Effectiveness of educational interventions to promote oral hypoglycaemic adherence in adults with Type 2 diabetes: a systematic review Effectiveness of a self-management intervention with personalised genetic and lifestyle-related risk information on coronary heart disease and diabetes-related risk in type 2 diabetes (CoRDia): study protocol for a randomised controlled trial Medication non-adherence and poor glycaemic control in patients with type 2 diabetes mellitus. Effects of cognitive behavioural group training (CBGT) in adult patients with poorly controlled insulin-dependent (type 1) diabetes: a pilot study. Mendelian randomization studies of biomarkers and type 2 diabetes Implementation and evaluation of a decision support system for type II diabetes. Cost-utility analysis in a UK setting of self-monitoring of blood glucose in patients with type 2 diabetes A trial of empowerment-based education in type 2 diabetes--global rather than glycaemic benefits. Association between circulating 25-hydroxyvitamin D and incident type 2 diabetes: a mendelian randomisation study Effect of culturally appropriate health education on glycaemic control and knowledge of diabetes in British Pakistani women with type 2 diabetes mellitus. The IMPROVE study--a multinational, observational study in type 2 diabetes: baseline characteristics from eight national cohorts. Alcohol: another risk factor for diabetic retinopathy? Treating depression in diabetes patients: does a nurse-administered minimal psychological intervention affect diabetes-specific quality of life and glycaemic control? A randomized controlled trial. Longitudinal study on glycaemic control and quality of life in patients with Type 2 diabetes mellitus referred for intensified control. Long-term effects of a structured intensive diabetes education programme (SIDEP) in patients with Type 2 diabetes mellitus--a 4-year follow-up study. Effects of the Diabetes Manual 1:1 structured education in primary care. The clinical effectiveness of different parenting programmes for children with conduct problems: a systematic review of randomised controlled trials Comparative Effectiveness of Dipeptidylpeptidase-4 Inhibitors in Type 2 Diabetes: A Systematic Review and Mixed Treatment Comparison Therapeutic education among adults with type 2 diabetes: effects of a three-day intervention on perceived competence, self-management behaviours and glycaemic control
Executive summary Background As a chronic condition , the prevalence of Type 2 diabetes is increasing worldwide and adherence to oral medications , an essential component of self‐management , has been shown to improve glycaemic control . However compliance with oral medication adherence remains poor . Educating people with Type 2 diabetes is an important strategy to enhance self‐management ability , including medication‐taking behaviour . Objectives The overall objective of the review was to determine the effectiveness of educational interventions to promote oral hypoglycaemic adherence in adults with Type 2 diabetes . Inclusion criteria Types of participants Studies involving adults over 18 years old with Type 2 diabetes , with or without co‐morbidities , currently taking oral hypoglycaemic medication without insulin treatment , and with aglycated haemoglobin ( HbA1c ) > 7.0 % prior to the intervention were considered . Aglycated haemoglobin ( HbA1c ) concentration of less than 7.0 % , is important in order to delay or prevent diabetes‐related complications . Participants could be from the primary , tertiary or acute care setting . Types of intervention The review focused on various forms of educational interventions delivered by healthcare professionals aim ed at improving participants ’ knowledge . Types of outcomes The review evaluated outcomes measuring oral hypoglycaemic adherence including HbA1c , fasting blood glucose levels and other relevant indicators . Types of studies Studies that were r and omized controlled trials ( RCTs ) or case‐control studies were considered . Search strategy A three‐stage search strategy was employed . Papers in English and between the years 1990‐2009 were search ed in the following data bases : CINAHL , Medline , Mosby 's Nursing Consult , PsycINFO , PubMed , ScienceDirect , Scopus , TRIP and Web of Science . Full text was retrieved when the titles and abstract s of studies fulfilled the inclusion criteria . Method ological quality Full papers were assessed for method ological quality independently by two review ers using critical appraisal checklists from the Joanna Briggs Institute ( JBI ) . A third review er was consulted whenever there were disagreements between the two review ers . Data collection / extraction Details of each study included in the review were extracted using st and ardized data extraction forms developed by JBI . Extraction was conducted independently by two review ers . Data synthesis Meta‐ analysis was not possible due to method ological and statistical heterogeneity of the included studies . Hence study findings are presented in narrative form . Results Seven studies included in the final review consisted of seven RCTs . Five studies concluded that the educational intervention was effective in promoting oral hypoglycaemic adherence compared to usual care . These included pharmacist‐led interventions , individual diabetes education provided by nurses and diabetes group education based on a self‐management approach . Similarities among these interventions were provision of information on oral hypoglycaemic medication and the need for regular education sessions . However , small sample s in some studies limited generalization of results . Conclusions Implication s for practice Increased knowledge of oral hypoglycaemic issues and reinforcement of the importance of medication adherence were useful in promoting adherence . Regular education sessions allow individuals to reinforce information and educators to identify barriers to medication adherence . Educational interventions focusing on self‐management strategies appear more likely to achieve positive outcomes . Implication s for research Further trials involving larger sample s and population s with poor glycaemic control are needed . The effects of educational interventions , influence of additional take‐home written material , the optimal interval length of follow‐up and duration of education sessions , and specific processes of individual or group education which have been identified as effective need further exploration Background Many patients with type 2 diabetes fail to achieve good glycaemic control . Poor control is associated with complications including coronary heart disease ( CHD ) . Effective self-management and engagement in health behaviours can reduce risks of complications . However , patients often struggle to adopt and maintain these behaviours . Self-management interventions have been found to be effective in improving glycaemic control . Recent developments in the field of genetics mean that patients can be given personalised information about genetic- and lifestyle-associated risk of developing CHD . Such information may increase patients ’ motivation to engage in self-management . The Coronary Risk in Diabetes ( CoRDia ) trial will compare the effectiveness of a self-management intervention , with and without provision of personalised genetic- and lifestyle-associated risk information , with usual care , on clinical and behavioural outcomes , the cognitive predictors of behaviour , and psychological wellbeing . Methods / Design Participants will be adults aged 25–74 years registered with general practice s in the East of Engl and , diagnosed with type 2 diabetes , with no history of heart disease , and with a glycated haemoglobin level of ≥6.45 % ( 47 mmol/mol ) . Consenting participants will be r and omised to one of three arms : usual care control , group self-management only , group self-management plus personalised genetic- and lifestyle-associated risk information . The self-management groups will receive four weekly 2-hour group sessions , focusing on knowledge and information sharing , problem solving , goal setting and action planning to promote medication adherence , healthy eating , and physical activity . Primary outcomes are glycaemic control and CHD risk . Clinical data will be collected from GP records , including HbA1c , weight , body mass index , blood pressure , and HDL and total cholesterol . Self-reported health behaviours , including medication adherence , healthy eating and physical activity , and cognitive outcomes will be assessed by question naire . Measures will be taken at baseline , 3 months ( question naire only ) , 6 months and 12 months post-baseline . Discussion This study will determine whether the addition of personalised genetic- and lifestyle-associated CHD risk information to a group self-management intervention  improves diabetes control and CHD risk compared with group self-management and usual care . Effectiveness of the combined intervention on health behaviours cognitions theorised to predict them , and psychological outcomes will also be investigated . Trial registration This study has been registered at Clinical Trials.gov ; registration identifier NCT01891786 , registered 28 June 2013 AIMS Our main aim was to analyse gender differences in the association of adherence and poor glycaemic control ( PGC ) in a cohort of patients with type 2 diabetes mellitus in Germany . METHODS Baseline data of the DIANA- study , a prospect i ve cohort study of type 2 diabetes mellitus patients in South-West Germany , were analysed . Information on medication adherence and factors related to PGC was obtained by self-administered question naire . PGC was defined as HbA(1c)≥7.5 % . Bivariate and multivariate analyses using log-binomial regression were employed to assess overall and gender-specific associations of non-adherence and PGC . RESULTS 624 men and 518 women were included in the analyses . In total , 147 men ( 24 % ) and 114 women ( 23 % ) reported non-adherence to medication . In men , PGC was found in 37 % of the participants reporting non-adherence and in 19 % reporting adherence ( adjusted prevalence ratio (PR)=1.90 , 95%-CI : 1.46 - 2.49 ) . In women , PGC was found in 19 % of the participants reporting non-adherence and in 18 % reporting adherence ( adjusted PR=0.97 , 95%-CI : 0.65 - 1.46 ) . CONCLUSIONS Our results show gender-specific differences in the association of adherence and PGC . This underlines the need for efforts to improve glycaemic control in patients with type 2 diabetes mellitus with a particular focus on men A substantial group of patients with type 1 diabetes has difficulty adhering to the treatment regimen , and as a consequence is at increased risk of developing microvascular complications .  Cognitive behavioural interventions may help these patients to cope more effectively with their diabetes . We developed a 4 weeks cognitive behavioural group training ( CBGT ) for patients with type 1 ( insulin-dependent ) diabetes in persistent poor glycaemic control , to help them overcome negative beliefs and attitudes towards diabetes and improve their self-care behaviours . Feasibility and efficacy of CBGT were tested in a non-r and omised prospect i ve study in 24 poorly-controlled type 1 diabetes patients ( mean age 35.2+/-11.1years ; 15 female ; mean HbA(1c ) 9.3 % ( + /-1.2 ) ) , with assessment s at 3 and 6 months follow-up . The programme was delivered in small groups ( n=6 - 8 ) , by a team of a diabetes nurse specialist and a psychologist . Primary outcome measures were glycosylated haemoglobin ( HbA(1c ) ) , diabetes-related emotional distress ( PAID ) and psychological well-being ( WBQ-12 ) . Changes in diabetes self-care activities ( DSCI ) were documented , along with perceived barriers in diabetes question niare ( BDQ ) and fear of hypoglycaemia survey ( HFS ) . Data were analysed using repeated measures analysis of variance . The CBGT proved to be feasible in this selected group of patients and was well appreciated . Following CBGT , mean HbA(1c ) dropped by 0.8 % at 6 months from baseline , while emotional well-being was preserved . It is concluded that CBGT is a promising intervention that deserves further evaluation in r and omised controlled trials Many biomarkers are associated with type 2 diabetes ( T2D ) risk in epidemiological observations . The aim of this study was to identify and summarize current evidence for causal effects of biomarkers on T2D . A systematic literature search in PubMed and EMBASE ( until April 2015 ) was done to identify Mendelian r and omization studies that examined potential causal effects of biomarkers on T2D . To replicate the findings of identified studies , data from two large-scale , genome-wide association studies ( GWAS ) were used : DIAbetes  Genetics Replication And Meta- analysis  ( DIAGRAMv3 ) for T2D and the Meta-Analyses of Glucose and Insulin-related traits Consortium ( MAGIC ) for glycaemic traits . GWAS summary statistics were extracted for the same genetic variants ( or proxy variants ) , which were used in the original Mendelian r and omization studies . Of the 21 biomarkers ( from 28 studies ) , ten have been reported to be causally associated with T2D in Mendelian r and omization . Most biomarkers were investigated in a single cohort study or population . Of the ten biomarkers that were identified , nominally significant associations with T2D or glycaemic traits were reached for those genetic variants related to bilirubin , pro-B-type natriuretic peptide , delta-6 desaturase and dimethylglycine based on the summary data from DIAGRAMv3 or MAGIC . Several Mendelian r and omization studies investigated the nature of associations of biomarkers with T2D . However , there were only a few biomarkers that may have causal effects on T2D . Further research is needed to broadly evaluate the causal effects of multiple biomarkers on T2D and glycaemic traits using data from large-scale cohorts or GWAS including many different genetic variants A decision support system for the management of  oral hypoglycaemic therapy  in type II diabetes was evaluated . The ruleset contained therein forms the basis of a prototype computer programme , but in order to assess the robustness of the individual rules , it was decided it was necessary to use a paper-based form of the ruleset . A nurse with no previous experience of managing type II diabetes was trained to use the system and then undertook the exclusive management of half of all new type II diabetics , from a district population of 300,000 , over a 16-month period . General practice s within this area were divided into two groups , study and control , matching for size , geographical area and st and ards of existing diabetes care . Patients ( n = 102 ) from the study group practice s were then assigned to her care . Those patients ( n = 116 ) in the control group of practice s were treated according to their normal procedures . The decision support system for oral hypoglycaemic therapy was based on the following criteria : the current type of treatment ( six levels ) ; current glycaemic control ( HbA1 and FBS)-whether improving , steady or worsening ; and weight-%IBW , whether rising , steady or falling . Each of these parameters was carefully defined on the basis of established practice and clinical experience . Patients after initial education were seen at their usual clinic by the nurse only , on a monthly basis , until satisfactory glycaemic control was established and thereafter review ed 3 monthly . She was also responsible for ensuring the organisation of Diabetes Annual Review procedures . The medical records of the control group patients were examined at the end of the study and data on glycaemic control and Annual Review s extracted . In the study group 98 % patients achieved HbA1 levels within the normal range and all patients had full annual review s performed . The control practice s achieved much poorer degrees of metabolic control ( P < 0.01 ) and completed fewer annual review s. The study group did not demonstrate a significantly increased frequency of clinical hypoglycaemia consequent upon better blood sugar control . No exceptions to the ruleset , as initially defined , were detected . In conclusion , this decision support system was successful at achieving st and ards of diabetes control and care equal to or better than conventional structures of diabetes care . Implementation of such a system , on a simple computer platform , could greatly assist and possibly improve diabetes management in general practice ABSTRACT Background : Self-monitoring of blood glucose ( SMBG ) in type 2 diabetes patients has been shown in meta-analyses of r and omized trials to improve HbA1c by ∼0.4 % when compared to no SMBG . However , the cost of testing supplies is high , improvements in health utility due to improved glycaemic control may be possible and cost-effectiveness has not been evaluated . Methods : A peer- review ed vali date d model projected improvements in lifetime quality -adjusted life years ( QALYs ) , long-term costs and cost-effectiveness of SMBG versus no SMBG . Markov/Monte Carlo modelling simulated the progression of complications ( cardiovascular , neuropathy , renal and eye disease ) . Transition probabilities and HbA1c-dependent adjustments came from the United Kingdom Prospect i ve Diabetes Study ( UKPDS ) and other major studies . Effects of SMBG on HbA1c came from clinical studies , meta-analyses and population studies , but can only be considered ‘ moderate ’ levels of evidence . Costs of complications were retrieved from published sources . Direct costs of diabetes complications and SMBG were projected over patient lifetimes from a UK National Health Service perspective . Outcomes were discounted at 3.5 % annually . Extensive sensitivity analyses were performed . Results : Depending on the type of diabetes treatment ( diet and exercise/oral medications/insulin ) , improvements in glycaemic control with SMBG improved discounted QALYs anywhere from 0.165 to 0.255 years , with increased total costs of £ 1013–£2564/patient , giving incremental cost-effectiveness ratios of £ 4508:£15 515/QALY gained , well within current UK willingness-to-pay limits . Results were robust under a wide range of plausible assumptions . Conclusions : Based on the moderate level of clinical evidence available to date , improvements in glycaemic control with interventions , including SMBG , can improve patient outcomes , with acceptable cost-effectiveness ratios in the UK setting We have assessed the effect of a structured , empowerment-based educational system ( " LAY or " Look After Yourself " ) for patients with type 2 diabetes . A r and omised controlled trial ( RCT ) was conducted , testing the system against st and ard support . Using 3 centres , 89 patients participated in the study . Outcome measures included glycated haemoglobin ( HbA(1c ) ) , body mass index ( BMI ) and a variety of quantitative psychological and educational measures . Assessment was made at 6 months ( " short-term " ) and 12 months ( " long-term " ) post-intervention . The educational programme was associated with benefits in HbA(1c ) levels ( p=0.005 ) , illness attitudes ( p=0.04 ) , and perceived treatment effectiveness ( p=0.03 ) at 6 months follow-up compared to controls . At 12 months however , only illness attitudes ( p=0.01 ) , and self-monitoring ( p=0.002 ) showed benefit . A combined outcome measure showed positive benefit for the educational programme both at 6 months ( p=0.001 ) and 12 months ( p=0.002 ) . This structured educational programme , aim ed at encouraging self-help , was associated with only limited benefits in glycaemic control , but there were significant educational and psychological benefits . Diabetes education should be regarded as having broad patient-based positive outcomes , and should not be expected to have lasting benefits on glycaemic control Summary Background Low circulating concentrations of 25-hydroxyvitamin D ( 25[OH]D ) , a marker of vitamin D status , are associated with an increased risk of type 2 diabetes  , but whether this association is causal remains unclear . We aim ed to estimate the unconfounded , causal association between 25(OH)D concentration and risk of type 2 diabetes using a mendelian r and omisation approach . Methods Using several data sources from population s of European descent , including type 2 diabetes cases and non-cases , we did a mendelian r and omisation analysis using single nucleotide polymorphisms ( SNPs ) within or near four genes related to 25(OH)D synthesis and metabolism : DHCR7 ( related to vitamin D synthesis ) , CYP2R1 ( hepatic 25-hydroxylation ) , DBP ( also known as GC ; transport ) , and CYP24A1 ( catabolism ) . We assessed each SNP for an association  with circulating 25(OH)D concentration ( 5449 non-cases ; two studies ) , risk of type 2 diabetes ( 28 144 cases , 76 344 non-cases ; five studies ) , and glycaemic traits ( concentrations of fasting glucose , 2-h glucose , fasting insulin , and HbA1c  ; 46 368 non-cases ; study consortium ) . We combined these associations in a likelihood-based mendelian r and omisation analysis to estimate the causal association of 25(OH)D concentration with type 2 diabetes and the glycaemic traits , and compared them with that from a meta- analysis of data from observational studies ( 8492 cases , 89 698 non-cases ; 22 studies ) that assessed the association between 25(OH)D concentration and type 2 diabetes . Findings All four SNPs were associated with 25(OH)D concentrations ( p<10−6 ) . The mendelian r and omisation-derived unconfounded odds ratio for type 2 diabetes was 1·01 ( 95 % CI 0·75–1·36 ; p=0·94 ) per 25·0 nmol/L ( 1 SD ) lower 25(OH)D concentration . The corresponding ( potentially confounded ) relative risk from the meta- analysis of data from observational studies was 1·21 ( 1·16–1·27 ; p=7·3 × 10−19 ) . The mendelian r and omisation-derived estimates for glycaemic traits were not significant ( p>0·25 ) . Interpretation The association between 25(OH)D concentration and type 2 diabetes is unlikely to be causal . Efforts to increase 25(OH)D concentrations might not reduce the risk of type 2 diabetes as would be expected on the basis of observational evidence . These findings warrant further investigations to identify causal factors that might increase 25(OH)D concentration and also reduce the risk of type 2 diabetes . Funding UK Medical Research Council Epidemiology Unit and European Union Sixth Framework Programme Type 2 diabetes is a growing problem in people of South Asian origin . It is associated with severe complications if it is not adequately controlled . This paper is a secondary assessment of 105 British Pakistani women within a larger r and omized controlled trial of 200 Pakistani patients with diabetes . The trial used one-to-one structured diabetes health education , delivered by a linkworker with pictorial flashcards as a visual aid . Earlier published results from this study have shown that the women in the study knew less about diabetes and had poorer glycaemic control than men , which is why this assessment was performed to see what happened to them when they received appropriate health education . All patients were assessed before and 6 months after intervention by question naire and haemoglobin A1c blood tests to measure their overall blood sugar control .  Nearly everyone improved their knowledge scores after 6 months in the intervention group , with women showing a catch-up improvement such that they equalled men . Multiple regression analysis found that glycaemic control improved in women receiving health education . Although this method of health education improved knowledge and glycaemic control in women in this sample , illiterate women did not do as well as their literate peers , continuing to score less on knowledge parameters . They also did not show an improvement in glycaemic control . Further work is needed to discover methods that will reach this sizeable subsection of the community AIMS The IMPROVE study is a multinational , open-label , non-r and omised , 26-week observational study assessing the safety and effectiveness of biphasic insulin aspart 30 ( BIAsp 30 ) treatment in type 2 diabetes in routine clinical practice . The principal aims of this report were to characterise the baseline population and physicians ' treatment decisions . METHODS Patients with type 2 diabetes who required insulin and whose physician had decided to initiate BIAsp 30 were eligible . At baseline , demographic data and detailed medical histories were collected and physicians recorded their reasons for starting BIAsp 30 , the glycaemic targets set and the regimens chosen . RESULTS Data from 51,286 patients were included in analyses . Baseline glycaemic control was poor in all eight countries in the present analysis and in all pre study treatment groups [ no therapy , oral antidiabetic drugs ( OADs ) only , insulin with or without OADs ] , and the rates of vascular complications were high . Although the management of each of the three main measures of glycaemic control were key reasons for starting BIAsp 30 , target- setting for postpr and ial glucose levels was variable . A twice-daily regimen was used to start BIAsp 30 therapy for 80 % or more of patients . CONCLUSIONS The IMPROVE baseline data reaffirm the global nature of poor glycaemic control in type 2 diabetes and echo the concerns that initiation of therapy , particularly insulin , is commonly delayed in clinical practice . Although postpr and ial glucose control was a key driver for physicians ' choice of BIAsp 30 , this was not consistently reflected in the targets set In a five year prospect i ve study clinical features associated with the development and progress of retinopathy were sought in 296 r and omly selected diabetic men aged 20 - 59 . None had ophthalmoscopically detectable retinopathy initially , but during follow up 66 developed the condition ( 47 background , 10 exudative , 9 proliferative ) . Linear logistic analyses ( two tailed tests ) showed that the initial features independently predictive of retinopathy were duration of diabetes , poor glycaemic control , impotence , and --unexpectedly -- heavy alcohol consumption . Poor glycaemic control in the interim and proteinuria at review were also associated with the development of retinopathy . No relation was found with smoking or obesity . Glycaemic control and alcohol consumption were therefore the only aetiologically relevant associations identified . The development of severe retinopathy ( exudative and proliferative ) showed a particular association with heavy alcohol consumption , occurring in nine of the 70 heavy drinkers ( 13 % ) compared with 10 ( 4.4 % ) of the rest . Alcohol consumption may be an important independent factor associated predictively with sight threatening diabetic retinopathy AIMS The aim of this study was to examine whether a nurse-administered minimal psychological intervention for depressive symptoms improves diabetes-specific quality of life and glycaemic control in older persons with diabetes . BACKGROUND Depression is common among persons with diabetes and may have a negative impact on diabetes . Interventions aim ed at reducing depressive symptoms may positively influence diabetes-specific quality of life as well . METHODS A pragmatic , r and omized controlled trial was carried out comparing the intervention with usual care among 208 Dutch primary care patients of ≥60 years with type 2 diabetes and co-occurring minor to moderate depression . Data on symptom distress and emotional distress were collected during 2003 - 2006 , and haemoglobin A1c levels were obtained from general practice s. Data were analysed using mixed model , repeated measures ANCOVAS . Hba1c was collected retrospectively from general practice s between December 2006-February 2007 . In July 2007 we retrieved some additional HbA1c data from the medical records of the university hospital . RESULTS Only in higher-educated persons did the intervention have statistically significant effect on both emotional distress and symptom distress ( DSC-R total score at 9 months P=0.001 ; PAID , 9 months P=0.03 ) . Furthermore , we found an effect on symptom distress in men ( 9 months P=0.01 ) , and on emotional distress in persons with a shorter diabetes duration ( < 7 years ) ( 9 months P=0.04 ) . A significant trend over time for haemoglobin A1c was found in favour of the intervention , with a statistically significant difference between groups after 9 months ( P=0.02 ) . CONCLUSION The nurse-administered intervention had limited effects on diabetes-specific quality of life . As only certain subgroups benefited , ways of increasing effectiveness in other groups should be explored . The potentially beneficial effect on glycaemic control is encouraging and needs further research because of small numbers in the analysis AIM The aim of our study was to describe investigate and association between improved glycaemic control on quality of life ( QoL ) during 1 year of treatment in a sample of 94 Type 2 diabetic patients referred for insulin therapy to an outpatient department ( OPD ) . Treatment was aim ed at achieving acceptable glycaemic control by means of maximizing oral therapy , if necessary switching over to insulin therapy , and information and education provided by a diabetes specialist nurse and dietitian . METHODS QoL was measured using a disease-specific ( Diabetes Health Profile ( DHP ) ) and a generic question naire ( R AND -36 ) . After 1 year the medical examination and QoL measurements were repeated . The association between 1-year changes in QoL and achievement of good metabolic control ( final glycosylated haemoglobin ( HbA1c ) < or = 8 % ) , switch to insulin therapy , and presence of hyperglycaemic complaints at baseline was analysed after adjustment for appropriate confounders . RESULTS After 1 year , mean HbA1c was reduced from 10.4 % to 7.8 % . Also QoL improved in the total group . Patients who achieved good glycaemic control after 1 year ( 61 % ) improved in a similar manner as the others . Patients switched over to insulin ( 65 % ) improved in a similar manner as the others , but at the final examination they experienced more problems with social functioning and pain . Patients with hyperglycaemic complaints at baseline ( 49 % ) improved more in QoL than those without , especially in physical functioning , vitality and health change , but at the final examination still scored lower on a majority of the DHP and R AND -36 dimensions . CONCLUSION Symptoms of hyperglycaemia predict the strength of an association between improvements of glycaemic control and AIMS Patient education is a very important part of diabetes care . However , until now , little data has been presented about the long-term effectiveness of structured intensive diabetes education programmes ( SIDEP ) for people with Type 2 diabetes mellitus . METHODS People with Type 2 diabetes ( n = 547 ) hospitalized from December 1999 to December 2000 were r and omly assigned to two groups . Two hundred and nineteen patients undertook an inpatient SIDEP and the remaining patients received conventional glycaemic control without intensive education . After discharge , all patients were monitored regularly . Laboratory data were obtained , and adherence to self-care behaviour was determined on a five-point scale by question naires completed annually . RESULTS Of the patients who completed the SIDEP , 160 ( 73.1 % ) were followed up for more than 4 years . The mean HbA(1c ) ( 7.9 + /- 1.2 vs. 8.7 + /- 1.6 % ; P < 0.05 ) and the frequency of hospitalization related to diabetes per patient per year ( 0.3 + /- 0.6 vs. 0.8 + /- 0.9 ; P < 0.05 ) was significantly lower in the SIDEP group than in the control group . The SIDEP group adhered more closely to self-care behaviour than the control group over 4 years ( P < 0.05 ) . People with Type 2 diabetes mellitus of longer duration and those treated with insulin had poorer HbA(1c ) at follow-up . CONCLUSIONS A well- design ed , intensive patient education programme is necessary for people with diabetes . However , regular and sustained reinforcement with encouragement is also required to maintain optimal glycaemic control , especially in insulin-treated patients AIMS To determine the effects of the Diabetes Manual on glycaemic control , diabetes-related distress and confidence to self-care of patients with Type 2 diabetes . METHODS A cluster r and omized , controlled trial of an intervention group vs. a 6-month delayed-intervention control group with a nested qualitative study . Participants were 48 urban general practice s in the West Midl and s , UK , with high population deprivation levels and 245 adults with Type 2 diabetes with a mean age of 62 years recruited pre-r and omization . The Diabetes Manual is 1:1 structured education design ed for delivery by practice nurses . Measured outcomes were HbA(1c ) , cardiovascular risk factors , diabetes-related distress measured by the Problem Areas in Diabetes Scale and confidence to self-care measured by the Diabetes Management Self-Efficacy Scale . Outcomes were assessed at baseline and 26 weeks . RESULTS There was no significant difference in HbA(1c ) between the intervention group and the control group [ difference -0.08 % , 95 % confidence interval ( CI ) -0.28 , 0.11 ] . Diabetes-related distress scores were lower in the intervention group compared with the control group ( difference -4.5 , 95 % CI -8.1 , -1.0 ) . Confidence to self-care Scores were 11.2 points higher ( 95 % CI 4.4 , 18.0 ) in the intervention group compared with the control group . The patient response rate was 18.5 % . CONCLUSIONS In this population , the Diabetes Manual achieved a small improvement in patient diabetes-related distress and confidence to self-care over 26 weeks , without a change in glycaemic control . Further study is needed to optimize the intervention and characterize those for whom it is more clinical ly and psychologically effective to support its use in primary care Background Conduct problems are common , disabling and costly . The prognosis for children with conduct problems is poor , with outcomes in adulthood including criminal behaviour , alcoholism , drug abuse , domestic violence , child abuse and a range of psychiatric disorders . There has been a rapid expansion of group based parent-training programmes for the treatment of children with conduct problems  in a number of countries over the past 10 years . Existing review s of parent training have method ological limitations such as inclusion of non-r and omised studies , the absence of investigation for heterogeneity prior to meta- analysis or failure to report confidence intervals . The objective of the current study was to systematic ally review r and omised controlled trials of parenting programmes for the treatment of children with conduct problems .  Methods St and ard systematic review methods were followed including duplicate inclusion decisions , data extraction and quality assessment . Twenty electronic data bases from the fields of medicine , psychology , social science and education were comprehensively search ed for RCTs and systematic review s to February 2006 . Inclusion criteria were : r and omised controlled trial ; of structured , repeatable parenting programmes ; for parents/carers of children up to the age of 18 with a conduct problem ; and at least one measure of child behaviour . Meta- analysis and qualitative synthesis were used to summarise included studies . Results 57 RCTs were included . Studies were small with an average group size of 21 . Meta-analyses using both parent ( SMD -0.67 ; 95 % CI : -0.91 , -0.42 ) and independent ( SMD -0.44 ; 95 % CI : -0.66 , -0.23 ) reports of outcome showed significant differences favouring the intervention group . There was insufficient evidence to determine the relative effectiveness of different approaches to delivering parenting programmes . Conclusion Parenting programmes are an effective treatment for children with conduct problems . The relative effectiveness of different parenting programmes requires further research Objective To compare the safety and efficacy of the dipeptidylpeptidase-4 ( DPP-4 ) inhibitors in patients with type 2 diabetes and inadequate glycemic control . Design Systematic review of r and omized controlled trials ( RCTs ) , health economic evaluation studies , systematic review s , and meta-analyses , followed by primary Bayesian mixed treatment comparison meta-analyses ( MTCs ) , and secondary frequentist direct-comparison meta-analyses using a r and om-effects model . Outcomes were reported as weighted mean change from baseline , or odds ratio ( OR ) with 95 % credible interval . Data sources MEDLINE , MEDLINE In-Process , EMBASE , and BIOSIS via Dialog ProQuest ; Cochrane Central Register of Controlled Trials and Cochrane Data base of Systematic Review s via EBSCO ; four diabetes and two technical congress abstract s ; and health technology assessment organization websites . Eligibility criteria Patients with type 2 diabetes and inadequate glycemic control receiving any pharmacological anti-diabetic treatment . Data extraction and analysis Title/ abstract s were review ed for eligibility , followed by full-text review of publications remaining after first pass . A three-person team filtered articles and an independent review er checked a r and om selection ( 10 % ) of filtered articles . Data extraction and quality assessment of studies were also independently review ed . Five DPP-4 inhibitors ( alogliptin , linagliptin , saxagliptin , sitagliptin , and vildagliptin ) were compared via meta- analysis ( where data were available ) as monotherapy , dual therapy ( plus metformin , sulfonylurea , pioglitazone , or insulin ) , and triple therapy ( plus metformin/sulfonylurea ) . Results The review identified 6,601 articles ; 163 met inclusion criteria and 85 publications from 83 RCTs contained sufficient or appropriate data for analysis . MTCs demonstrated no differences between DPP-4 inhibitors in mean change from baseline in glycosylated hemoglobin ( HbA1c ) or body weight , or the proportions of patients achieving HbA1c < 7 % or experiencing a hypoglycemic event , apart from in patients on alogliptin plus metformin , who achieved HbA1c < 7 % more frequently than those treated with saxagliptin plus metformin [ OR 6.41 ( 95 % CI 3.15–11.98 ) versus 2.17 ( 95 % CI 1.56–2.95 ) ] . Conclusions This systematic review and MTC showed similar efficacy and safety for DPP-4 inhibitors as treatment for type 2 diabetes , either as monotherapy or combination therapy The purpose of this study was to evaluate the impact of a three-day therapeutic education programme on perceived competence , self-management behaviours ( i.e. physical activity , diet and medication ) and glycaemic control among adults with type 2 diabetes . A total of 120 participants were included in this r and omized , wait list control group trial . The results confirm that therapeutic education may be a powerful healthcare intervention to improve lifestyle and health status of people with type 2 diabetes . We observed that the education programme used in this study generated positive changes in glycaemic control and adherence to physical activity and diet after three months follow-up . Furthermore , the intervention positively impacted participants ’ perceived competence towards physical activity and diet . The latter finding is of particular importance , given that perceived competence has been found to be involved in long-term adherence to self-management behaviours
INTERPRETATION In type 2 diabetes , there are improvements in long-term glycaemic control and psychological distress but not in weight control or blood glucose concentration in people who receive psychological therapies
BACKGROUND Adherence difficulties and psychological problems are associated with poor glycaemic control  in diabetes .
We undertook a systematic review and meta- analysis of psychological therapies to assess their effectiveness in improving glycaemic control in type 2 diabetes .