A Comparison of Learning Activity Packages and Classroom Instruction for Diet Management of Patients with Non-Insulin-Dependent Diabetes Mellitus Work absenteeism in type 2 diabetes mellitus: results of the prospective Diabetes Intervention Study. One-to-one teaching with pictures--flashcard health education for British Asians with diabetes. Sex differences in weight loss among adults with Type II diabetes mellitus Culturally Competent Diabetes Education for Mexican Americans: The Starr County Study Improving self-care among older patients with type II diabetes: the "Sixty Something..." Study. The development and evaluation of a computer-aided diabetes education program. Lifestyle intervention in people with insulin-dependent diabetes mellitus (IDDM) Effects of a Brief Office-Based Intervention to Facilitate Diabetes Dietary Self-Management Prevention of amputation by diabetic education. Telematic expert system Diabeto: New Tool for Diet Self-Monitoring for Diabetic Patients Influence of Small-Group Education Sessions on Glucose Homeostasis in NIDDM Long-term effects and costs of brief behavioural dietary intervention for patients with diabetes delivered from the medical office. Prospective Evaluation of HDL Cholesterol Changes After Diet and Physical Conditioning Programs for Patients with Type II Diabetes Mellitus Diabetes Intervention Study: Multi-Intervention Trial in Newly Diagnosed NIDDM Impact of Intensive Educational Approach to Dietary Change in NIDDM A Controlled Trial on the Effects of Patient Education in the Treatment of Insulin-dependent Diabetes A Randomized Controlled Trial of Weight Reduction and Exercise for Diabetes Management in Older African-American Subjects The Relative Effectiveness of Educational and Behavioral Instruction Programs for Patients With NIDDM: A Randomized Trial Does self-monitoring of blood glucose levels improve dietary compliance for obese patients with type II diabetes? Group Education for Obese Patients with Type 2 Diabetes: Greater Success at Less Cost Nutrition Education and Social Learning Interventions for Type II Diabetes A project in diabetes education for children. Efficacy of dietary instructions in newly diagnosed non-insulin-dependent diabetic patients. Comparison of two different patient education regimens. An assessment of drug information sheets for diabetic patients: only active involvement by patients is helpful. Intensive education improves knowledge, compliance, and foot problems in type 2 diabetes. Diabetes support groups improve health care of older diabetic patients. Improved control of type 2 diabetes mellitus: a practical education/behavior modification program in a primary care clinic. Developing and Implementing a Pharmaceutical Care Model in an Ambulatory Care Setting for Patients With Diabetes Is glucose self-monitoring beneficial in non-insulin-treated diabetic patients? Results of a randomized comparative trial. A Randomized Study of the Effects of a Home Diabetes Education Program Effectiveness of medical nutrition therapy provided by dietitians in the management of non-insulin-dependent diabetes mellitus: a randomized, controlled clinical trial. A Randomized, Controlled Comparison of Instruction by a Diabetes Educator Versus Self-Instruction in Self-Monitoring of Blood Glucose Foot Care: Knowledge Retention and Self-care Practices DIABEDS: a randomized trial of the effects of physician and/or patient education on diabetes patient outcomes. Follow-up Intervention: Its Effect on Compliance Behavior to a Diabetes Regimen Reduction of Lower Extremity Clinical Abnormalities in Patients with Non-Insulin-Dependent Diabetes Mellitus Behavioral Analysis and Behavioral Strategies to Improve Self-Management of Type II Diabetes A brief office-based intervention to facilitate diabetes dietary self-management. Utilizing a 24-Hour Dietary Recall and Culturally Specific Diabetes Education in Mexican Americans With Diabetes Management of Obese Patients With Diabetes Mellitus: Comparison of Advice Education With Group Management Patient Choice in Diabetes Education Curriculum: Nutritional versus standard content for type 2 diabetes Early lifestyle intervention in patients with non-insulin-dependent diabetes mellitus and impaired glucose tolerance. Dietary assessment instruments are susceptible to intervention-associated response set bias. The impact of diabetes education and peer support upon weight and glycemic control of elderly persons with noninsulin dependent diabetes mellitus (NIDDM). Quality of reporting in diabetes patient education research: 1954-1986. A randomized, controlled study on the effect of diabetes counseling in the offices of 12 general practitioners. Problem oriented participatory education in the guidance of adults with non-insulin-treated type-II diabetes mellitus. Impact of intensified dietary therapy on energy and nutrient intakes and fatty acid composition of serum lipids in patients with recently diagnosed non-insulin-dependent diabetes mellitus. The Diabetes Education Study: A Controlled Trial of the Effects of Diabetes Patient Education Calorie-counting compared to exchange system diets in the treatment of overweight patients with type II diabetes. Can patients set their own educational priorities? The Effectiveness of Diabetes Education for Non-Insulin-Dependent Diabetic Persons Patient Empowerment: Results of a randomized controlled trial A Randomized Clinical Trial Comparing Behavior Modification and Individual Counseling in the Nutritional Therapy of Non-insulin-dependent Diabetes Mellitus: Comparison of the Effect on Blood Sugar, Body Weight, and Serum Lipids The effect of health education on the rate of ophthalmic examinations among African Americans with diabetes mellitus.
Forty patients were r and omly assigned to receive either the individualized learning activity packages or classroom instruction .  Effectiveness was evaluated on the basis of fasting plasma glucose , glycosylated hemoglobin , percent of ideal body weight , and knowledge and behavior scores . No significant differences were found between the groups at entry or at the 2-month follow-up . At the 5-month follow-up , the group that received the learning activity packages scored significantly higher on knowledge assessment , significantly increased their behavior score , and decreased their percent of ideal body weight . Patients who received classroom instruction increased their behavior score and exhibited significantly decreased glycosylated hemoglobin levels . Behavior and blood glucose levels were significantly correlated . Although the learning activity packages proved effective in increasing knowledge , no significant improvement was observed in blood glucose levels Newly diagnosed mild Type 2 diabetic patients , aged 30 - 55 years , were included in the prospect i ve , multi-centre Diabetes Intervention Study . They were r and omly allotted to either an intervention group receiving intensified health education or to a control group on usual care . This paper reports the incidence , duration of and causes for absence from work due to any disease in the patients who were working during the first 5-year follow-up . Data from 817 patients could be taken into account . 14.5 % of the intervention patients and 17.3 % of the control patients had never been on the sick list . Those patients who had undergone intensified health education were listed sick less often . Women showed a higher work absenteeism in either group ; they had higher blood pressure and higher body mass index at entry . Cardiovascular diseases and musculo-skeletal disorders were major reasons for absence from work . However , when compared to the general population , these Type 2-diabetic patients were approximately four times more often on the sick list . Thus , the health education programme of the Diabetes Intervention Study was shown to be effective with respect to work absenteeism . Teaching patients is recommended as an important part of the therapeutic regimen BACKGROUND Type 2 diabetes is up to four times more common in British Asians , but they know little about its management and complications . AIM To design and evaluate a structured pictorial teaching programme for Pakistani Moslem patients in Manchester with type 2 diabetes . METHOD A r and omized controlled trial of pictorial flashcard one-to-one education in 201 patients attending a hospital outpatient clinic or diabetic clinics in ten general practice s in Manchester . Patients ' knowledge , self-caring skills and attitudes to diabetes were measured on four topics before the structured teaching , and compared with results six months later . RESULTS All parameters of knowledge were increased in the study group ; for example , percentage scores for correctly identifying different food values increased from 57 % to 71 % ( Analysis of Variance ( ANOVA ) adjusted difference + 11.8 % ) and knowledge of one diabetic complication from 18 % to 78 % . Self-caring behaviour improved , with 92 % of patients doing regular glucose tests at six months compared with 63 % at the start . Attitudinal views were more resistant to change , with patients still finding it hard to choose suitable foods at social occasions . Haemoglobin A1c control improved by 0.34 % over six months ( ANOVA adjusted difference , 95 % CI -0.8 % to + 0.1 % ) . CONCLUSION It is concluded that this health education programme can empower Asian diabetics to take control of their diets , learn to monitor and interpret glucose results , and underst and the implication s of poor glycaemic control for diabetic complications The treatment of choice for Type II or non-insulin-dependent diabetes mellitus is a behavioral program for the management of weight . However , compliance with this lifelong dietary regimen is often poor . In the current investigation male and female adults with diagnosed Type II diabetes were r and omly assigned to either a behavior modification , a cognitive modification , a cognitive-behavior modification , or a control group . Patients were evaluated in terms of weight , percentage of body fat , and glycosylated hemoglobin measures . Men lost signficantly more weight than women and subjects in the behavior modification group lost more weight and demonstrated greater decreases in diabetes control than subjects in the cognitive-behavior modification , cognitive , and control groups . A significant interaction indicated that diabetic men may benefit more from  behavioral weight reduction programs  than diabetic women . Several explanations for these findings are considered PURPOSE Few culturally competent health programs have been design ed for Mexican Americans , a group that bears a disproportionate burden of Type 2 diabetes . In Starr County , a Texas-Mexico border community , investigators design ed and tested a culturally competent intervention aim ed at improving the health of this target population . The purpose of this article is to describe the development process of this diabetes education and support group intervention . METHODS The development stages were ( 1 ) community assessment , ( 2 ) intervention design , ( 3 ) selection or development of outcomes , ( 4 ) pilot testing , and ( 5 ) a r and omized clinical investigation . RESULTS Focus group participants identified knowledge deficits regarding diabetes and self-management strategies , and suggested characteristics of an effective intervention for Mexican Americans . Outcome measures included metabolic control indicators , a newly developed knowledge instrument , and an existing health belief instrument . Preliminary analyses indicated that the intervention was successful in significantly improving metabolic control in the target population . CONCLUSIONS Developing successful diabetes interventions for minority groups requires a number of stages , careful planning , assessment of cultural characteristics of the target population , and a systematic approach to implementation A 10-session , self-management training program was design ed specifically for persons over 60 years of age having Type II diabetes . It targeted social learning variables , especially problem-solving skills and self-efficacy , found to be related to diabetes self-care in earlier correlational research . One hundred two adults were r and omized to immediate or delayed intervention conditions . At posttest , subjects in the immediate intervention condition showed significantly greater reductions in caloric intake and percent of calories from fat than control subjects . The intervention also produced greater weight reductions and increases in the frequency of glucose testing than did the control condition . Improvements among immediate intervention subjects were generally maintained at a 6-month follow-up . Intervention results from subjects receiving delayed intervention closely replicated those for immediate intervention subjects . We conclude that a relatively short-term program can improve self-management skills of older diabetic adults , and that there is an important need for such interventions This paper describes the development and evaluation of a computer-aided learning ( CAL ) program . The program was tested in a trial that involved 36 people with diabetes ; 20 received CAL lessons in diabetes management and 16 attended conventional diabetes classes conducted by diabetes educators . When measurements taken before and three months after the education were compared , both groups showed significant improvement in their knowledge ; the blood glucose levels of the CAL group were significantly lower but those of the conventional education group were higher . This means that the CAL program was as effective as conventional education in imparting knowledge but it was more likely to motivate people to control their glucose levels . The CAL program allows diabetes educators to spend less time on education in basic knowledge and to concentrate more on motivational and social factors that are important determinants of patient compliance . It can also benefit people with diabetes whose access to health professionals and /or conventional diabetes education is restricted Objective : To investigate the impact of intensive lifestyle education on dietary practice s , exercise and metabolic measurements in people with insulin-dependent diabetes mellitus ( IDDM ) . Design : Sixty-one volunteer subjects with IDDM were r and omised to intensive ( Group 1 ) or st and ard ( Group 2 ) education programmes for six months . During a second six month period of observation Group 1 subjects received routine surveillance for their condition and those in Group 2 were given intensive advice ( phase 2 ) . Current insulin regimens were modified to optimise glycaemic control before the start of the intervention phase . Nutrient intakes , weight , blood pressure , glycated haemoglobin ( HbA ) , plasma lipids , lipoproteins and maximal oxygen consumption ( VO max ) were measured at the time of recruitment and at three monthly intervals during the trial and phase 2 . Setting : Department of Human Nutrition at the University of Otago . Results : Glycated haemoglobin decreased significantly in both groups between recruitment and r and omisation , the improvement being sustained during the six months of the r and omised trial and for group 1 during the six months of post trial observation . A further decrease was seen in Group 2 during the second six month period when they were given intensive advice . Comparable changes were seen with total and low density lipoprotein ( LDL ) cholesterol in Group 1 during the trial , but significant decreases were only seen in Group 2 in association with intensive intervention ( phase 2 ) . These changes occurred in parallel with increases in intakes of carbohydrate and monounsaturated fatty acids , a reduction in intakes of total and saturated fat , and an improvement in maximum oxygen consumption . Conclusions : A lifestyle programme for people with IDDM results in modest changes in diet and exercise habits sufficient to improve measures of glycaemic control and lipoprotein mediated risk of coronary heart disease independent of changes in insulin regime . More innovative approaches to achieve lifestyle changes are required to meet current recommendations which in turn are likely to produce even greater beneficial changes than those observed here . Sponsorship : This study was supported by the Eli Lilly Research Grant ( Eli Lilly and Company ( New Zeal and ) Ltd ) , The Deans Research Grant ( Otago Medical School , New Zeal and ) and The New Zeal and Dietetic Association ( Abbott Award ) OBJECTIVE There is a pressing need for brief practical interventions that address diabetes management . Using a r and omized design , we evaluated a medical office-based intervention focused on behavioral issues relevant to dietary self-management . RESEARCH DESIGN AND METHODS There were 206 adult diabetes patients r and omized to usual care or brief intervention  , which consisted of touchscreen computer-assisted assessment to provide immediate feedback on key barriers to dietary self-management , and goal setting and problem-solving counseling for patients . Follow-up components to the single session intervention included phone calls and interactive video or videotape instruction as needed . RESULTS Multivariate analyses of covariance revealed that the brief intervention produced greater improvements than usual care on a number of measures of dietary behavior ( e.g. , fewer calories from saturated fat , fewer high-fat eating habits and behaviors ) at the 3-month follow-up . There were also significant differences favoring intervention on changes in serum cholesterol levels and patient satisfaction but not on glycosylated hemoglobin . The intervention effects were relatively robust across a variety of patient characteristics , the two participating physicians , and intervention staff members . CONCLUSIONS If the long-term results are equally positive and generalize to other setting , this intervention could provide a prototype for a feasible cost-effective way to integrate patient views and behavioral management into office-based care for diabetes This prospect i ve r and omized study evaluated the influence of a simple education program on the incidence of lower extremity amputation in diabetic patients . Two hundred three patients were r and omized into two groups : Group 1 , education ( 103 patients , 203 limbs ) and Group 2 ,  no education ( 100 patients , 193 limbs ) . There were no significant differences in medical management or clinical risk factors between the two groups . The amputation rate was three times higher in Group 2 ( 21 of 177 limbs versus 7 of 177 limbs ; p less than or equal to 0.025 ) , the ulceration rate was three times higher in Group 2 ( 26 of 177 limbs versus 8 of 177 limbs ; p less than or equal to 0.005 ) , and there was no difference in the overall incidence of infection ( 2 of 177 limbs ) . Overall success in Group 1 was highly significantly different from Group 2 ( 160 of 177 limbs versus 128 of 177 limbs ; p less than or equal to 0.0005 ) . This study demonstrated that a simple education program significantly reduced the incidence of ulcer or foot and limb amputation in diabetic patients Objective — To evaluate Diabeto , a computer-assisted diet education system . Research Design And Methods — One hundred five patients with insulin-dependent diabetes mellitus ( IDDM ) or non-insulin-dependent diabetes mellitus ( NIDDM ) were divided into two r and omized groups to participate in the evaluation of Diabeto . With free access through Minitel , the French public videotex network , Diabeto helps diabetic patients self-monitor their diets and balance their meals with personalized counseling . Results — During the first 6-mo study , group A ( 54 patients ) used Diabeto , whereas group B ( 51 patients ) were control subjects . For the second 6-mo study , group B used the system . Evaluation was based on patients ' dietetic knowledge , dietary habits , and metabolic balance . Conclusions –Diabeto led to a significant improvement of dietetic , knowledge in group A ( P < 0.0005 ) and also to improved dietary habits ; decreased caloric intake in patients initially overeating ( P < 0.05 ) , increase of dietary carbohydrate from 39.7 ± 0.7 to 42.9 ± 0.9 % in patients with an initial intake < 45 % carbohydrate , and decrease of fat intake from 41.9 ± 0.9 to 37.4 ± 1.1 % in patients with an initial intake of > 35 % fat ( P < 0.0005 ) . In the second study , in addition to similar improvements to those observed in the first study , HbA1 decreased from 11.0 ± 0.4 to 9.9 ± 0.4 % ( P < 0.005 ) and fructosamine from 5.00 ± 0.17 to 4.57 ± 0.17 % ( P < 0.001 ) . Diabeto appears to be an effective therapeutic tool in the control of metabolic diseases In patients with non-insulin-dependent diabetes mellitus ( NIDDM ) , the influence of knowledge about their disease on the treatment and control of the disease is not clear . We evaluated the efficacy of educational group meetings with NIDDM patients on improving their knowledge of the disease and on disease management .  Fifty-one NIDDM patients were r and omly assigned to either intervention or control groups . The intervention group participated in courses of three weekly lessons presented by a physician , nurse , and dietitian once every 4 mo . The intervention and control groups were also followed once every 2 mo in the clinic by the same staff . Medical treatment remained unchanged during the study . After a 12-mo follow-up of the intervention group , no significant improvement in their knowledge of diabetes could be demonstrated . However , mean fasting and postpr and ial blood glucose levels and HbA1c improved significantly in comparison with the control goup . The same tendency was evident with the weight and lipoprotein profile . We conclude that educational group therapy can improve diabetes control in patients with NIDDM This study evaluated the 12-month follow-up results and costs of a personalized , medical office-based intervention focused on behavioral issues related to dietary self-management . Two hundred and six adults having diabetes attending an internal medicine outpatient clinic visit were r and omized to either Usual Care or to Brief Intervention . The single session intervention involved touchscreen computer-assisted assessment that provided immediate feedback on key barriers to dietary self-management , goal setting and problem-solving counselling . Follow-up components included phone calls and videotape intervention relevant to each participant . Brief Intervention produced significantly greater improvement than Usual Care on multiple measures of change in dietary behaviour ( e.g. , covariate adjusted difference of 2.2 % of calories from fat ; p = 0.023 ) and on serum cholesterol levels ( covariate adjusted difference of 15 mg/dl ; p = 0.002 ) at 12-month follow-up . There were also significant differences favouring intervention on patient satisfaction ( p < 0.02 ) but not on HbA1c levels . The costs of intervention ( $ 137 per patient ) were modest relative to many commonly used practice High-density lipoprotein ( HDL ) cholesterol is known to be low in patients with diabetes mellitus . Low HDL levels are correlated with premature cardiovascular mortality in several major epidemiologic studies and many investigators believe increases in HDL cholesterol may reduce the risk of coronary heart disease . We evaluated dietary and exercise interventions in relation to HDL cholesterol in patients with type II diabetes mellitus . Sixty-five volunteers were r and omly assigned to one of four experimental conditions : diet , exercise , diet plus exercise , or education control . Three months after entering the program , those exposed to the dietary intervention had significant increases in HDL cholesterol . HDL increases for the other two treatment groups did not differ significantly from the education control Objective In a r and omized 5-yr multi-intervention trial , we tested the efficacy of intensified health education ( IHE ) in improving metabolic control and reducing the level of coronary risk factors and incidence of ischemic heart disease ( IHD ) . Research Design and Methods Within the intervention group , the benefit of clofibric acid was evaluated in a double-blind study . One thous and one hundred thirty-nine newly diagnosed middle-aged ( 30- to 55-yr-old ) patients with non-insulindependent diabetes mellitus ( NIDDM ) entered the study . They were classified as diet controlled after a 6- wk screening phase with conventional dietary treatment . During the follow-up , the control group ( n = 378 ) was cared for at different diabetes outpatient clinics with a st and ardized surveillance . The intervention group ( n = 761 ) had a structured IHE that included dietary advice , antismoking and antialcohol education , and ways to enhance physical activity . Results R and omly , 379 of the IHE patients received 1.6 g clofibric acid/day , and the others received placebo . IHE result ed in improved glucose control ( adjusted fasting blood glucose ) levels after 5 yr ( control subjects 9.27 mM , IHE group 8.71 mM , and IHE plus clofibric acid group 8.60 mM , P < 0.01 ) . The better glycemic control was achieved with fewer antidiabetic drugs . After 5 yr , antidiabetic drugs were prescribed to 47 % of the control subjects , 28 % of the IHE group , and 34 % of the IHE plus clofibric acid group ( cutoff limit for drug application was postpr and ial blood glucose of ≥13.87 mM ) . The ratio of polyunsaturated to saturated fatty acids ( 0.26 vs. 0.40 , P < 0.01 ) and physical activity ( 174 vs. 327 scores , P < 0.01 ) were increased , and blood pressure , tobacco , and alcohol consumption were significantly reduced by IHE . However , IHE had no effect on calorie intake , percentage of fat in the diet ( 45 % ) , and body weight . The most important finding was the significant increase of blood cholesterol in all three groups ( + 0.47 , + 0.36 , and + 0.34 mM , respectively ) . Clofibric acid only prevented the increase of triglyceride levels ( + 0.56 , + 0.24 , and + 0.05 mM , respectively ) . The incidence rate per 1000 for myocardial infa rct ion was 30.3 for control subjects , 53.6 for the IHE group , and 55.6 for the IHE plus clofibric acid group . The corresponding rates for IHD incidence were 90.9 , 97.8 , and 98.8 , respectively . Men suffered more frequently from myocardial infa rct ion , whereas women developed ECG criteria for IHD more frequently . Among the 35 cases of death , besides cardiovascular diseases , liver cirrhosis and neoplasia were the predominant causes . The death rate per 1000 in control subjects was 46.2 , 30.6 in the IHE group , and 27 among patients with IHE plus clofibric acid . Conclusions IHE was of substantial benefit for the control of glycemia , significantly diminished the need for antidiabetic drugs , and reduced a cluster of risk factors but had no effect on the control of blood lipids . This could be one major reason for the failure of IHE , effective lowering of blood pressure , and clofibric acid to prevent cardiovascular complications .  Clofibric acid was only effective in reducing triglycerides The aim of this study was to compare the effects of an intensive educational approach incorporating longer time , greater simplicity , repetition , and cognitive motivational techniques with a conventional one in subjects with established non-insulin-dependent diabetes mellitus ( NIDDM ) whose weight , glycemic control , and diet were not optimal . Subjects were r and omly allocated to intensive or conventional education .  Of 350 subjects , 70 met the study criteria , which included established NIDDM ( ≥3 mo ) , suboptimal recent glycemic control , dietary fat intake ≥35 % of total energy intake , and body massindex ≥25 kg/m2 . The intensive approach was associated with significantly greater improvements in dietary compliance , dietary intake ( complex carbohydrate , [ P = 0.013 ] , legumes [ P < 0.0001 ] , fiber [ P < 0.0001 ] , total fat [ P < 0.004 ] , saturated fat [ P < 0.004 ] ) , and total cholesterol level ( P = 0.007 ) . The transient improvement in glycemic control was similar in both groups . An intensive education program can improve dietary compliance in established NIDDM subjects more than a conventional one . These recommended dietary improvements achieve better improvement in total cholesterol but do not necessarily improve glycemic control The effect of patient education on diabetic control in insulin-treated diabetic adults was studied in 77 subjects r and omized into two groups : intensive patient education ( group A ) and control ( group B ) . The subjects in group A received intensive patient instruction , both individually and in small groups , from a team of physicians , teaching nurses , and a dietitian . The patients in group B received a short instruction course consisting mainly of printed material . A highly significant improvement in diabetic control was observed in both groups immediately after the education programs , with gradual return to the original level during the following 3–6 mo . No difference was observed between the two groups in any of the measured parameters during the 18-mo investigation . Factors related to good control during the study included the length of school education , the quality of the control at the beginning of the study , and the high degree of self-confidence and lack of signs of anxiety in the psychological tests . The results demonstrate that the effects of educational programs are of limited value if they do not lead to permanent changes in attitudes and motivation , which are critical factors affecting long-term diabetic control OBJECTIVE To evaluate a weight loss and exercise program design ed to improve diabetes management in older African-Americans . RESEARCH DESIGN AND METHODS Overweight African-Americans ( n = 64 ) ages 55–79 years with NIDDM were r and omized to either an intervention ( 12 weekly group sessions , 1 individual session , and 6 biweekly group sessions ) or usual care ( 1 class and 2 informational mailings ) . Clinical and behavioral variables were assessed at 0 , 3 , and 6 months of treatment . RESULTS Significant net differences in the intervention versus usual care were observed for weight ( −2.0 kg , P = 0.006 ) , physical activity , and dietary intake of fat , saturated fat , cholesterol , and nutrition knowledge at 3 months ( all P < 0.05 ) and for weight at 6 months ( −2.4 kg ; P = 0.006 ) and mean HbA1c values at 3 and 6 months ( respectively , −1.6 and −2.4 % , both P < 0.01 ) . After the adjustment for changes in weight and activity , the intervention participants were ∼ twice as likely to have a one unit decrease in HbA1c value as those in usual care . Blood pressure increase sin usual care participants result ed in net differences ( intervention minus control ) at 3 and 6 months of −3.3 ( P = 0.09 ) and −4.0 ( P = 0.05 ) mmHg diastolic , respectively , and −8.4 ( P = 0.06 ) and −5.9 ( P > 0.10 ) mmHg systolic , respectively . Blood lipid profiles improved more in intervention than usual care participants , but not significantly . CONCLUSIONS The intervention program was effective in improving glycemic and blood pressure control . The decrease in HbA1c values was generally independent of the relatively modest changes in dietary intake , weight , and activity and may reflect indirect program effects on other aspects of self-care In this r and omized trial patients with non-insulin-dependent diabetes were allocated to one of four programs : a minimal instruction program ( n=59 ) . an education program of individual visits ( n=57 ) , an education program incorporating a group education course ( n=66 ) , and a behavioral program ( n=59 ) . Individual and group education programs had higher attrition rates than the behavioral and minimal programs . The four programs , which involved different amounts of patient contact time , delivery format , and instructional strategies . all produced reductions in HbA atid BMI , with no significant differences between the programs . There were no differences between groups over three time periods in total cholesterol , HDL cholesterol , systolic blood pressure , or proportion of patients consulting an ophthalmologist . The behavioral program ploduced a greater reduction in diastolic blood pressure over 12 months that the education programs and a greater reduction in the cholesterol risk ratio over 3 months than the other programs . The behavioral program patients were more likely to have visited a podiatrist after 6 months and reported higher satisfaction Self-monitoring of blood glucose levels is currently being recommended for obese patients with type II diabetes to improve weight loss and glycemic control . To determine whether self-monitoring of blood glucose levels improves dietary compliance in these patients , 50 obese patients with type II diabetes were r and omly assigned either to a st and ard behavioral weight control program or to a weight control program that included self-monitoring of blood glucose levels and focused on the weight-blood glucose relationship . Both groups lost significant amounts of weight and maintained their losses for at least one year ; reductions in medication could be made for 70 percent of patients . These data suggest that the behavioral weight control used in this study may be of benefit to patients with type II diabetes . However , there was no evidence that the addition of self-monitoring of blood glucose levels to the treatment program improved the outcome in terms of weight loss , reduction in medication , dietary compliance , or mood state It has been suggested that much effort expended in teaching diabetic diets is ineffective and wasteful . We have tested a different system by r and omly allocating 75 newly diagnosed obese Type 2 diabetic patients to usual ‘ unstructured ’ clinic care or to group education by diabetes specialist nurses and a dietitian . Patients allocated to group education attended five 90‐min group sessions during the first 6 months . Six months after diagnosis they had lost more weight ( median ( 95 % CI ) , 7 ( 5.5–9 ) vs 2 ( 1–5 ) kg , p<0.002 ) and were better controlled ( HbA1 : 7.5 ( 7.0–8.1 ) vs 9.5 ( 8.7–10.4 ) % , p<0.001 ) than those r and omized to the usual clinic system . At 1 year ( after no further visits ) the difference in weight loss was less ( 5.5 ( 4–6.5 ) vs 3 ( 2–4 ) kg , p<0.05 ) and diabetic control was similar ( HbA1:9.0 ( 8.2–9.8 ) vs 9.9 ( 8.9–10.9 ) % . At 1 year only 14 ( 39 % ) of the education group and 9 ( 23 % ) of those attending the clinic had a fasting blood glucose less than 7.0 mmol l−1 Two diabetes education programs were compared to a control condition . Seventy-eight type II ( non-insulindependent ) diabetic out patients were r and omly assigned to nutrition education , nutrition education plus social learning intervention , or wait-list control conditions . Both interventions involved five weekly meetings that focused on reducing calorie intake , increasing dietary fiber , and decreasing fat consumption . The social learning condition also included individualized goal setting and feedback and training in problem-solving and relapse prevention . Within-group analyses and between-group comparisons generally revealed greater improvement in targeted goals ( e.g. , calorie intake , fat reduction ) among intervention conditions than the control condition . There were few differences in more distal measures of outcome such as weight or glycosylated hemoglobin . The social learning component did not improve outcome more than the nutrition education program . Possible reasons for the observed findings and the advantages and limitations of focused time-limited diabetes education efforts are discussed Forty-eight families with children less than 13 years old attending a paediatric diabetic clinic volunteered for a 2-year r and omized crossover trial to determine whether an informal education programme ( diabetic club ) could improve diabetic control . Group A attended the diabetic club for 10 afternoons of informal education in the first year , while Group B continued at the routine clinic ( 5 visits per year ) . For the second year Group A returned to the clinic , Group B attended the club .  Glycosylated haemoglobin ( HbA1 ) remained stable while attending the club but rose significantly ( p less than 0.01 ) while attending the clinic in both groups ( HbA1 at baseline , 1 year , and 2 years : Group A , 9.6 ( SD 1.2 ) , 9.6(1.4 ) , 10.7(2.1)% ; Group B 8.9(1.3 ) , 10.4(1.4 ) , 10.5(1.4)% ( normal reference range 4.7 - 7.9 % ) ) . Other indices of control were unchanged . Diabetic problem-solving scores of parents improved ( p less than 0.01 ) but their knowledge of diabetes did not correlate with their child 's HbA1 . Dietary intake showed a reduction in percentage of energy taken as fat ( 40 % vs 37.7 % , p less than 0.05 ) during club attendance . The percentage of parents reporting helpful social contact between families increased during their club year ( Group A 50 to 78 % , Group B 32 to 57 % , p less than 0.001 ) . Psychological measurements remained unchanged . An education programme for diabetic children may stabilize diabetic control in the short term but this effect is not sustained . The main benefit was the support provided by increased social contact with families of other diabetic children within the informal framework of the diabetic club Eighty consecutive newly diagnosed non-insulin-dependent diabetic patients were r and omly allocated into two groups to compare two different patient education regimens . One group received individual dietary instructions by a nurse and the other a short , written leaflet given by a doctor . The principal aim of the dietary instructions was weight reduction . A significant weight loss and improvement in the control of diabetes occurred in both groups , and these changes were similar in the two groups . At the end of one year 's follow-up , however , only 25 % of the patients were satisfactorily controlled ( fasting blood glucose less than or equal to 6.0 mmol/l ) . The degree of weight loss correlated only weakly with the improvement in the metabolic control . The degree of obesity and insulin secretion capacity as measured at the beginning of the study did not predict the improvement of glycaemic control during the study . At the end of the study a significant improvement was observed in serum lipids of patients with good control ( fasting blood glucose less than or equal to 6.0 mmol/l ) or weight loss ( greater than 5 kg ) . In conclusion , both brief , written and individual dietary instructions induced a significant weight loss as well as improved glucose and lipid metabolism in newly diagnosed non-insulin-dependent diabetic patients , but satisfactory metabolic control was achieved only in a minority of the patients Insulin/sulphonylurea-treated diabetics attending a busy university diabetic clinic were studied to determine whether issuing drug information sheets and /or age influenced underst and ing and behaviour regarding their disease and its treatment , especially with respect to avoiding hypoglycaemia . Patients were each asked 10 basic questions ( each correct answer scoring 1 ) , stratified by age ( 20 were less than or equal to 45 years and 91 greater than 45 years ) . According to a single-blind r and omised protocol , they were issued or not issued with drug information sheets ( providing information to correctly answer all 10 questions ) . After 2 - 3 months , 107 ( 88 aged greater than 45 years ) were retested and asked whether they recalled an information sheet , read it themselves or had it read to them . Whether or not patients received sheets , corresponding mean aggregate scores were very similar in both age groups and there was no correlation with age . Second test scores yielded clinical ly and statistically significant increments in both the sheet and no sheet groups , respective mean aggregate scores increasing from 4.48 to 5.80 and 5.14 to 6.27 ( P less than 0.001 ) . Among patients issued with sheets , 32 who recalled reading them achieved the greatest improvement in mean scores ( 4.53 to 6.16 , P less than 0.001 ) . Active interaction/communication ( participation in first test , recall and reading of information sheet ) had a favourable educational impact irrespective of age , but merely issuing drug information sheets had no benefit Despite the established role of foot care education in diabetes management , reports evaluating such interventions are rare . The effectiveness of an intensive foot care intervention programme and a conventional one were therefore compared in Type 2 diabetes . The intensive group showed significantly greater improvements than the conventional group in foot care knowledge ( p less than 0.001 ) , compliance with the recommended foot care routine ( p = 0.012 ) , and compliance with the initial advice to consult  a podiatrist ( other than the project podiatrist ) for further treatment ( p = 0.008 ) . At the first follow-up visit the intensive group also showed a significantly greater reduction in the number of foot problems requiring treatment than the conventional group OBJECTIVE To assess whether knowledge or psychosocial and glycemic benefits of a diabetes education program are enhanced by a support group for older patients . DESIGN A partially r and omized controlled trial involving two groups of patients : Group A , subjects who received an education program followed by 18 months of support group sessions ; Group B , only the diabetes education program . A third convenience sample , Group C , received neither intervention . Groups A and B were assessed before and immediately after the education program , and all groups were assessed 2 years after the education program . SETTING Diabetes clinic at a Veterans Affairs Medical Center . PATIENTS All subjects were male ( mean age = 68 + /- 1.3 years , range = 57 - 82 years ; duration of diabetes = 10 + /- 2 years , range 3 - 16 ) . Sample sizes were 11 in Group A , 13 in Group B , and 8 in Group C. INTERVENTION The education program consisted of six weekly sessions covering aspects of diabetes self-care . The support group consisted of 18 monthly sessions for continuing education , discussion , and structured social activities . OUTCOME MEASURES Diabetes knowledge , psychosocial factors ( self-care-related quality of life , stress , family involvement in care , and social involvement ) , depression , and glycemic control . RESULTS Group A scored better ( at least P less than 0.05 ) on knowledge , quality of life , and depression than the other groups . Groups A and B showed less stress , greater family involvement , better glycemic control , but less involvement in social activities than Group C. CONCLUSION Diabetes education programs can have long term benefits on knowledge , psychosocial functioning , and glycemic control for older diabetic patients . The addition of support groups enhances diabetes knowledge and psychosocial functioning BACKGROUND This study was done to determine the efficacy and ease of administration of education/behavior modification classes , provided by a nurse and a dietitian in a primary care clinic for improving control of type 2 diabetes mellitus .  METHODS Patients were divided r and omly into two groups . Eighteen patients completed 6 months of structured , office-based classes , and 20 similar patients served as control subjects . All were patients of the same group practice and had their usual office visits .  Glycemic control , lipid levels , body weight , knowledge about diabetes , medication requirements , and symptoms were monitored during the 6 months , with follow-up at 12 months . RESULTS At the end of 6 months , the intervention group had significant reductions in mean fasting blood glucose , glycosylated hemoglobin , total cholesterol , and low-density lipoprotein cholesterol ( LDL-C ) values . Their mean body weight was significantly reduced at 12 months , and their knowledge of diabetes was improved . Control patients had significant improvement only in glycosylated hemoglobin and body weight at 6 months . Minimal physician time was required . CONCLUSION The education/behavior modification program was clinical ly worthwhile , and it was easy to administer This study evaluated pharmaceutical care as an adjunct to an existing , coordinated-care program at a Regional Diabetes Center . The progress of a control group receiving the st and ard pharmacist instruction  was compared with two treatment groups receiving additional small group or individual supplementary education  for a 2-month period . Outcome evaluation included assessment of individual diabetes management through blood glucose monitoring and responses on a pretest and posttest question naire . Patients in the treatment groups demonstrated significantly lower average weekly blood glucose levels and a decreased incidence of hyperglycemic episodes compared with the control group . Question naire data for both treatment groups demonstrated a significant increase in patient underst and ing of diabetes medications and medications for associated illnesses , an increase in knowledge about blood glucose monitoring , and a positive difference in perceptions/attitudes toward diabetes and communication with the pharmacist . This approach is consistent with the concept of pharmaceutical care in which the pharmacist helps patients avoid long-term complications and thus improve their quality of life To study if self-monitoring of glucose , urinary or capillary , could help them to improve their metabolic control through better compliance to diet and /or hypoglycaemic agents , 208 non-insulin-treated poorly controlled diabetic patients were r and omized to : group A -- regular HbA1c determinations but no self-monitoring , group B -- self-urine glucose monitoring , twice every other day , group C -- self blood glucose monitoring , twice every other day , and followed six months . At the end of the study period , the decrease of HbA1c over six months -- main endpoint -- was not significantly different between the three groups ( mean + /- SEM ; group A : -0.5 + /- 0.2 % ; group B : -0.1 + /- 0.3 % ; group C : -0.4 + /- 0.3 % ) . However , the degree of compliance to  blood glucose self-monitoring  in group C appeared to relate to the outcome : a significant correlation was found between the number of blood glucose strips used and the decrease of HbA1c ( r = .36 , p less than .02 ) . We conclude that regular self-monitoring has no definite advantage over the usual management for improving metabolic control in non-insulin-treated diabetic patients , though it may possibly help patients ready to comply with its use Home health nurses provided individualized instruction in diabetes self-care within the home environment of 393 diabetic individuals . Each subject was r and omly assigned to either the intervention ( those receiving home teaching ) or control ( those not receiving home teaching ) group . At 6 mo postenrollment , intervention subjects showed significantly greater self-care knowledge and skills than control subjects , although the actual differences between the two groups in terms of self-care skills were probably too small to have any practical meaning . The primary objective of the study , which was the reduction of the number of preventable diabetes-related hospitalizations ( ketoacidosis , ketotic coma , nonketotic coma , insulin reaction , and diabetes out of control ) , was not achieved ; no differences between the groups were noted after 12 mo of follow-up . Similarly , length of hospital stay , foot problems , emergency room and physician visits , and sick days were roughly equivalent in both groups during the follow-up year . These results suggest that , in the absence of concurrent changes in the health-care delivery system and strategies for influencing attitudes toward self-care , education alone is ineffective OBJECTIVE To assess the effect of medical nutrition therapy ( MNT ) provided by dietitians on medical and clinical outcomes for adults with non-insulin-dependent diabetes mellitus ( NIDDM ) , and to compare MNT administered according to practice guidelines nutrition care ( PGC ) to MNT administered with basic nutrition care ( BC ) . DESIGN A prospect i ve , r and omized , controlled clinical trial of two levels of MNT on metabolic control in persons newly diagnosed with or currently under treatment for NIDDM was conducted at diabetes centers in three states ( Minnesota , Florida , and Colorado ) .  BC consisted of a single visit with a dietitian ; PGC involved an initial visit with a dietitian followed by two visits during the first 6 weeks of the study period . Data were collected at entry to the study and at 3 and 6 months . SUBJECTS Results are reported for 179 men and women aged 38 to 76 years : 85 assigned r and omly to BC and 94 to PGC . This represents 72 % of the 247 subjects enrolled . An additional 62 adults with NIDDM at one site who had no contact with a dietitian were identified as a nonr and om comparison group . OUTCOMES Medical outcome measures included fasting plasma glucose ( FPG ) , glycated hemoglobin ( HbA1c ) , and serum lipid levels . Clinical outcomes included weight , body mass index , waist-to-hip ratio , and changes in medical therapy . STATISTICAL ANALYSES Initial analysis of the discrete variables was done using the chi 2 statistic with Yates ' correction . Initial analysis of continuous variables was done by analysis of variance . The changes in variables between time periods were analyzed by paired t test , and comparisons between groups were analyzed using a t test for independent groups . RESULTS At 6 months , PGC result ed in significant improvements in blood glucose control as indicated by FPG and HbA1c levels and BC result ed in significant improvements in HbA1c level . Participants assigned to the PGC group had a mean FPG level at 6 months that was 10.5 % lower than the level at entry , and those in the BC group had a 5.3 % lower value . Among subjects who had diabetes for longer than 6 months , those who received PGC had a significantly better HbA1c level at 3 months compared with those receiving BC . The comparison group showed no improvement in glycemic control over a comparable 6 months . PGC subjects had significant improvements in cholesterol values at 6 months , and subjects in both the PGC and the BC groups had significant weight loss . CONCLUSIONS MNT provided by dietitians result ed in significant improvements in medical and clinical outcomes in both the BC and PGC groups and is beneficial to persons with NIDDM . Persons with a duration of diabetes longer than 6 months tended to do better with PGC than with BC . Because of the upward trend in glucose levels after 3 months , ongoing MNT by dietitians is important for long-term metabolic control It is not clear whether diabetic patients can learn accurate self-monitoring of blood glucose ( SMBG ) by use of written package instructions . In addition , it is unclear whether the improvement in accuracy of monitoring that results from professional training is due to the professional intervention or to a personal practice effect . For these reasons , improvement in accuracy of SMBG ( using Chemstrip bG , Biodynamics Division , Boehringer-Mannheim , Indianapolis , Indiana ) after a 30-min session of professional instruction in one group of diabetic patients was compared with improvement after 30 min of practice and study of package instructions in another group . After initial reading of package instructions in both groups , and after the practice session in the control group , mean percent error was 22–37 % . In contrast , mean percent error declined to 9 % after a professional training session . We conclude that learning SMBG solely by reading package instructions leads to unacceptable inaccuracy . However , by use of short , intensive instruction sessions , a diabetes educator can reduce such errors and teach highly accurate monitoring to most diabetic patients This study investigated the effectiveness of a " h and s-on " foot care teaching/learning approach for adults with diabetes . By r and om assignment , the control group received a lecture presentation on foot care , while the experimental group participated in a h and s-on session on foot care in addition to the lecture presentation . Data concerning the subjects ' foot care knowledge and skills , the condition of their feet , and their level of HbA1c were gathered prior to and six months after the foot care educational sessions . No significant increases in knowledge about foot care were observed in the experimental group . The experimental group reported improvements in inspecting and washing their feet on a daily basis , and in care of the toenails . No significant differences were observed in the status of the subjects ' feet . The HbAlc readings were significantly improved for both the experimental ( t=4.10 , df=10 , p=0.002 ) and control ( t=2.25 , df=9 , p=0.051 ) groups . A h and s-on educational session may improve foot care practice s temporarily . However , long term effects need to be studied to discern overall improvement of foot care practice s and physical status of the feet To examine the effects of intensive patient and /or physician diabetes education on patient health outcomes , a controlled trial was conducted in which internal medicine residents and their 532 diabetic patients were r and omly assigned to : routine care ; patient education ; physician education ; or both patient and physician education . Patient outcome data were analyzed either by analysis of covariance on post intervention values ( 2-hour post-pr and ial plasma glucose [ PPG ] ; body weight [ BW ] ; blood pressure [ BP ] ; or analysis of variance conducted on change values ( fasting plasma glucose [ FPG ] and glycosylated hemoglobin [ A1Hgb ] ) . After patient education , significant improvements were observed in FPG , A1Hgb , BW , and systolic and diastolic BP . Physician education result ed in significant decreases in FPG , A1Hgb and BW . The combination of patient plus physician education result ed in the greatest improvements in patients ' health outcomes including FPG , A1Hgb , PPG , BW and diastolic BP . Adjusted systolic BPs were not significantly different in the two groups . While these physiologic improvements were statistically and probably clinical ly significant , hyperglycemia and obesity still persisted . Thus , achieving optimal patient outcomes for a chronic disease like diabetes mellitus may require a greater or more effective use of re sources than currently estimated This study tested the hypothesis that follow-up intervention ( by telephone calls and home visit ) affects compliance in patients with non-insulin-dependent diabetes mellitus ( NIDDM ) . Sixty NIDDM patients were r and omly assigned to two groups — a control group , which received the st and ard protocol ( 3-day educational program and a review session 1 month after the program ) ; and an intervention group , which received the st and ard protocol as well as a series offour telephone calls and one home visit by a registered nurse over a 3-month period .  Compliance to prescribed regimens was determined by analyzing three sets of data : changes in pre- to post study glycosylated hemoglobin ( HbA1c ) values ; changes in pre- to post study weight ; and frequency with which self-monitoring of blood glucose ( SMBG ) was practice d. Results showed that SMBG practice was significantly better for the intervention group . No significant differences were seen in post study HbA 1c values and weight changes between the two groups . Follow-up inter vention by telephone calls and home visit can enhance patient compliance to certain aspects of the prescribed diabetes management plan Given that 14 million Americans have diabetes [ 1 ] , the common complications of this disorder , such as foot ulcers and lower extremity amputations , are of major concern to the medical community . Approximately 20 % of all diabetic patients hospitalized in the United States are admitted because of foot complications [ 2 , 3 ] . Furthermore , about 50 % of all nontraumatic amputations in the United States are done in patients with diabetes [ 1 , 4 ] . This proportion equates to about 55 000 amputations a year [ 1 ] or 59.7 amputations for every 10 000 persons with diabetes [ 5 ] . Patients who undergo an amputation are at greater risk for a second similar procedure on either the same or the other leg [ 6 , 7 ] . Yet , it has been estimated that about one half of the amputations in patients with diabetes , or about one fourth of the total amputations done in the United States , are preventable [ 1 , 4 ] . Recently , the focus has been on preventive strategies that minimize foot damage in diabetic patients and thereby reduce the rates of ulcers and amputations . These preventive strategies are based on two observations : first , that simple efforts on the part of the health care provider or patient can reduce the likelihood of subsequent amputation due to diabetes-associated foot disease [ 8 ] ; and second , that many of these simple procedures are not being systematic ally applied by health care providers or patients [ 9 ] . For example , studies indicate that physicians infrequently examine the feet of patients with diabetes [ 9 , 10 ] . Also , most patients with diabetes do not engage in simple foot-care assessment s to identify lesions requiring early treatment [ 11 ] . Preventive strategies are not systematic ally applied for several reasons : First , patients may not be aware of foot-care procedures or how to do them , or they may not believe that such procedures can make a difference ; second , podiatry and orthopedics services that could assist in foot salvage in diabetic patients may not be available ; and , finally , the health care system may make it difficult for patients or health care providers to examine the feet of patients with diabetes [ 10 ] . Several uncontrolled studies found that implementation of improved foot-care programs can significantly reduce lower extremity complications in patients with diabetes ; these studies showed a 44 % to 85 % reduction in the rate of lower extremity amputations [ 4 , 12 - 14 ] . A recent casecontrol study also supports the implementation of preventive strategies , such as foot care , use of protective footwear , and aggressive treatment of foot  infection by patients or health care providers , to decrease the risk for lower extremity amputation [ 15 ] . The intervention in our study was design ed to reduce the prevalence of risk factors for lower extremity amputations  in patients with noninsulin-dependent diabetes and involved the three major elements of a prevention program : the patient , health care providers , and the health care system . Specifically , we did a r and omized , controlled trial to determine whether a comprehensive foot-care intervention could improve patients ' knowledge and performance of appropriate foot care ; increase the number of referrals to specialty clinics such as the podiatry clinic ; increase the frequency of foot examinations by health care providers and the documentation of risk factors in the medical record ; and improve short-term patient outcomes such as skin and nail conditions known to be risk factors for ulcers and amputations . Methods Setting Our study , the design of which is summarized in Figure 1 , was done from April 1989 to March 1991 in the academic general medicine practice of the Regenstrief Health Center in Indianapolis , Indiana [ 16 ] . The practice is subdivided into four primary care teams ( labeled A , B , C , and D ) , each with its own nursing and clerical staff . Each team sees patients for eight half-day sessions per week , with each session staffed by one or two faculty internists and two to four housestaff . Teams A and C were r and omly assigned to the intervention group ; teams B and D were assigned to the control group . Previous studies in which this method of r and omization was used have shown no baseline interteam differences in patient characteristics and physician practice behavior and no effect of the team on the study outcome [ 16 - 19 ] . Figure 1 . Summary of the study design . Patient Identification and Recruitment The computerized Regenstrief Medical Record System [ 20 ] was used to identify approximately 3000 patients with noninsulin-dependent diabetes , as well as the date and time of their next appointment . Only patients with noninsulin-dependent diabetes who were seen at least two times in the preceding year by the same provider were included in the study . Additional criteria for inclusion were as follows : an age greater than 40 years ; a diagnosis of diabetes after 30 years of age ; a diagnosis of diabetes based on National Diabetes Data Group criteria [ 21 ] or the presence of disease requiring medication for the control of hyperglycemia ; an intention to obtain care at the general medicine practice for the next 2 years ; and a body weight that was either ideal or heavier than ideal . Exclusion criteria included pregnancy ; major psychiatric illness , including dementia ; terminal illness likely to cause death within 1 year ; renal failure ( serum creatinine > 440 mol/L ) ; previous bilateral amputations above or below the knee ; or an inability to provide any self-care . Patients of investigators involved in the protocol were also excluded from the study . Of the 728 eligible patients , 244 refused to participate , 89 enrolled in the study but failed to keep their appointments for assessment , and 395 were assessed by trained nurse-clinicians . Of the 395 patients assessed , 352 ( 89 % ) completed the study ; 43 patients ( 11 % ) did not complete the study for the following reasons : death ( 11 patients ) ; change of residence ( 15 patients ) ; illness ( 6 patients ) ; transportation problems ( 3 patients ) ; and miscellaneous reasons ( 8 patients ) . Patient Assessment Sample s for determining fasting plasma glucose , cholesterol , triglyceride , high-density lipoprotein , hemoglobin A1C , and C-peptide levels were obtained from enrolled patients and immediately transported to a certified laboratory for analysis . Patients gave a history and had a physical examination at study entry and approximately 1 year later ( mean , 11.8 1.5 months ) . These examinations focused on risk factors for amputation and were administered by two trained nurse-clinicians who were blinded to the patients ' experimental conditions . Foot-related data derived from the history and physical examination included the patient 's self-reported foot-care behaviors ; the quality of the patient 's examination of his or her feet ; the severity of any foot lesions ; and the presence of musculoskeletal abnormalities , dermatologic conditions , peripheral vascular disease , and peripheral neuropathy ( the neuropathy assessment included quantitative measures of pressure and temperature sensation ) . Patients were question ed about their regular foot-care routine and were asked to show how they examined their feet . During this self-examination , nurse-clinicians observed whether patients ' scrutinized the toenails , the soles of the feet , and the area between toes . Musculoskeletal and dermatologic abnormalities were assessed using st and ard definitions of findings such as callus , hammer toe , and Charcot foot [ 3 , 22 ] . The nurse-clinicians palpated the dorsalis pedis , posterior tibial , and femoral pulses bilaterally in their assessment for peripheral vascular disease . If a pulse was absent at any one of the six sites palpated , the assessment was considered abnormal . Foot lesions were rated for severity using the Seattle Wound Classification System [ 23 ] , which ranges from a grade of 1.1 ( absence of lesions ) to a grade of 10 ( entire foot or leg is gangrenous ) . In our study , a foot lesion was defined as any wound , with or without functional interruption of the protective cutaneous barrier , ranging from a superficial scratch to an ulcer involving the epidermis . A serious foot lesion was defined by a severity grade of at least 1.3 , which indicates a minor , nonulcerated lesion with clinical evidence of healing sufficient to close previous interruption of the cutaneous barrier [ 23 ] or a blister . Pressure and temperature sensations were measured using the 5.07-log ( 0.1 mg)-force Semmes-Weinstein monofilament and the thermal sensitivity testing apparatus , according to st and ard techniques [ 24 - 26 ] . Thermal sensitivity was considered abnormal if the patient had a value greater than 2 st and ard deviations from the mean value for a group of healthy persons without diabetes ( warm > 2.04 C ; cool > 1.58 C ) . Practice Patterns of Health Care Providers Immediately after each scheduled visit , study patients had a structured interview [ 10 ] with a research assistant , who asked about foot self-examination and foot-care education given by health care providers ( the primary care physician or nursing personnel ) . In addition , a chart audit was conducted by a nurse-clinician who was blinded to the patients ' experimental condition . Information abstract ed from the medical record included the physician 's documentation of the findings from the history and physical examination ; any referral to podiatry , orthopedics , or vascular surgery clinics ; and diagnostic-test ordering related to the evaluation and treatment of diabetes-associated foot problems . Intervention The intervention cohort was exposed to several risk-reduction strategies . The nurse-clinicians conducted the patient education session with one to four patients , covering appropriate foot-care behaviors and footwear , using a commercially available slide and audiotape presentation [ 27 ] and pamphlets [ 28 ] . Behavioral contracts regarding desired foot-care behaviors were negotiated with each patient . Follow-up was done by telephone 2 weeks after the education sessions to remind patients The implication s of behavioral analysis for practice and research have significant potential for nursing . This present study was conducted to determine the effectiveness of nurses and patients actively participating in behavioral analysis and the implementation of behavioral strategies in order to improve the patients ' self-management of their Type H diabetes . Patients ( N = 156 ) were r and omly assigned to one of four groups . The attention control group ( n = 41 ) received routine care . The compliance group ( n = 32 ) agreed to practice compliance behaviors related to the prescribed medical regimen . The behavioral strategies group ( n = 42 ) participated in behavioral analysis and agreed to practice behavioral strategies . The behavioral strategies with instruction group ( n = 41 ) participated in behavioral analysis , agreed to practice behavioral strategies , and received classes and programmed instruction about behavioral analysis and behavioral strategies . There were no outcome differences between groups relative to glycosylated hemoglobin ( GHb ) and weight loss . There were differences in the outcome measures in subgroups by age , gender , and employment , which have practice and research implication s for the individualization of interventions using behavioral strategies There is a pressing need for brief , practical interventions that address diabetes management . We have developed an office-based intervention to prompt both patients and providers to focus on behavioral issues relevant to dietary self-management that is being evaluated in a r and omized trial . The intervention is design ed to be broadly applicable to the majority of adult diabetes out patients during medical visits ; uses touchscreen computer assessment to provide immediate feedback on key issues to patients and providers just prior to their interaction ; and provides goal setting and problem-solving assistance to patients following their meeting with the physician . Follow-up components include phone calls and videotape or interactive video instruction as needed . The program is described , and demographic and behavioral characteristics of participants are presented for the first 95 patients r and omized . Initial process results suggest success in producing modest , targeted behavior changes among a broad cross-section of patients . If the long-term results are equally positive , this intervention could provide a prototype for a feasible , cost-effective way to integrate patient views and behavioral management into office-based care for diabetes Two objectives were established for this study : 1 ) to assess the impact of a culturally specific , intensive diabetes education program on dietary patterns , and 2 ) to assess nutrient consumption relative to the Recommended Dietary Allowances . The study population consisted of elderly Mexican Americans with diabetes living in Harlingen and Brownsville , Texas . The experimental group ( n=78 ) participated in an intense , 2-hour nutrition education session , while the  control group ( n=74 )  did not . The education session was conducted for groups of eight subjects via videotapes and interactive discussion . All groups experienced significant weight loss except the women in the experimental group . After the education program , however , the experimental women had increased the percentage of calories consumed daily from carbohydrate . Mean calcium consumption was substantially less than the RDA in all groups , and inadequate amounts of ascorbic acid and vitamin A often were consumed . Intensive , frequent , long-term follow-up appears essential for more sustained results The purpose of our study was to compare the effect on diabetes control of group management with the advice-educational technique traditionally used in managing obese out patients with poorly controlled non-insulin-dependent diabetes mellitus ( NIDDM ) . Forty-one patients were r and omly assigned to these two treatment programs , and 32 patients completed the 6-mo study . Initially , patients were seen for 1-h sessions at 1- and 2-wk intervals and later at 1-mo intervals . Patients were asked to do home blood glucose monitoring , decrease caloric intake , increase exercise , and if they were taking insulin , to adjust the dose to attain approximate euglycemia  and to stabilize food and exercise patterns  . The combined groups reduced mean ± SD glycohemoglobin from 10.9 ± 3.1 to 9.4 ± 2.4 % ( P < .05 ) . Internal Health Locus of Control Scale was negatively and significantly correlated with initial and subsequent glycohemoglobin values ( the more internal , the lower the glycohemoglobin ) . At the end of the study the patients in the group management program had significantly lower blood glucose levels than those given advice and education , but no significant differences in glycohemoglobin values or percentage overweight were observed . One patient had a normal initial glycohemoglobin , and only 4 patients had values in the normal range of 4–6.8 % at the end of the study . Better management programs need to be developed for treating obese out patients with NIDDM OBJECTIVE To examine the effects of patient choice between two education curriculums that emphasized either the st and ard or nutritional management of type 2 diabetes on class attendance and other outcomes among a mostly Hispanic patient population . RESEARCH DESIGN AND METHODS A total of 596 patients with type 2 diabetes were r and omly assigned to either a choice or no choice condition . Patients in the choice condition were allowed to choose their curriculum , while patients in the no choice condition were r and omly assigned to one of the two curriculums . Outcomes were assessed at baseline and at a 6-month follow-up . RESULTS When given a choice , patients chose the nutrition curriculum almost four times more frequently than the st and ard curriculum . Contrary to our hypothesis , however , patients who had a choice did not significantly increase their attendance rates or demonstrate improvements in other diabetes outcomes compared with patients who were r and omly assigned to the two curriculums . Patients in the nutrition curriculum had significantly lower serum cholesterol at a 6-month follow-up , whereas patients in the st and ard curriculum had significant improvements in glycemic control . Of the r and omized patients , 30 % never attended any classes ; the most frequently cited reasons for nonattendance were socioeconomic . Hispanic patients , however , were just as likely as non-Hispanic patients to attend classes and participate at the follow-up . Patients who attended all five classes of either curriculum significantly increased their diabetes knowledge , gained less weight , and reported improved physical functioning compared with patients who did not attend any classes . CONCLUSIONS Although providing patients with a choice in curriculums at the introductory level did not improve outcomes , differential improvements were noted between patients who attended curriculums with different content emphasis . We suggest that diabetes education programs should provide the opportunity for long-term , repetitive contacts to exp and on the modest gains achieved at the introductory level , as well as provide more options to match individual needs and interests and to address socioeconomic barriers to participation Non-insulin-dependent diabetes mellitus ( NIDDM ) is preceded by impaired glucose tolerance ( IGT ) lasting for years before manifesting as overt hyperglycaemia . Both genetic and environmental factors contribute to the development of IGT and NIDDM . Obesity , physical inactivity and high-fat diet have been found to predict IGT and NIDDM . Therefore , a diet and exercise intervention from diagnosis of NIDDM could improve the treatment outcome and prognosis of patients with NIDDM . Furthermore , because subjects with IGT are at increased risk for diabetes and atherosclerotic vascular disease , it is reasonable to assume that in terms of reducing the incidence and longterm consequences of NIDDM an intervention at this phase is more effective than in overt diabetes . Although the nonpharmacological approach is generally accepted as the first-line treatment of NIDDM its efficacy has often been question ed . Therefore , it is important to carry out long-term controlled studies to find out to what extent lifestyle modification could improve the metabolic control and level of major cardiovascular risk factors known to be associated with poor outcome in NIDDM . This kind of study also gave relevant experience in planning studies aim ing at primary prevention of NIDDM . One-year dietary and exercise intervention on newly diagnosed NIDDM patients in Kuopio , Finl and result ed in a better metabolic control and a moderate reduction in cardiovascular risk factors as compared to the conventional treatment group . After the second year of follow-up only 12.5 % in the intervention group were receiving  oral antidiabetic drugs  vs. 34.8 % in the conventional treatment group . Weight reduction and a reduced use of saturated fats appeared to be the main determinants of successful treatment results . Good aerobic capacity was associated with an increase in HDL cholesterol . A multicentre primary prevention study on IGT patients is continuing in Finl and applying the same principles of intervention as used in the study on newly diagnosed NIDDM patients . Pilot results show that glucose tolerance can be improved by lifestyle changes OBJECTIVE Evaluations of trials of the effectiveness of dietary intervention programs may be compromised by response set biases , such as those attributable to social desirability . Participants who receive a behavioral intervention  may bias their reports of diet to appear in compliance with intervention goals . This study examined whether responses to st and ard dietary assessment instruments could be affected by a brief dietary intervention . DESIGN We assigned 192 undergraduate students r and omly to ( a ) see a 17-minute videotape on the consequences of eating a high-fat diet or a placebo videotape on workplace management and ( b ) receive preintervention and post-intervention assessment s or only postintervention assessment .  Dietary assessment s included 4 independent measures of fat intake . RESULTS Among women , bias ( intervention minus control ) was -9.7 g fat ( from a short food frequency question naire ) and -0.6 high-fat foods ( from a question naire about use of 23 foods in the previous day ) ( P < .05 for both ) . No results were significant among men or for 2 instruments that measured more qualitative aspects of fat-related dietary habits . APPLICATIONS Even a modest dietary intervention can affect responses to dietary assessment instruments . Nutritionists should recognize that assessment of adherence to dietary change recommendations , when based on dietary self-report , can be overestimated as a result of response set biases We assessed diabetes education and peer support interventions as facilitators of weight loss and glycemic control in a community sample of 79 elderly persons with noninsulin-dependent diabetes mellitus ( NIDDM ) . Different groups received : education only , education and peer support , and no treatment .  Peer support was higher in groups where it was actively facilitated . Weight loss and reduction in level of glycemic control occurred within groups receiving both diabetes education and peer support The quality of reported research representing a number of disciplines involved in diabetes patient education was investigated in this study . A rigorous literature search identified 47 studies reported between 1954 and 1986 that met inclusion criteria ; 29 were published studies , 18 were unpublished .  Quality of the research was measured by Duffy 's Research Appraisal Checklist ( RAC ) and also by coding each study as to the number of threats to internal and external validity present . Overall quality as measured by the RAC ranged from 34 to 95 on a 100-point scale . A statistically significant relationship was found between publication date of the research report and quality , indicating improvement in quality during recent years . Quality of published versus unpublished research reports was not found to differ significantly . Recommendations for improving method ological rigor of future studies include : ( a ) the use of more rigorous design s , particularly those involving control groups such as r and omized clinical trials ; ( b ) reporting of more complete data in research reports ; and ( c ) monitoring of the quality of future studies The design of the study was " 2-period changeover " ; each period lasted 6 months and 6 counseling sessions were offered during each period . Group 1 ( n = 81 ) , counseled  in the first period , was controlled by a noncounseled group 2 ( n = 82 ) . R and omization of patients into the 2 groups took place at each office . The primary variable for consideration was the postpr and ial ( pp ) blood sugar level ( mg/dl ) . Weight reduction of overweight patients was also considered . A highly significant ( p less than 0,01 ) difference of mean pp-blood sugar reduction between the groups was found during both periods . In view of the large estimated difference in the residual effects of both treatments ( counseling , no counseling ) a crossover analysis was excluded . The best pp-blood sugar effect was obtained for patients with high pp-blood sugar level ( greater than or equal to 250 ) at the beginning of the counseling period A population -based study on the therapeutic effects of a diabetes teaching programme ( DTP ) based on problem oriented participatory education (POPE)--a method based on learner activity in group meetings -- was undertaken at the Primary Health Care Centre , Kisa , Sweden , in collaboration with educationalists . A control group was given conventional classroom teaching . To be included a patient had to be aged 55 - 73 years , to live in his own home , and to have non-insulin-treated type II diabetes mellitus . The therapeutic effects of the DTP were studied before , during , and after POPE with regard to three factors , diabetes related knowledge , behaviour assessed by dietary and exercise habits , and the quality of the anti-diabetic therapy as assessed by metabolic profile including Hb-A1 . Significant improvement in knowledge and transient improvement in Hb-A1 concentration were recorded among patients taking part in a DTP adjusted to their individual problems and needs . When improvement in metabolic control does not last , group meetings should be continued for more than the three months used in the present study . We believe that such improvement is intimately bound up with the psycho-social process that is involved in the group meetings and that helps the patient to cope with the disease in particular and life in general Compliance with dietary recommendations and the effect of intensified dietary therapy on energy and nutrient intakes and fatty acid composition of serum lipids were studied in 86 obese subjects ( aged 40 to 64 years ) with recently diagnosed non-insulin-dependent diabetes mellitus ( NIDDM ) . After three months of basic education , the subjects were r and omly separated into an intervention group ( n = 40 ) and a conventional treatment group ( n = 46 ) . Members of the intervention group participated in 12 months of intensified education ; those in the conventional group visited local health centers . Compliance with dietary instructions was monitored through food records . Intensified dietary therapy result ed in greater weight loss , better metabolic control , and a less atherogenic lipid profile than conventional treatment . Intake of energy and saturated fatty acids tended to decline in the intervention group . A higher percentage of patients in the intervention group had a total fat intake of 30 % of energy or less after 15 months ( 32.5 % [ 12 of 38 ] vs 17.4 % [ 8 of 46 ] ) . Similarly , more patients in the intervention group had a saturated fatty acid intake of 10 % or less of total energy intake at the end of the study ( 35.0 % [ 13 of 38 ] vs 8.7 % [ 4 of 46 ] ) . The mean dietary cholesterol intake was within recommendations in both groups at the end of the study . The relative percentage of linoleic acid of serum lipids increased significantly and the relative percentage of palmitic acid of serum triglycerides , phospholipids , and cholesterol esters decreased in the intervention group . These changes indicate that intensified dietary therapy improved the quality of fat in the diet of patients with NIDDM The Diabetes Education Study ( DIABEDS ) was a r and omized , controlled trial of the effects of patient and physician education . This article describes a systematic education program for diabetes patients and its effects on patient knowledge , skills , self-care behaviors , and relevant physiologic outcomes . The original sample consisted of 532 diabetes patients from the general medicine clinic at an urban medical center . Patients were predominantly elderly , black women with non-insulin-dependent diabetes mellitus of long duration . Patients r and omly assigned to experimental groups ( N = 263 ) were offered up to seven modules of patient education . Each content area module contained didactic instruction ( lecture , discussion , audio-visual presentation ) , skill exercises ( demonstration , practice , feedback ) , and behavioral modification techniques ( goal setting , contracting , regular follow-up ) .  Two hundred seventy-five patients remained in the study throughout baseline , intervention , and postintervention periods ( August 1978 to July 1982 ) . Despite the requirement that patients demonstrate mastery of educational objectives for each module , postintervention assessment 11–14 mo after instruction showed only rare differences between experimental and control patients in diabetes knowledge . However , statistically significant group differences in self-care skills and compliance behaviors were relatively more numerous . Experimental group patients experienced significantly greater reductions in fasting blood glucose ( −27.5 mg/dl versus −2.8 mg/dl , P < 0.05 ) and glycosylated hemoglobin ( −0.43 % versus + 0.35 % , P < 0.05 ) as compared with control subjects . Patient education also had similar effects on body weight , blood pressure , and serum creatinine . Continued follow-up is planned for DIABEDS patients to determine the longevity of effects and subsequent impact on emergency room visits and hospitalization Patients with diabetes are usually placed on exchange system diets to ensure a nutritionally adequate intake . However , there have been few studies which have actually compared the nutritional adequacy of diets selected by patients on exchange system diets  , with that selected by patients on the calorie-counting diets typically used in behavioral weight control programs . This study compared the nutritional adequacy of the diets selected by overweight patients with Type II diabetes who had been r and omly assigned to either an exchange system diet or  a calorie-counting diet . Three-day food diaries were completed by all patients at the start and end of a 16-week weight control program . No significant differences were observed between patients on the calorie-counting diet compared to those on the exchange system diet with respect to nutrient intake , macronutrient distribution , or percent of the RDA obtained . Patients on both types of diet reported decreases in the proportion of calories from fat . The average intake exceeded 100 % of the RDA for all nutrients except calcium . This study suggests that patients are able to improve the nutritional adequacy of their intake while following either a calorie-counting or an exchange system diet This study aim ed to determine if patients can set their own educational priorities accurately and if the impact of diabetes education on knowledge differed between patients who did and did not set their own priorities . Forty patients referred for individual education were r and omly assigned to one of two groups . Prior to education with a diabetes specialist nurse ( DSN ) patients ranked 10 diabetes care topics in order of perceived importance and relevance to their needs and completed a knowledge question naire . Group 1 set their own priorities and the DSN directed education according to the patients stated priorities . In Group 2 the DSN set the educational priorities without seeing the patients priority list . The priority ranking by the two groups of the 10 topics and their pre-education knowledge score were not significantly different . Post-education knowledge scores improved equally and significantly in both groups ( Group 1 from 23 to 87 % ; Group 2 from 21 to 79 % ) ; P < 0.0001 ) . In both groups , knowledge scores for the top three priorities were significantly higher than for the three lowest ranked topics . Knowledge is neither dependent on , nor a good discriminator of , patient-selected priorities . There may be reasons why it is important for patients to set their own priorities , but education directed solely at those priorities may leave knowledge deficits which could compromise diabetes care Individuals with noninsulin depend ent diabetes mellitus referred to a dia betes education programme  were al located at r and om to treatment ( n = 32 ) or non-treatment ( n = 28 ) groups to assess the effectiveness of this pro gramme . The education course lasted four weeks , at the end of which the participants showed reductions of HbA1c and post-pr and ial glucose levels , improvement in knowledge and less anxiety . On the other h and , the control group experienced more anxiety and did not show significant changes in measured indices of glu cose control . Nevertheless , these i m provements in glucose control were not sustained . Within four weeks of cessation of the intervention pro gramme , HbA1c and glucose levels were not significantly different from those measured at entry to the pro gramme . In addition , a delay of four weeks from the time of referral until initiation of education was associated with lack of significant reduction of HbA1c and glucose levels OBJECTIVE The purpose of this study was to determine if participation in a patient empowerment program would result in improved psychosocial self-efficacy and attitudes toward diabetes , as well as a reduction in blood glucose levels . RESEARCH DESIGN AND METHODS This study was conducted as a r and omized , wait-listed control group trial . The intervention group received a six-session ( one session per week ) patient empowerment education program ; the control group was assigned to a wait-list . At the end of 6 weeks , the control group completed the six-session empowerment program . Six weeks after the program , both groups provided follow-up data . RESULTS The intervention group showed gains over the control group on four of the eight self-efficacy subscales and two of the five diabetes attitude subscales . Also , the intervention group showed a significant reduction in glycated hemoglobin levels . Within groups , analysis of data from all program participants showed sustained improvements in all of the self-efficacy areas and two of the five diabetes attitude subscales and a modest improvement in blood glucose levels . CONCLUSIONS This study indicated that patient empowerment is an effective approach to developing educational interventions for addressing the psychosocial aspects of living with diabetes . Furthermore , patient empowerment is conducive to improving blood glucose control . In an ideal setting , patient education would address equally blood glucose management and the psychosocial challenges of living with diabetes To determine whether a group behavior modification approach might be preferable to individual counseling in the nutritional therapy of non-insulin-dependent diabetes mellitus , 40 adults younger than 65 yr of age with diabetes mellitus who were not receiving insulin were r and omized to either a program of individualized dietary review and recommendations or a program of group meetings aim ed at controlling the signals leading to overeating and noncompliance with a diabetic dietary regimen . Statistically significant ( P < 0.05 ) decreases in body weight , sum skin-fold thickness , fasting serum glucose , and serum triglycerides but not LDL-C or HDL-C were observed . The individual counseling group had a greater amount of weight loss than the behavior modification group . There were no significant ( P < 0.05 ) differences between the two groups with respect to the biochemical outcome variables . Patient characteristics assessed at entry — namely anxiety , internal versus external locus of control and perceived disease severity , and compliance with advice — were significantly associated with weight loss in the behavior modification group while only the latter index was of value in the individual counseling group . Thus , our use of these programs does not identify a clear advantage of either approach in the nutritional therapy of non-insulin-dependent diabetic patients OBJECTIVES This study evaluated a multicomponent educational intervention to increase ophthalmic examination rates among African Americans with diabetes . METHODS A r and omized trial was conducted with 280 African Americans with diabetes , enrolled from outpatient departments of 5 medical centers in the New York City metropolitan area , who had not had a dilated retinal examination within 14 months of r and omization ( 65.7 % female , mean age = 54.7 years [ SD = 12.8 years ] ) . RESULTS After site differences were controlled , the odds ratio for receiving a retinal examination associated with the intervention was 4.3 ( 95 % confidence interval = 2.4 , 7.8 ) . The examination rate pooled across sites was 54.7 % in the intervention group and 27.3 % in the control group . CONCLUSIONS The intervention was associated with a rate of ophthalmic examination double the rate achieved with routine medical care
OBJECTIVE To systematic ally review the effectiveness of self-management training in type 2 diabetes .