study populationrepresents target population
C: Three-day group education98 n 5 22; F/U 32 weeks from
BL; 61 yearsI: Weekly to biweekly home visits:
nutrition, exercise, foot care,SMBG; by nursing students
C: Usual care
NSD knowledge between groupsIncreased self-care competency in
I vs. C, P 5 0.003
Attrition 24%, no comparisondropouts to completers
No mention blinding assessorUnclear if study population
represents target population99 n 5 56; F/U 6 months;
64 yearsI: Monthly 3 6 group sessions:
behavior modification (contracts,feedback), and general knowledge
C: Usual care
Increased knowledge at 6 months,P 5 0.0003
I more contact than CAttrition 32%, no comparison
dropouts to completersParticipation rate 37%, no
comparison participants tononparticipants
108 n 5 280; F/U 6 months;55 years
I: Education on importance of eyeexamination: booklet, video; oneinteractive TC
C: Usual care
Increased rate of retinal examinationin I (OR 5 4.3, 95% CI 2.47.8)
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DIABETES CARE, VOLUME 24, NUMBER 3, MARCH 2001 565
Table 2Continued
Referencen, F/U interval,
mean age Interventions Outcomes Comments
3. Lifestyle interventions31 n 5 40; F/U 6 months from
BL; 35 yearsI-1: Lunch demonstrationsI-2: Videotape educationC: Dietitian instruction and written
informationThree visits total for all groups over 6
months
Increased knowledge in I-1 and I-2,P , 0.001
No mention blinding assessorStudy population selected by
researchers; low participation rateType of diabetes unclear (insulin
dependent)
36 n 5 87; F/U 12 monthsfrom BL; 56 years
I: Five group sessions over 6 months,focus on weight loss
Increased knowledge I . C,P , 0.001
C: Individual education on weightloss by dietitian; 3 or more visits in12 months
37 n 5 105; F/U 6 months;58 years
I: Diet guide: guidelines, nutritiongoals, food logs
C: Traditional exchange list teachingBoth groups taught at 3 3 2.25-h
weekly sessions
NSD diet principals; Increasedapplied nutrition knowledgeI . C, P , 0.01
Attitude to life and diet, and dietknowledge improved I and C,P , 0.05
Attrition 21%, no information ondropouts
Unclear how patients recruited
38 n 5 32; F/U immediate;53 years
I: Two sessions: dietitian and CAIC: 2 3 30-min sessions: dietitian
onlyTeaching for both over ;1 month
Increased exchange list knowledgefor I, P , 0.05; NSD C
No BL statisticsUnclear if blinding assessorType of DM unclear
39 n 5 105; F/U immediate,12 months; 45 years
I: Interactive computer program ondiet; 90 min/month over 6 months
C: Wait listed for IBoth groups received 5 days of
teaching
Increased knowledge for I,P , 0.0001; NSD for C
I more contact than CAttrition appears to be 76% at 12
months F/UNo comparison dropouts to
completersNo mention blinding assessorNo information on patient
recruitmentCrossover design
43 n 5 201; F/U 6 months;53 years
I: Culturally appropriate flashcards:diet, SMBG; delivered by lay HCW
Increased knowledge, self-care inI vs. C, P , 0.05
I more contact than CIntensity of intervention unclear
C: Usual care49 n 5 41; F/U 6 months;
61 yearsI: Psychologist-led group sessions on
PA and dietC: Didactic lectures on diet and DMBoth groups 10 3 1-h sessions over
6 months
Increased knowledge for bothgroups, P , 0.05, NSD betweengroups
Dropouts (22%) had higher mean BS;equal number dropouts I and C
Low participation rate, noinformation on nonparticipants
75 n 5 66; F/U 4 months;3086 years
I: 5 3 90-min weekly sessions bynurse: diet, PA, barriers, social andgroup support
C: No information on care received
Improved health attitudes I vs. C,P 5 0.015
NSD perceptions of health relating toDM
No BL statisticsVolunteer study populationNumber of visits uncertain
76 n 5 64; F/U 3, 6 monthsfrom BL; 62 years
I: 12 3 1.5-h weekly (didactic)sessions, then 6 3 1.5-h biweeklyparticipatory sessions; based onsocial action theory
Increased nutrition knowledge at 3months; NSD from BL at 6 months
I more visits than CMore C dropouts, no comparison
dropouts to completersVolunteer study population
C: One didactic class and twomailings
80 n 5 40; F/U 2, 5 monthsfrom BL; 59 years
I: 3 3 1.5-h individual learningactivity packages with dietinformation, goals, activities
C: 3 3 1.5-h didactic lectures
Increased knowledge for 1 at 5months, P , 0.05
Attrition 23%, no comparisondropouts to completers
Volunteer study population from DMeducation program
83 n 5 596; F/U immediate, 6months; 51 years
I: More nutrition content, follow foodpyramid
C: Usual education, given meal planBoth I and C: 5 3 2-h weekly group
sessions
NSD attrition, knowledge, self-carebetween choice/no choice groups
NSD knowledge, self-care betweenI and C
Randomized into choice/no choice ofprogram, then I and C
Attrition 28%, dropouts younger,more male
No mention blinding assessorPhysician-referred patients or
volunteers95 n 5 120; 12 months from
BL; 61 yearsI: Group education (diet, PA, BS
control) q3 months 3 4C: Usual care
Increased knowledge in I,P , 0.001
I more contact than CUnclear if study population
represents target population
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566 DIABETES CARE, VOLUME 24, NUMBER 3, MARCH 2001
66,68,74,78,8083) (Fig. 1). All studieswere unblinded. In 14 studies, an im-provement was noted in glycemic controlin the intervention group compared withthe control group (26,28,32,33,47,48,50,
65,71,76,79,8487). Percentage changein glycated hemoglobin ranged from 26to 14% in the intervention groups andfrom 33 to 115% in the control groups.In three studies, glycated hemoglobin de-
creased more in the control group(61,80,83), although the difference wassignificant in only one study (80).
Length of follow-up after completionof an intervention seemed to have a major
Table 2Continued
Referencen, F/U interval,and mean age Interventions Outcomes Comments
4. Skills teaching interventions41 n 5 70; F/U 6
months; 59 yearsI: 9 h over 4 weeks: participatory foot
care based on cognitive motivationtheory
C: Usual DM teaching: 14 h didactic/3 days, including 1 h foot care
Increased knowledge both groups at 6months, I . C, P , 0.001
Increased compliance foot care routines at 6months, I . C, P 5 0.012
Compliance correlates with decreased footproblems, P 5 0.002
Decreased food problems both I and C, NSDbetween groups at 6 months
Compliance correlates with decreased footproblems, P 5 0.002
Volunteer study population
45 n 5 34; F/U 8 weeks;37 years
I: Self-study course on self-controland self-management SMBG, over4 weeks
C: Usual care
Increased knowledge and skills for I . C,P , 0.01
Increased SMBG goal adherance rate morefor I than C, P , 0.01
No BL statisticsAttrition 26%, no comparison
dropouts to completersCommunity recruitment; participants
self-selectedType of DM unclear
53 n 5 50; F/U 1month; 73 years
I: 24-min instructional video ontechnique SMBG
Increased knowledge both groups, NSDbetween groups
No mention blinding assessor
C: Group didactic instruction ontechnique SMBG
No improvement SMBG technique I or C
58 n 5 30; F/Uimmediate;55 years
I: SMBG instruction for 30 min byeducator
C: Self-instruction SMBG for 30 min
Decreased error BS measurement in I,P , 0.01
62 n 5 395; F/U 12months from BL;60 years
I: Group foot education with F/U 33over 3 months; chart reminders forproviders, provider guidelines
C: Usual care
Decreased serious foot lesions in I at 1 year,P 5 0.05
I had more appropriate foot care behaviors,P , 0.05
Physicians examined I feet more often atoffice visits, P , 0.001
Randomized by practice teamI more contact than CLow participation rate; no
information on nonparticipants
63 n 5 50; F/U 6months; adult
I: Additional participatory teachingon foot care
Self-care practices increased both groups, nostatistics
Randomized by week enteringprogram; no BL comparisons
C: Usual education, with routine,didactic foot education
Both groups: 5 days of OP DMeducation
Increased knowledge foot care for C only,P 5 0.02
NSD physical assessment feet I or C
Attrition 35% I, 44% C, nocomparison dropouts tocompleters
No mention blinding assessorNo demographic data; type of DM
unclear64 n 5 203; F/U 13
months I, 9 monthsC; ?age
I: 1-h didactic group education onfoot care
C: No education
Decreased foot ulcer rate, P , 0.005Decreased amputation rate, P , 0.025NSD infection rate
Randomized on SSNNo information on dropoutsNo mention blinding assessorNo information on nonparticipantsType of DM unclear
5. Coping skills interventions85 n 5 64; F/U 6 weeks;
50 yearsI: 6 3 2-h weekly group sessions:
patient empowerment, goal-setting, problem solving, stressmanagement
C: Wait listed
Increased 4/8 self-efficacy subscales, betweengroup difference, P , 0.02
No BL comparisons; 18 patients notrandomly assigned
I more contact than CVolunteer study population64% DM2HbA1c measured immediately after
program for C, 6 weeks after for I86 n 5 32; F/U 2 years;
68 yearsI-1: Six weekly sessions 1 18
monthly support group sessions:coping, discussion, education
Increased knowledge maintained for I-1 at 2years, P , 0.05
C is nonrandomized comparisongroup
More visits for I-1 . I-2 . CI-2: Six-week sessions only; wait list
for support groupC: Usual care
No information on attritionUnclear if study population
represents target populationType of DM unclear
BL, baseline; BS, blood sugar; BP, blood pressure; C, C-1, C-2, control groups; CAI, computer-assisted instruction; CHO, carbohydrate; D/SBP, diastolic/systolicblood pressure; DM, diabetes mellitus; DM2, type 2 diabetes; FBS, fasting blood sugar; F/U, follow-up; HCW, health-care worker; I, I-1, I-2, I-3, intervention groups;IP, inpatient; NSD, no significant difference; OP, outpatient; PA, physical activity; q, every; RN, registered nurse; SD, significant difference; TC, telephone call.
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Table 3Effect of self-management training on lifestyle behaviors, psychological outcomes, and quality of life
Referencen, F/U interval,and mean age Interventions Outcomes Comments
1. Didactic, knowledge, and information interventions33 n 5 60; F/U
immediate, 4weeks; ?age
I: Four weekly group sessions: individualas needed
C: Started same education 4 weeks later
Decreased anxiety at 4 weeks I vs. C,P , 0.05
NSD depression score
No BL statisticsI more visits than CAttrition 29%, dropouts not equal
completers at BLLow participation rate, but NSD
participants and nonparticipants35 n 5 77; F/U 6 to
18 months fromBL; 33 years
I: Five days IP teaching: didactic,individual F/U q3 months, phoneaccess; instruction in self-adjustmentinsulin
C: Five days IP traditional education 1written information; 3 3 1.5-hsessions; q3 months F/U
NSD diet adherence at 18 months No BL comparison statisticsNo attrition informationNo blinding for diet historyLow recruitment rate and no
information on nonparticipants
65, 109 n 5 1,139; F/U 5years; 46 years
I-1: Didactic individual and groupsessions q3 months: focus on diet, PA,smoking, BP, and BS control
I-2: I-1 1 clofibric acidC: Usual care at DM clinics; q34
months
Increased polyunsaturated fats in Ivs. C, P , 0.01
Increased PA in I vs. C, P , 0.01
No mention blinding assessorLow participation rate, no
information on nonparticipantsClofibric acid arm double-blinded
2. Collaborative, knowledge, and information interventions30 n 5 46; F/U
immediate, 6months; 66 years
I: 8 3 2-h small group sessions over3 months; problem- and participant-focused
NSD exercise I more visits than CMore C excluded due to poor controlNo mention blinding assessor
C: One day didactic teaching Nonparticipants older and heavier40, 60 n 5 558; F/U 6
months; 45 yearsI-1: Collaborative education by HCW,
3 h/week 3 4 weeksNSD hypoglycemic reactions,
anxiety, PAHospitals randomizedI more visits than C
I-2: Same education, led by fellowpatient
Uncertain blinding assessor
C: No interventionI based on Fishbein and Ajzen Health
Belief Model54 n 5 107; F/U 1,
4 months; 60 years1: 2 3 2-h group didactic 1 practice 1
feedback 1 usual careIncreased exercise I vs. C at 1 and 4
months, P 5 0.05Randomized by hospital numberNo binding assessor
C: Usual care: individual educationbased on perceived patient need
Both in IP setting
No information on participation rates
98 n 5 22; F/U 32weeks frombaseline; 61 years
I: Weekly to biweekly home visits:nutrition, exercise, foot care, SMBG;by nursing students
C: Usual care
NSD food assessment, 3-day dietaryrecall, functional health statusbetween groups
Attrition 24%, no comparisondropouts to completers
No mention blinding assessorUnclear if study population
represents target population3. Lifestyle interventions31 n 5 40; F/U 6
months from BL;35 years
I-1: Lunch demonstrationsI-2: Videotape educationC: Dietitian instruction and written
informationThree visits total for all groups over 6
months
Decreased CHO variation in I-1 andI-2, P , 0.01
No mention blinding assessorStudy population selected by
researchers; low participation rateType of diabetes unclear (insulin
dependent)
38 n 5 32; F/Uimmediate;53 years
I: Two sessions: dietitian and CAIC: 2 3 30-min sessions: only dietitianTeaching for both over approximately 1
month
Decreased % fat intake I, P , 0.005;NSD C
No BL statisticsUnclear if blinding assessorType of DM unclear
39 n 5 105; F/Uimmediate, 12months; 45 years
I: Interactive computer program on diet;90 min/month over 6 months
C: Wait listed for IBoth groups received 5 days teaching
Decreased caloric and fat intake forthose in I with initial high intake,P , 0.05
I more contact than CAttrition appears to be 76% at 12
months F/U, no comparisondropouts to completers
No mention blinding assessorNo information on patient recruitmentCrossover design
66 n 5 148; F/U 6months from BL;55 years
I: Advice to decrease fat to ,30% totalcalorie intake
C: Advice to decreased CHO to ,40%total calorie intake
Both individual counseling by dietitian,three home visits
Decreased fat and cholesterol intake,increased CHO for I, betweengroup difference,P , 0.001
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568 DIABETES CARE, VOLUME 24, NUMBER 3, MARCH 2001
Table 3Continued
Referencen, F/U interval,and mean age Interventions Outcomes Comments
67, 68, 104 n 5 206; F/U 12months from BL;62 years
I: Single visit: focus on diet; goal-setting,interactive video on barriers; F/U q3months
C: Usual care q3 months
Improvement in I vs. C at 12 monthsfor food habits, 4-day food record,kcal/day, % calories from fat,P , 0.05
Unclear if food record reviewersblinded
Low participation rate; participantsdiffer from nonparticipants
69, 82, 89,103
n 5 86; F/U 15, 27months from BL;53 years
I: Six individual visits at 2-monthintervals: intensive therapy for weight,BS control, diet, PA; then q3 monthsvisits
C: Usual care q23 months
Fat intake ,30% of total energy,I . C at 15 months, P , 0.05
NSD energy intakeNSD physical activity, Vo2max at
15 months
I more visits than CNo mention blinding assessorNo information on nonparticipants
Both groups got 3 visits/3 months basiceducation before randomization
70 n 5 75; F/U 12months from BL;61 years
I: Educational videos, personal andfamily support q2 weeks for 6 months1 3 h counseling by dietitian
C: Review session 3 3
Decreased self-reported fat intake,P 5 0.0002
NSD self-reported total food or fiberintake
I more contact than C
71 n 5 60; F/U 12weeks from BL;55 years
I: Individualized advice on low glycemicindex foods
C: Standard, individualized diet advice
Consumption of lower glycemicindex foods I . C, P , 0.01
No mention blinding assessorUnclear how much intervention time
72 n 5 78; F/U 2months;4275 years
I-1: 5 3 2-h weekly education: calories,fat, fiber
I-2: I-1 1 goal setting, problem-solving,feedback
C: Wait listed for I
Decreased calories and % fat F/U forI-2 at immediate and 2 months,P , 0.01
Decreased calories for I-1 at 2months, P , 0.05
No BL informationI more visits than CMore attrition in C, no comparison
dropouts to completersUnclear if assessor blindedUnclear how study population
recruited73 n 5 70
F/U immediate 6months; 42 years
I: Monthly (or more) meetings: diet andPA prescription, feedback, behaviormodification
C: Usual care, wait listed for I
Decreased total fat intake atimmediate F/U, I vs. C,P 5 0.047
Deterioration of diet improvementsat 6 months
Incomplete BL statisticsI more visits than CNo mention blinding assessorVolunteer study population; cross-
over designType of DM uncertain (IDDM)
74 n 5 102; F/U 3, 6months from BL;67 years
I: Ten weekly sessions: problem-solving,increased self-efficacy; diet and PAfocus
C: Wait listed for I
Increased problem-solving for I at 3and 6 months; between group,P , 0.05
Randomization blocked bymedication
I more visits than CVolunteer study population
75 n 5 66; F/U 4months; 3086years
I: Five 3 90-min weekly sessions bynurse: diet and PA, barriers, social andgroup support
Improved health practices (diet, PA)I vs. C, P 5 0.015
No BL statisticsVolunteer study populationNumber of visits uncertain
C: No information on care received76 n 5 64; F/U 3, 6
months from BL;62 years
I: 12 3 1.5-h weekly (didactic) sessions,then 6 3 1.5-h biweekly participatorysessions; based on social action theory
Increased PA 3 months; NSD 6months
I more visits than CMore C dropouts, no comparison
dropouts to completersC: One didactic class and two mailings Volunteer study population
77 n 5 53; F/U 16months from BL;55 years
I-1: 16 weekly sessions of behavioralmodification: calorie logs, group PA,monetary incentives
I-2: 16 weekly didactic sessions:nutrition and PA
C: Four monthly didactic sessions
Improved eating and PA all groups at4 months, NSD between groups;regression toward BL at 16 m butremained significant
I more visits than CVolunteer study population
78, 97 n 5 79; F/Uimmediate;68 years
I-1: 10 3 60-min diet education sessionsover 4 months; adapted for elderly
I-2: I-1 1 peer support: group sessions;modeling, reinforcement
C: Usual care
Peer support levels correlated withweight loss, glycemic control,P , 0.05
Randomized by siteNo BL comparisons or attrition
informationI more visits than CCommunity recruitment; volunteer
study population83 n 5 596; F/U
immediate, 6months; 51 years
I: More nutrition content, follow foodpyramid
C: Usual education, given meal planBoth I and C: 5 3 2-h weekly group
sessions
NSD physical function betweenchoice/no choice groups orbetween I and C
Randomized into choice/no choice ofprogram, then I and C
Attrition 28%, dropouts younger,more male
No mention blinding assessorPhysician-referred patients or
volunteers93 n 5 70; F/U 6
months from BL;58 years
I: 22 h over 11 weeks, interactiveteaching based on cognitivemotivational theory
C: Didactic teaching, 14 h over 3 daysFocus for both I and C: diet and foot care
Increased dietary CHO but NSDbetween groups
Decreased % fat for both groups at 1month, I . C, P 5 0.004
I more contact than C
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DIABETES CARE, VOLUME 24, NUMBER 3, MARCH 2001 569
effect on outcomes, and studies with a fol-low-up period of #6 months tended todemonstrate greater effectiveness (3133,48,50,71,76,84). Few studies had fol-low-up periods longer than 1 year afterthe last intervention contact, and theseshowed mixed effects on glycemic con-trol. The positive studies were either veryintensive interventions (79) or had a highattrition rate, leaving a very select group atfollow-up (28). Studies with prolongedinterventions (follow-up periods .1 yearand regular contacts with the interventionsubjects during that time) also had mixedresults. Two studies (47,65) demon-strated improved glycemic control, al-though generalizability of these studies isdifficult due to a low participation rate(65) and a lack of information on studyparticipation (47). Ten others producedno significant effects, despite regular pa-tient contact (29,34,35,67,69,82,86,8890).
For knowledge and information in-
terventions, the method of deliveryseemed to have a relationship to glycemiccontrol. Compared with didactic inter-ventions, collaborative interventions pro-duced somewhat more favorable results,particularly if interventions were repeti-tive and ongoing (26,28,48,50,76,84,86).
Most studies focusing on changes inlifestyle generally failed to show improve-ments in glycemic control compared withcontrol groups (36,39,43,49,66,67,70,7274,77,78,81 83,88,90 95), but afew studies (31,71,79,84) showed im-proved glycemic control in researcher-selected or volunteer populations withfollow-up ,6 months. Improved glyce-mic control was associated with weightloss in some studies (28,47,48,76,79) andnot others (31,65,71,84). Increased phys-ical activity levels were associated withimproved glycemic control in one study(65), although another study noted no
changes in physical activity despite im-provements in glycemic control (76).
Improved glycemic control and in-creased knowledge were not consistentlycorrelated. Although a number of studiesdemonstrated an increase in knowledgewith an improvement in glycemic control(2628,3133,50), others demonstratedimproved metabolic control with nochange in knowledge (47,76), and eightstudies demonstrated increased knowl-edge but no significant improvement inglycemic control (29,34 36,40,49,80,88). Two of three studies focusing oncoping-skills training produced improve-ments in glycemic control (85,86); theseinvolved frequent group support meet-ings.
Computers have been used recentlyas an educational tool in a number ofstudies, and effects on glycemic controlhave been mixed: positive results in threestudies (32,39,50) and negative results inanother study (67,68). Additionally, vid-
Table 3Continued
Referencen, F/U interval,and mean age Interventions Outcomes Comments
95 n 5 20; 12 monthsfrom BL; 61 years
I: Group education (diet, PA, BS control)q3 months 3 4
C: Usual care
NSD quality of life I more contact than CUnclear if study population
represents target population106 n 5 53; F/U 16
weeks from BL;55 years
I-1: Nutrition education: 16 weeklysessions; exchange system diet, goal-setting
I-2: Nutrition education: four monthlysessions; exchange system diet, goal-setting
C: Behavior modification: 16 weeklyvisits; calorie-counting diet, goal-setting
Decreased caloric intake and %calories from fat in I and C,P , 0.001; NSD between groups
I-2 more visits than CVolunteer study populationI-1 and I-2 combined in analysis, as
NSD between groups
107 n 5 152; F/U 10, 14weeks from BL;.50 years
I: 10 3 2-h sessions over 14 weeks,culturally sensitive video; nutritionfocus
C: No intervention
Decreased intake kcal/d C males,P 5 0.04
Decreased cholesterol intake Cfemales, P 5 0.013
No BL comparisonsI more visits than CAttrition 30.2%No information on dropoutsNo information on blinding assessorVolunteer study population
4. Skills teaching interventions90 n 5 50; F/U 1 year
from BL; 54 yearsI: Focused on relationship weight loss
and BS control; monetary incentivesReduction in medications both
groups, NSD between groupsVolunteer study population
C: Weight loss programBoth groups: 12 weekly meetings, then
monthly 3 6, F/U in 3 months;behavioral weight control program
Decreased caloric intake C,P , 0.004
Decreased depression both groups,NSD between groups
5. Coping skills interventions86 n 5 32; F/U 2 years;
68 yearsI-1: Six weekly sessions 1 18 monthly
support group sessions: coping,discussion, education
Increased quality of lifeDecreased stress I-1 vs. C at 6
months P , 0.05
C is nonrandomized comparisongroup
More visits for I-1 . I-2 . CI-2: Six weekly sessions only; wait list for
support groupC: Visual care
No information on attritionUnclear if study population
represents target populationType of DM unclear
BL, baseline; BS, blood sugar; BP, blood pressure; C, C-1, C-2, control groups; CAI, computer-assisted instruction; CHO, carbohydrate; D/SBP, diastolic/systolicblood pressure; diabetes mellitus; DM2, type 2 diabetes; FBS, fasting blood sugar; F/U, follow-up; HCW, health-care worker; I, I-1, I-2, I-3, intervention groups; IP,inpatient; NSD, no significant difference; OP, outpatient; PA, physical activity; q, every; RN, registered nurse; SD, significant difference; TC, telephone call.
Self-management training in type 2 diabetes
570 DIABETES CARE, VOLUME 24, NUMBER 3, MARCH 2001
Table 4Effect of self-management training on glycemic control
Referencen, F/U interval,and mean age Interventions Outcomes Comments
1. Didactic, knowledge, and information interventions33 n 5 60; F/U
immediate, 4weeks, ?age
I: Four weekly group sessions; individualsessions as needed
C: Started same education 4 weeks later
Decreased HbA1c at 4 weeks I vs. C,P , 0.05
I more visits than CNo BL statisticsAttrition 29%, dropouts not equal
to completers at BLLow participation rate, but NSD
participants and nonparticipants34 n 5 345; F/U
immediate; 58years
I: Nine multimedia education classesover 1.5 years
C: Usual care
NSD HbA1c or FBS No mention blinding assessorLow participation rate;
nonparticipants older, more male35 n 5 77; F/U 618
months from BL;33 years
I: Five days IP teaching: didactic,individual F/U q3 months, phoneaccess; instruction in self-adjustmentinsulin
C: Five days IP traditional education 1written information; 3 3 1.5-hsessions; q3 months F/U
Decreased FBS for C and I at 1month, NSD between groups
NSD from BL at 6 months
No BL comparison statistics;no attrition information;No blinding for diet history
Low recruitment rate and noinformation on nonparticipants
47 n 5 51; F/U 12months from BL;53 years
I: Three weekly didactic, small groupsessions q4 months 1 q2 months visitwith doctor
Decreased HbA1c and FBS in I vs. C,P , 0.05
Exact values not given
I more visits than CNo information on participation rates
C: Visit with doctor q2 months57 n 5 31; F/U 1 week,
HbA1c F/U 2months; 65 years
I: Four weekly TC after hospitaldischarge: identify deficits and teach
C: No TC or other contact
NSD HbA1c between groups I more contacts than CUnclear if assessor blinded
No information on nonparticipants65, 109 n 5 1,139; F/U 5
years; 46 yearsI-1: Didactic individual and group
sessions q3 months; focus on diet, PA,smoking, BP and BS control
I-2: I-1 1 clofibric acidC: Usual care at DM clinics; q34 months
Decreased FBS in I vs. C, P , 0.01 No mention blinding assessorLow participation rate, no
information on nonparticipantsClofibric acid arm double-blinded
2. Collaborative, knowledge, and information interventions26 n 5 80; F/U 6 months
from BL; 53 yearsI: Group sessions: didactic and
discussions; no details duration orfrequency; F/U q3 months
C: Care at general medical clinicq3 months
Decreased FBS in I vs. C at 6 months(9.7 vs. 6.4 mmol/l), P , 0.01
Attrition 25%, no comparisondropouts to completers
27, 28 n 5 532; F/U 1214months; 57 years
I: Average 2.4 sessions 3 1.5-h over 2months 1 home visit, TC F/U,contracting, skill excercises,goal-setting; over 26 months
C: Usual care
Decreased HbA1c in I (0.43%),P , 0.05, increased in C (0.35%)
Decreased FBS I vs. C, P , 0.05
I more visits than CAttrition 51%, differences
dropouts and completersNo blinding assessorLow participation rate
29 n 5 238; F/U 3, 6,12 months post BL;56 years
I-1: 13 individual sessions in 12 monthsI-2: Three-day group interactive course
1 F/U 3 and 9 months 1 2 individualsessions
I-3: Six or more individual sessionsbased on cognitive behavioral theory,TC F/U over 12 months
C: 2 3 1-h group education
Decreased HbA1c for all groups at allF/U intervals
NSD between groups
BL differences: I-2 better educated;I-1 had longer duration DM
I more visits than CDropouts longer duration DM than
completersUnclear if study population
represents target population
30 n 5 46; F/Uimmediate,6 months; 66 years
I: 8 3 2-h small group sessions over 3months; problem- and participant-focused
NSD HbA1c at 6 months More C excluded due to poor controlI more visits than CNo mention blinding assessor
C: One-day didactic teaching Nonparticipants older and heavier32 n 5 174; F/U 46
months; 57 yearsI-1: Computer knowledge assessment
program (KAP) 1 interactivecomputer teaching (60 min)
I-2: KAP (2040 min) 1 feedbackI-3: KAP onlyC: No intervention
Decreased HbA1c I-2 (21.3%,P , 0.05) and I-3 (20.08%,P , 0.05)
Randomization by year and monthbirth (no details given)
I more contact than CNIDDM results reported here (49%
of total study population IDDM)
40, 60 n 5 558; F/U 6months;45 years
I-1: Collaborative education by HCW,3 h/week 3 4 weeks
I-2: Same education led by fellow patientC: No interventionI based on Fishbein and Ajzen Health
Belief Model
NSD HbA1c at 6 months Hospitals randomizedI more visits than CUncertain blinding assessor
48 n 5 82; F/U 6months post BL;56 years
I-1: 11 3 2-h weekly didactic course1 1 individual session
I-2: 11-week course 1 three individualsessions: barriers and support
C: Usual care
FBS and HbA1c decreased for I-1 andI-2 at 3 and 6 months, P , 0.05
No BL statistics comparing groupsI more visits than CAttrition 40%, no comparison
dropouts to completersVolunteer study population
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DIABETES CARE, VOLUME 24, NUMBER 3, MARCH 2001 571
Table 4Continued
Referencen, F/U interval,and mean age Interventions Outcomes Comments
50 n 5 40; F/U 3months; 57 years
I: CAI, 4 3 1-h session: didactic, somefeedback and testing
C: Didactic group teaching; 4 3 3-h
Decreased GHb I (relative change11%), P , 0.05, increased C(14%), P , 0.05, between groupdifference, P 5 0.001
No BL group comparison statisticsLow participation rate, no information
on nonparticipants or dropouts
54 n 5 1.07; F/U 1,4 months; 60 years
I: 2 3 2-h group didactic 1 practice1 feedback 1 usual care
NSD BS at 4 months Randomized by hospital numberNo blinding assessor
C: Usual care: individual educationbased on perceived patient need
Both in IP setting
No information on participation rates
55 n 5 41; F/U 2months; 60 years
I-1: Three-day program 1 group sessionwith pharmacist
NSD % change in BS betweenI and C
No BL comparisonsI more contact than C
I-2: Three-day program 1 individualsession with pharmacist; TC F/U
23% had unusable data for SMBG
C: Standard center 3-day educationprogram
59 n 5 60; F/U 3months from BL;55 years
I: Three-day group education, with F/Uof 4 TC and 1 home visit; reinforceknowledge and skills
NSD HbA1c between groups I more contact than CUnclear if study population represents
target populationC: Three-day group education
87 n 5 247; F/U12 months fromBL; 54 years
I: 12 weekly sessions over 3 months;Spanish videos, followed by 14group support sessions in 9 months,by lay HCW
C: Wait listed for the intervention
Decreased GHb 1.7% in I, increased0.3% in C
Decreased FBS 18.9 mg/dl in I,increased 3.9 in C
No BL comparisonI more contact than CNo information on attritionNo mention blinding assessorNo statistics
96 n 5 156; F/U ?immediate;58 years
I-1: Patient selects behavior forimprovement
I-2: Behavioral strategies to increasecompliance
I-3: Behavioral strategies 1instruction on behavioral analysis
C: Routine care with consistent F/Uby RN:
I-1,2,3 based on social cognitive theoryI over 13 months
NSD GHb I and C No information on attritionVolunteer study populationNumber of patient contacts unclearF/U interval unclear
98 n 5 22; F/U 32weeks frombaseline; 61 years
I: Weekly to biweekly home visits:nutrition, exercise, foot care,SMBG; by nursing students
C: Usual care
NSD GHb or BS at 32 weeks Attrition 24%, no comparisondropouts to completers
No mention blinding assessorUnclear if study population
represents target population99 n 5 56; F/U 6
months; 64 yearsI: Monthly 36 group sessions:
behavior modification (contracts,feedback), general knowledge
C: Usual care
Decreased GHb immediate F/U I andC (P ,0.05), NSD betweengroups; NSD at 6 months
Decreased FBS I at immediate F/U,NSD between groups
I more contact than CAttrition 32%, no comparison dropouts
to completersParticipation rate 37%, no comparison
participants to nonparticipants3. Lifestyle interventions31 n 5 40; F/U 6
months from BL;35 years
I-1: Lunch demonstrationsI-2: Videotape educationC: Dietitian instruction and written
informationThree visits total for all groups
over 6 months
Decreased HbA1c I-1 (22.4%,P , 0.025) and I-2 (23.3%,P , 0.001)
Decreased HbA1c correlated withdecreased CHO variation, P , 0.02
No mention blinding assessorStudy population selected by researchers;
low participation rateType of diabetes unclear (insulin
dependent)
36 n 5 87; F/U 12months from BL;56 years
I: Five group sessions over 6 months,focus on weight loss
Decreased HbA1c I at 6 months,P , 0.001; NSD I vs. C at 1 year
C: Individual education on weight lossby dietitian; 3 or more visits in 12months
39 n 5 105; F/Uimmediate,12 months; 45years
I: Interactive computer program on diet;90 min/month over 6 months
C: Wait listed for IBoth groups received 5 days of teaching
NSD HbA1 or fructosamine atimmediate F/U
Decreased HbA1 at 18 months(10.8 to 9.6, P , 0.001)
I more contact than CAttrition appears to be 76% at 12
months F/U; no comparisondropouts to completers
No mention blinding assessorCrossover designNo information on patient recruitment
43 n 5 201; F/U 6months; 53 years
I: Culturally appropriate flashcards: diet,SMBG; delivered by lay HCW
Decreased HbA1c in I (20.34%,P . 0.05)
I more contact than C
C: Usual care Intensity of intervention unclear
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572 DIABETES CARE, VOLUME 24, NUMBER 3, MARCH 2001
Table 4Continued
Referencen, F/U interval,and mean age Interventions Outcomes Comments
49 n 5 41, F/U 6 months;61 years
I: Psychologist-led group sessions onPA and diet
Decreased HbA1c for I and C, NSDbetween groups
Dropouts (22%) had higher mean BS;equal number dropouts I and C
C: Didactic lectures on diet and DMBoth groups 10 3 1-h sessions over
6 months
Decreased mean BS at 6 months for I,between group difference, P , 0.05
Low participation rate, no informationon nonparticipants
66 n 5 148; F/U 6 monthsfrom BL; 55 years
I: Advice to decrease fat to ,30%total calorie intake
C: Advice to decrease CHO to ,40%total calorie intake
Both I and C received individualcounseling by dietitian; threehome visits
NSD HbA1c between groupsNSD fasting plasma glucose between
groups
67, 68, 104 n 5 206; F/U 12 monthsfrom BL; 62 years
I: Single visit: focus on diet; goal-setting, interactive video onbarriers, F/U q3 months
C: Usual care q3 months
NSD HbA1c at 12 months Unclear if food record reviewers wereblinded
Low participation rate; participants differfrom nonparticipants
69, 82, 89,103
n 5 86; F/U 15,27 months from BL;53 years
I: Six individual visits at 2-monthintervals; intensive therapy forweight, BS control, diet, PA; thenq3 months visits
Decreased FBS for I . C at 15months, P 5 0.02; NSD27 months
NSD HbA1c 15 and 27 months
I more visits than CNo mention blinding assessorNo information on nonparticipantsI more contact than C
C: Usual care q23 monthsBoth groups 3 visits/3 months basic
education before randomization70 n 5 75; F/U 12 months
from BL; 61 yearsI: Educational videos, personal and
family support q2 weeks for 6months 1 3 h counseling bydietitian
NSD GHb
C: Review session 3 371 n 5 60; F/U 12 weeks
from BL; 55 yearsI: Individualized advice on low
glycemic index foodsDecreased FBS I and C, significant
only for I, P , 0.05No mention blinding assessorUnclear how much intervention time
C: Standard, individualized dietadvice
Decreased fructosamine I vs. C,P , 0.05
72 n 5 78; F/U 2 months;4275 years
I-1: 5 3 2-h weekly education:calories, fat, fiber
NSD GHb No BL informationI more visits than C
I-2: I-1 1 goal setting, problem-solving, feedback
More attrition in C, no comparisondropouts to completers
C: Wait listed for I Unclear if assessor blindedUnclear how study population recruited
73 n 5 70; F/U immediate,6 months; 42 years
I: Monthly (or more) meetings: dietand PA prescription, feedback,behavior modification
C: Usual care; wait listed for I
NSD HbA1 immediate or 6 months Incomplete BL statisticsI more visits than CNo mention blinding assessorVolunteer study populationCrossover designType of DM uncertain (IDDM)
74 n 5 102; F/U 3, 6months from BL;67 years
I: 10 weekly sessions: problem-solving, increased self efficacy, dietand PA focus
C: Wait listed for I
Decreased HbA1c in I and C at 3months (0.5%), NSD betweengroups, return to BL at 6 months
Randomization blocked bymedication
I more visits than CVolunteer study population
76 n 5 64; F/U 3, 6 monthsfrom BL; 62 years
I: 12 3 1.5-h weekly (didactic),sessions then 6 3 1.5-h biweeklyparticipatory diet and exercisesessions, based on socialaction theory
Decreased HbA1c at 3 months(21.5%) and 6 months (21.1%),P , 0.01
I more visits than CMore C dropouts, no comparison
dropouts to completersVolunteer study population
C: One didactic class and twomailings
77 n 5 53; F/U 16 weeks,16 months from BL;55 years
I-1: 16 weekly sessions: behavioralmodification, calorie logs, groupPA, monetary incentives
Decreased FBS and HbA1c allgroups at 16 weeks, P , 0.01,NSD between groups
I more visits than CVolunteer study population
I-2: 16 weekly didactic sessionsnutrition and PA
NSD FBS and HbA1c at 16 months
C: Four monthly didactic sessions78, 97 n 5 79; F/U immediate;
68 yearsI-1: 10 3 60-min diet education
sessions over 4 months; adaptedfor elderly
Decreased HbA1c at 8 weeks, for I-2,P , 0.05, not maintained at16 weeks
Randomized by siteNo BL comparisons or attrition
informationI-2: I-1 1 peer support: group
sessions, modeling, reinforcementC: Usual care
I more visits than CCommunity recruitment; volunteer
study population
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DIABETES CARE, VOLUME 24, NUMBER 3, MARCH 2001 573
Table 4Continued
Referencen, F/U interval,and mean age Interventions Outcomes Comments
79, 100,101
n 5 76; F/U 3, 6,18 months from BL;54 years
I-1: Diet focus; goal-setting, modifyenvironment
I-2: PA focus with participationI-3: Diet 1 PAC: Didactic teachingAll groups: 10 3 2-h weekly
sessions: I based on behavior andcognitive modification strategies
Decreased BS I-1 vs. C at 6 months,P , 0.037; NSD HbA1c
Decreased HbA1c 13 vs. C at 18months (difference 1.8%, P , 0.05)
Randomized by group meetingattended
Volunteer study population
80 n 5 40; F/U 2, 5 monthsfrom BL; 59 years
I: 3 3 1.5-h individual learningactivity packages with dietinformation, goals, activities
C: 3 3 1.5-h didactic lectures
Decreased HbA1c in C (4.5%) at 5months, P , 0.05; NSD I group
Attrition 23%, no comparisondropouts to completers
Volunteer study population from DMeducation program
81, 102 n 5 247; F/U 6 monthsfrom BL; 57 years
I: Three or more individual visitswith dietitian, over 6 weeks,following practice guidelines
C-1: One visit producing nutritioncare plan
C-2: Nonrandomized comparisongroup; no intervention
Decreased FBS and HbA1c I at 6months, P , 0.001; decreased C-1,P , 0.01; NSD between I and C-1
Nonrandomized C-2C less time with dietitianAttrition 28% for lab studies, unclear
if dropouts equal completers at BLVolunteer study population or
physician-referred
83 n 5 596; F/U immediate,6 months; 51 years
I: More nutrition content, follow foodpyramid
Decreased HbA1c in C (0.9%,P 5 0.035)
Randomized into choice/no choice ofprogram, then I and C
C: Usual education, given meal planBoth I and C: 5 3 2-h weekly group
sessions
Patient choice had no effect Attrition 28%, dropouts younger,more male
No mention blinding assessorPhysician-referred patients or volunteers
84 n 5 163; F/U immediate,6 months; 64 years
I: Six monthly sessions on dietC: Usual care; wait listed
Decreased postprandial BS at 6months in I vs. C, P 5 0.009
No BL statisticsI more visits than CAttrition 47%, but dropouts equal
completers at BLNo information on patient recruitmentType of DM unclear
88 n 5 80; F/U 12 monthsfrom BL; 56 years
I: Six individual sessions on diet, bynurse
Decreased FBS all groups, P , 0.01,NSD between groups
No BL statistics
C: Physician gave handout at initialvisit on weight loss
Both groups 6 visits/12 months
Decreased HbA1c C females and Imales, P , 0.001, NSD betweengroups
90 n 5 50; F/U 1 year fromB/L; 54 years
I: Focused on relationship weightloss and BS control; monetaryincentives
C: Weight loss program
NSD HbA1c at 1 year for I or C Volunteer study population
Both groups: 12 weekly meetings,then monthly 36, F/U in 3months; behavioral weight controlprogram
91 n 5 120; F/U 7,11 months from BL;54 years
I-1: Six monthly small-groupmeetings, diet and PA information;audio-visual materials culturallysensitive
NSD HbA1c between or withingroups at 7 or 11 months
I more visits than CAttrition 32% at 11 months, NSD
dropouts to completers
I-2: 1-h didactic 1 five monthlydiscussions on BS control
C: 1-h didactic only92 n 5 40; F/U immediate,
6 weeks; 54 yearsI: Behavioral group: 6 3 1.5-h
weekly meetings; cues for eating,daily record
Decreased BS immediate F/U for I,P , 0.05, NSD 6 weeks
NSD between groups for BS
I more visits than CUnclear how patients selected
C: Individual diet counseling, total1.25 h
93 n 5 70; F/U 6 monthsfrom BL; 58 years
I: 22 h over 11 weeks, interactiveteaching based on cognitivemotivational theory
C: Didactic teaching, 14 h over 3 daysFocus for both I and C: diet andfoot care
NSD FBS either groupDecreased fructosamine both groups
at 1 month, P , 0.0001, returnto BL at 6 months
I more contact than C
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574 DIABETES CARE, VOLUME 24, NUMBER 3, MARCH 2001
eotapes have been used as adjuncts forteaching, with positive (31) and negative(91) results.
Cardiovascular disease risk factorsA large number of studies examined theeffects of diabetes self-management train-ing on risk factors for cardiovascular dis-ease, including body weight, serum lipid
levels, and blood pressure (Table 5). Thir-teen studies demonstrated positive effectson weight loss; the average weight loss forthese studies was ;2 kg (range 1.33.1)(28,36,38,47,66,72,74,76,80,82,84,89).Most studies with positive results in-volved regular contacts or reinforcementsessions (38,47,66,76,82,84) or veryshort follow-up periods (72,74), al-