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Background The need for structured education programmes for type 2 diabetes is a high priority for many governments around the world . One such national education programme in the United Kingdom is the DESMOND Programme , which has been shown to be robust and effective for patients in general . However , these programmes are not generally targeted to people with intellectual disabilities ( ID ) , and robust evidence on their effects for this population is lacking . We have adapted the DESMOND Programme for people with ID and type 2 diabetes to produce an amended programme known as DESMOND-ID.This protocol is for a pilot trial to determine whether a large-scale r and omised trial is feasible , to test if DESMOND-ID is more effective than usual care in adults with ID for self-management of their type 2 diabetes , in particular as a means to reduce glycated haemoglobin ( Hb1Ac ) , improve psychological wellbeing and quality of life and promote a healthier lifestyle . This protocol describes the rationale , methods , proposed analysis plan and organisational and administrative details . Methods / Design This trial is a two arm , individually r and omised , pilot trial for adults with ID and type 2 diabetes , and their family and /or paid carers . It compares the DESMOND-ID programme with usual care .  Approximately 36 adults with mild to moderate ID will be recruited from three countries in the United Kingdom . Family and /or paid carers may also participate in the study . Participants will be r and omly assigned to one of two conditions using a secure computerised system with robust allocation concealment . A range of data will be collected from the adults with ID ( biomedical , psychosocial and self-management strategies ) and from their carers . Focus groups with all the participants will assess the acceptability of the intervention and the trial . Discussion The lack of appropriate structured education programmes and educational material s for this population leads to secondary health conditions and may lead to premature deaths . There are significant benefits to be gained globally , if structured education programmes are adapted and shown to be successful for people with ID and other cognitive impairments . Trial registration Registered with International St and ard R and omised Controlled Trial ( identifier : IS RCT N93185560 ) on 10 November 2014 Background Type 2 Diabetes Mellitus ( T2DM ) is common , affecting nearly 400 million people worldwide . Achieving good health for people with T2DM requires active self-management ; however , uptake of self-management education is poor , and there is an urgent need to find better , more acceptable , cost-effective methods of providing self-management support . Web-based self-management support has many potential benefits for patients and health services . The aim of this trial is to determine the effectiveness and cost-effectiveness of a web-based self-management support programme for people with T2DM . Methods This will be a multi-centre individually r and omised controlled trial in primary care , recruiting adults with T2DM who are registered with participating general practice s in Engl and . Participants will be r and omised to receive either an evidence -based , theoretically informed , web-based self-management programme for people with T2DM which addresses medical , emotional , and role management , called Healthy Living for People with type 2 Diabetes ( HeLP-Diabetes ) or a simple information website . The joint primary outcomes are glycated haemoglobin ( HbA1c ) and diabetes-related distress , measured by the Problem Areas In Diabetes ( PAID ) question naire . Secondary outcomes include cardiovascular risk factors , depression and anxiety , and self-efficacy for self-management of diabetes . Health economic data include health service use , costs due to the intervention , and EQ-5D for calculation of Quality Adjusted Life Years ( QALYS ) . Data will be collected at baseline , 3 months and 12 months , with the primary endpoint at 12 months . Practice nurses , blinded to patient allocation , collect clinical data ; patients complete online question naires for patient reported measures . A sample size of 350 recruited participants allows for attrition of up to 15 % and will provide 90 % power of detecting at a 5 % significance level a true average difference in the PAID score of 4.0 and 0.25 % change in HbA1c ( both small effect sizes ) . The analysis will follow a pre-specified analysis plan , based on comparing the groups as r and omised ( intention-to-treat ) . Discussion The findings of this trial are likely to be of interest to policy makers , clinicians , and commissioners , all of whom are actively seeking additional forms of self-management support for people with T2DM.Trial registration The Trial Registration number is IS RCT N02123133 ; date of registration 14.2.13 Background The Diabetes Manual is a type 2 diabetes self-management programme based upon the clinical ly effective ' Heart Manual ' . The 12 week programme is a complex intervention theoretically underpinned by self-efficacy theory . It is a one to one intervention meeting United Kingdom requirements for structured diabetes-education and is delivered within routine primary care . Methods / design In a two-group cluster r and omized controlled trial , GP practice s are allocated by computer minimisation to an intervention group or a six-month deferred intervention group . We aim to recruit 250 participants from 50 practice s across central Engl and . Eligibility criteria are adults able to undertake the programme with type 2 diabetes , not taking insulin , with HbA1c over 8 % ( first 12 months ) and following an agreed protocol change over 7 % ( months 13 to 18 ) . Following r and omisation , intervention nurses receive two-day training and delivered the Diabetes Manual programme to participants . Deferred intervention nurses receive the training following six-month follow-up . Primary outcome is HbA1c with total and HDL cholesterol ; blood pressure , body mass index ; self-efficacy and quality of life as additional outcomes . Primary analysis is between-group HbA1c differences at 6 months powered to give 80 % power to detect a difference in HbA1c of 0.6 % . A 12 month cohort analysis will assess maintenance of effect and assess relationship between self-efficacy and outcomes , and a qualitative study is running alongside . Discussion This trial incorporates educational and psychological diabetes interventions into a single programme and assesses both clinical and psychosocial outcomes . The trial will increase our underst and ing of intervention transferability between conditions , those diabetes related health behaviours that are more or less susceptible to change through efficacy enhancing mechanisms and how this impacts on clinical outcomes Background An estimated 285 million people worldwide have diabetes and its prevalence is predicted to increase to 439 million by 2030 . For the year 2010 , it is estimated that 3.96 million excess deaths in the age group 20 - 79 years are attributable to diabetes around the world . Self-management is recognised as an integral part of diabetes care . This paper describes the protocol of a r and omised controlled trial of an automated interactive telephone system aim ing to improve the uptake and maintenance of essential diabetes self-management behaviours . Methods / Design A total of 340 individuals with type 2 diabetes will be r and omised , either to the routine care arm , or to the intervention arm in which participants receive the  Telephone-Linked Care ( TLC ) Diabetes program in addition to their routine care . The intervention requires the participants to telephone the TLC Diabetes phone system weekly for 6 months . They receive the study h and book and a glucose meter linked to a data uploading device . The TLC system consists of a computer with software design ed to provide monitoring , tailored feedback and education on key aspects of diabetes self-management , based on answers voiced or entered during the current or previous conversations . Data collection is conducted at baseline ( Time 1 ) , 6-month follow-up ( Time 2 ) , and 12-month follow-up ( Time 3 ) . The primary outcomes are glycaemic control ( HbA1c ) and quality of life ( Short Form-36 Health Survey version 2 ) . Secondary outcomes include anthropometric measures , blood pressure , blood lipid profile , psychosocial measures as well as measures of diet , physical activity , blood glucose monitoring , foot care and medication taking . Information on utilisation of healthcare services including hospital admissions , medication use and costs is collected . An economic evaluation is also planned . Discussion Outcomes will provide evidence concerning the efficacy of a telephone-linked care intervention for self-management of diabetes . Furthermore , the study will provide insight into the potential for more widespread uptake of automated telehealth interventions , globally . Trial Registration 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 Background Addressing the increasing prevalence , and associated disease burden , of diabetes is a priority of health services internationally . Interventions to support patients to effectively self-manage their condition have the potential to reduce the risk of costly and debilitating complications . The utilisation of mobile phones to deliver self-management support allows for patient-centred care at the frequency and intensity that patients desire from outside the clinic environment . Self-Management Support for Blood Glucose ( SMS4BG ) is a novel text message-based intervention for supporting people with diabetes to improve self-management behaviours and achieve better glycaemic control and is tailored to individual patient preferences , demographics , clinical characteristics , and culture . This study aims to assess whether SMS4BG can improve glycaemic control in adults with poorly controlled diabetes . This paper outlines the rationale and methods of the trial . Methods / design A two-arm , parallel , r and omised controlled trial will be conducted across New Zeal and health districts . One thous and participants will be r and omised at a 1:1 ratio to receive SMS4BG , a theoretically based and individually tailored automated text message-based diabetes self-management support programme ( intervention ) in addition to usual care , or usual care alone ( control ) . The primary outcome is change in glycaemic control ( HbA1c ) at 9 months . Secondary outcomes include glycaemic control at 3 and 6 months , self-efficacy , self-care behaviours , diabetes distress , health-related quality of life , perceived social support , and illness perceptions . Cost information and healthcare utilisation will also be collected as well as intervention satisfaction and interaction . Discussion This study will provide information on the effectiveness of a text message-based self-management support tool for people with diabetes . If found to be effective it has the potential to provide individualised support to people with diabetes across New Zeal and ( and internationally ) , thus extending care outside the clinic environment . Trial registration Australian New Zeal and Clinical Trials Registry : ACTRN12614001232628 Background Despite the efforts of the healthcare community to improve the quality of diabetes care , about 50 % of people with type 2 diabetes do not reach their treatment targets , increasing the risk of future micro- and macro-vascular complications . Diabetes self-management education has been shown to contribute to better disease control . However , it is not known which strategies involving educational programs are cost-effective . Telehealth applications might support chronic disease management . Transferability of successful distant patient self-management support programs to the Belgian setting needs to be confirmed by studies of a high method ological quality . “ The COACH Program ” was developed in Australia as target driven educational telephone delivered intervention to support people with different chronic conditions . It proved to be effective in patients with coronary heart disease after hospitalization . Clinical and cost-effectiveness of The COACH Program in people with type 2 diabetes in Belgium needs to be assessed . Methods / Design R and omized controlled trial in patients with type 2 diabetes . Patients were selected based on their medication consumption data and were recruited by their sickness fund . They were r and omized to receive either usual care plus “ The COACH Program ” or usual care alone . The study will assess the difference in outcomes between groups . The primary outcome measure is the level of HbA1c . The secondary outcomes are : Total Cholesterol , LDL-Cholesterol , HDL-Cholesterol , Triglycerides , Blood Pressure , body mass index , smoking status ; proportion of people at target for HbA1c , LDL-Cholesterol and Blood Pressure ; self-perceived health status , diabetes-specific emotional distress and satisfaction with diabetes care . The follow-up period is 18 months . Within-trial and modeled cost-utility analyses , to project effects over life-time horizon beyond the trial duration , will be undertaken from the perspective of the health care system if the intervention is effective . Discussion The study will enhance our underst and ing of the potential of telehealth in diabetes management in Belgium . Research on the clinical effectiveness and the cost-effectiveness is essential to support policy makers in future reimbursement and implementation decisions . Trial registration Belgian number : B322201213625 . Clinical Trials.gov Identifier : Objectives To assess the long term clinical and cost effectiveness of the diabetes education and self management for ongoing and newly diagnosed ( DESMOND ) intervention compared with usual care in people with newly diagnosed type 2 diabetes . Design We undertook a cost-utility analysis that used data from a 12 month , multicentre , cluster r and omised controlled trial and , using the Sheffield type 2 diabetes model , modelled long term outcomes in terms of use of therapies , incidence of complications , mortality , and associated effect on costs and health related quality of life . A further cost-utility analysis was also conducted using current “ real world ” costs of delivering the intervention estimated for a hypothetical primary care trust . Setting Primary care trusts in the United Kingdom . Participants Patients with newly diagnosed type 2 diabetes . Intervention A six hour structured group education programme delivered in the community by two professional healthcare educators . Main outcome measures Incremental costs and quality adjusted life years ( QALYs ) gained . Results On the basis of the data in the trial , the estimated mean incremental lifetime cost per person receiving the DESMOND intervention is £ 209 ( 95 % confidence interval −£704 to £ 1137 ; € 251 , −€844 to € 1363 ; $ 326 , −$1098 to $ 1773 ) , the incremental gain in QALYs per person is 0.0392 ( −0.0813 to 0.1786 ) , and the mean incremental cost per QALY is £ 5387 . Using “ real world ” intervention costs , the lifetime incremental cost of the DESMOND intervention is £ 82 ( −£831 to £ 1010 ) and the mean incremental cost per QALY gained is £ 2092 . A probabilistic sensitivity analysis indicated that the likelihood that the DESMOND programme is cost effective at a threshold of £ 20 000 per QALY is 66 % using trial based intervention costs and 70 % using “ real world ” costs . Results from a one way sensitivity analysis suggest that the DESMOND intervention  is cost effective even under more modest assumptions that include the effects of the intervention being lost after one year . Conclusion Our results suggest that the DESMOND intervention is likely to be cost effective compared with usual care , especially with respect to the real world cost of the intervention to primary care trusts , with reductions in weight and smoking being the main benefits delivered AIM To report on the outcomes of a pilot feasibility study of a structured self-management diabetes education programme targeting HbA1c . METHODS We conducted a two-arm , individually r and omized , pilot superiority trial for adults with intellectual disability and Type 2 diabetes mellitus . A total of 66 adults with disabilities across the UK met the eligibility criteria . Of these , 39 agreed to participate and were r and omly assigned to either the DESMOND-ID programme ( n = 19 ) or a control group ( n = 20 ) . The programme consisted of seven weekly educational sessions . The primary outcome was HbA1c level , and secondary outcomes included BMI , diabetes illness perceptions , severity of diabetes , quality of life , and attendance rates . RESULTS This study found that the DESMOND-ID programme was feasible to deliver . With reasonable adjustments , the participants could be recruited successfully , and could provide consent , complete the outcome measures , be r and omized to the groups and attend most of the sessions , with minimal loss to follow-up . The fixed-effects model , the interaction between occasion ( time ) and condition , showed statistically significant results ( 0.05 level ) for HbA1c ; however , the CI was large . CONCLUSION This is the first published study to adapt and pilot a national structured self-management diabetes education programme for adults with intellectual disability . This study shows it is possible to identify , recruit , consent and r and omize adults with intellectual disabilities to an intervention or control group . Internationally , the results of this pilot are promising , demonstrating that a multi-session education programme is acceptable and feasible to deliver . Its effectiveness should be further tested in an adequately powered trial Internet-based support groups are a rapidly growing segment of mutual aid programs for individuals with chronic illnesses and other challenges . Previous studies have informed us about the content of online exchanges between support group members , but we know little about the ability of these interventions to change participants ' perceptions of support . A r and omized trial of 160 adult Type 2 diabetes patients provided novice Internet users with computers and Internet access to 1 of 4 conditions :  (  a ) diabetes information only , ( b ) a personal self-management coach , ( c ) a social support intervention , or ( d ) a personal self-management coach and the support intervention . After 3 months , individuals in the 2 support conditions reported significant increases in support on a diabetes-specific support measure and a general support scale . Participants ' age was significantly related to change in social support , but intervention effects were still significant after accounting for this relationship . This report is a critical first step in evaluating the long-term effects of  Internet-based support for diabetes self-management . The discussion identifies directions for future research Background Patients with long-term conditions are increasingly the focus of quality improvement activities in health services to reduce the impact of these conditions on quality of life and to reduce the burden on care utilisation . There is significant interest in the potential for self-management support to improve health and reduce utilisation in these patient population s , but little consensus concerning the optimal model that would best provide such support . We describe the implementation and evaluation of self-management support through an evidence -based ' whole systems ' model involving patient support , training for primary care teams , and service re-organisation , all integrated into routine delivery within primary care . Methods The evaluation involves a large-scale , multi-site study of the implementation , effectiveness , and cost-effectiveness of this model of self-management support using a cluster r and omised controlled trial in patients with three long-term conditions of diabetes , chronic obstructive pulmonary disease ( COPD ) , and irritable bowel syndrome ( IBS ) . The outcome measures include healthcare utilisation and quality of life . We describe the methods of the cluster r and omised trial . Discussion If the ' whole systems ' model proves effective and cost-effective , it will provide decision-makers with a model for the delivery of self-management support for population s with long-term conditions that can be implemented widely to maximise ' reach ' across the wider patient population .Trial registration numberIS RCT N : IS RCT UNLABELLED In June 2008 , the Medical Advisory Secretariat began work on the Diabetes Strategy Evidence Project , an evidence -based review of the literature surrounding strategies for successful management and treatment of diabetes . This project came about when the Health System Strategy Division at the Ministry of Health and Long-Term Care subsequently asked the secretariat to provide an evidentiary platform for the Ministry 's newly released Diabetes Strategy .After an initial review of the strategy and consultation with experts , the secretariat identified five key areas in which evidence was needed . Evidence -based analyses have been prepared for each of these five areas : insulin pumps , behavioural interventions , bariatric surgery , home telemonitoring , and community based care . For each area , an economic analysis was completed where appropriate and is described in a separate report . To review these titles within the Diabetes Strategy Evidence series , please visit the Medical Advisory Secretariat Web site , http://www.health.gov.on.ca/english/providers/program/mas/mas_about.html,DIABETES STRATEGY EVIDENCE PLATFORM : Summary of Evidence -Based AnalysesContinuous Subcutaneous Insulin Infusion Pumps for Type 1 and Type 2 Adult Diabetics : An Evidence -Based Analysis Behavioural Interventions for Type 2 Diabetes : An Evidence -Based Analysis  BARIATRIC SURGERY FOR PEOPLE WITH DIABETES AND MORBID OBESITY : An Evidence -Based Summary Community-Based Care for the Management of Type 2 Diabetes : An Evidence -Based Analysis Home Telemonitoring for Type 2 Diabetes : An Evidence -Based Analysis Application of the Ontario Diabetes Economic Model ( ODEM ) to Determine the Cost-effectiveness and Budget Impact of Selected Type 2 Diabetes Interventions in Ontario OBJECTIVE The objective of this report is to determine whether behavioural interventions are effective in improving glycemic control in adults with type 2 diabetes . BACKGROUND Diabetes is a serious chronic condition affecting millions of people worldwide and is the sixth leading cause of death in Canada . In 2005 , an estimated 8.8 % of Ontario 's population had diabetes , representing more than 816,000 Ontarians . The direct health care cost of diabetes was $ 1.76 billion in the year 2000 and is projected to rise to a total cost of $ 3.14 billion by 2016 . Much of this cost arises from the serious long-term complications associated with the disease including : coronary heart disease , stroke , adult blindness , limb amputations and kidney disease . Type 2 diabetes accounts for 90 - 95 % of diabetes and while type 2 diabetes is more prevalent in people aged 40 years and older , prevalence in younger population s is increasing due to a rise in obesity and physical inactivity in children . Data from the United Kingdom Prospect i ve Diabetes Study ( UKPDS ) has shown that tight glycemic control can significantly reduce the risk of developing serious complications in type 2 diabetics . Despite physicians ' and patients ' knowledge of the importance of glycemic control , Canadian data has shown that only 38 % of patients with diabetes have HbA1C levels in the optimal range of 7 % or less . This statistic highlights the complexities involved in the management of diabetes , which is characterized by extensive patient involvement in addition to the support provided by physicians . An enormous dem and is , therefore , placed on patients to self-manage the physical , emotional and psychological aspects of living with a chronic illness . Despite differences in individual needs to cope with diabetes , there is general agreement for the necessity of supportive programs for patient self-management . While traditional programs were didactic models with the goal of improving patients ' knowledge of their disease , current models focus on behavioural approaches aim ed at providing patients with the skills and strategies required to promote and change their behaviour . Several meta-analyses and systematic review s have demonstrated improved health outcomes with  self-management support programs in type 2 diabetics . They have all , however , either looked at a specific component of self-management support programs ( i.e. self-management education ) or have been conducted in specific population s. Most review s are also qualitative and do not clearly define the interventions of interest , making findings difficult to interpret . Moreover , heterogeneity in the interventions has led to conflicting evidence on the components of effective programs . There is thus much uncertainty regarding the optimal design and delivery of these programs by policymakers . EVIDENCE -BASED ANALYSIS OF EFFECTIVENESS : RESEARCH QUESTIONS Are behavioural interventions  effective in improving glycemic control in adults with type 2 diabetes?Is the effectiveness of the intervention impacted by intervention characteristics ( e.g. delivery of intervention , length of intervention , mode of instruction , interventionist etc . ) ? INCLUSION CRITERIA English Language Published between January 1996 to August 2008 Type 2 diabetic adult population ( > 18 years)R and omized controlled trials ( RCTs ) Systematic review s , or meta-analyses Describing a multi-faceted self-management support intervention as defined by the 2007 Self-Management Mapping Guide (1)Reporting outcomes of glycemic control ( HbA1c ) with extractable data Studies with a minimum of 6-month follow up EXCLUSION CRITERIA Studies with a control group other than usual care Studies with a sample size < 30 Studies without a clearly defined intervention OUTCOMES OF INTEREST PRIMARY OUTCOME glycemic control ( HbA1c ) SECONDARY OUTCOMES systolic blood pressure ( SBP ) control , lipid control , change in smoking status , weight change , quality of life , knowledge , self-efficacy , managing psychosocial aspects of diabetes , assessing dissatisfaction and readiness to change , and setting and achieving diabetes goals . SEARCH STRATEGY A search was performed in OVID MEDLINE , MEDLINE In-Process and Other Non-Indexed Citations , EMBASE , the Cumulative Index to Nursing & Allied Health Literature ( CINAHL ) , The Cochrane Library , and the International Agency for Health Technology Assessment ( INAHTA ) for studies published between January 1996 and August 2008 . Abstract s were review ed by a single author and studies meeting the inclusion criteria outlined above were obtained . Data on population characteristics , glycemic control outcomes , and study design were extracted . Reference lists were also checked for relevant studies . The quality of the evidence was assessed as being either high , moderate , low , or very low according to the GRADE methodology . SUMMARY OF FINDINGS The search identified 638 citations published between 1996 and August 2008 , of which 12 met the inclusion criteria and one was a meta- analysis ( Gary et al. 2003 ) . The remaining 11 studies were RCTs ( 9 were used in the meta- analysis ) and only one was defined as small ( total sample size N=47 ) . SUMMARY OF PARTICIPANT DEMOGRAPHICS ACROSS STUDIES : A total of 2,549 participants were included in the 11 identified studies . The mean age of participants reported was approximately 58 years and the mean duration of diabetes was approximately 6 years . Most studies reported gender with a mean percentage of females of approximately 67 % . Of the eleven studies , two focused only on women and four included only Hispanic individuals . All studies evaluated type 2 diabetes patients exclusively . STUDY CHARACTERISTICS : The studies were conducted between 2002 and 2008 . Approximately six of 11 studies were carried out within the USA , with the remaining studies conducted in the UK , Sweden , and Israel ( sample size ranged from 47 to 824 participants ) . The quality of the studies ranged from moderate to low with four of the studies being of moderate quality and the remaining seven of low quality ( based on the Consort Checklist ) . Differences in quality were mainly due to method ological issues such as inadequate description of r and omization , sample size calculation allocation concealment , blinding and uncertainty of the use of intention-to-treat ( ITT ) analysis . Patients were recruited from several setting s : six studies from primary or general medical practice s , three studies from the community ( e.g. via advertisements ) , and two from outpatient diabetes clinics . A usual care control group was reported in nine of 11 of the studies and two studies reported some type of minimal diabetes care in addition to usual care for the control group . INTERVENTION CHARACTERISTICS : All of the interventions examined in the studies were mapped to the 2007 Self-management Mapping Guide . The interventions most often focused on problem solving , goal setting and encouraging participants to engage in activities that protect and promote health ( e.g. modifying behaviour , change in diet , and increase physical activity ) . All of the studies examined comprehensive interventions targeted at least two self-care topics ( e.g. diet , physical activity , blood glucose monitoring , foot care , etc . ) . Despite the homogeneity in the aims of the interventions , there was substantial clinical heterogeneity in other intervention characteristics such as duration , intensity , setting , mode of delivery ( group vs. individual ) , interventionist , and outcomes of interest ( discussed below ) . DURATION , INTENSITY AND MODE OF DELIVERY : Intervention duration s ranged from 2 days to 1 year , with many falling into the range of 6 to 10 weeks . The rest of the interventions fell into categories of ≤ 2 weeks ( 2 studies ) , 6 months ( 2 studies ) , or 1 year ( 3 studies ) . Intensity of the interventions varied widely from 6 hours over 2 days , to 52 hours over 1 year ; however , the majority consisted of interventions of 6 to 15 hours . Both individual and group sessions were used to deliver interventions . Group counselling was used in five studies as a mode of instruction , three studies used both individual and group sessions , and one study used individual sessions as its sole mode of instruction . ( ABSTRACT BACKGROUND A prerequisite to translating research findings into practice is information on consistency of implementation , maintenance of results , and generalization of effects . This follow-up report is one of the few experimental studies to provide such information on Internet-based health education . METHODS We present follow-up data 10 months following r and omization on the " Diabetes Network ( D-Net ) " Internet-based self-management project , a r and omized trial evaluating the incremental effects of adding ( 1 ) tailored self-management training or ( 2 ) peer support components to a basic Internet-based , information-focused comparison intervention .  Participants were 320 adult type 2 diabetes patients from participating primary care offices , mean age 59 ( SD = 9.2 ) , who were relatively novice Internet users . RESULTS All intervention components were consistently implemented by staff , but participant website usage decreased over time . All conditions were significantly improved from baseline on behavioral , psychosocial , and some biological outcomes ; and there were few differences between conditions . Results were robust across on-line coaches , patient characteristics , and participating clinics . CONCLUSIONS The basic D-Net intervention was implemented well and improvements were observed across a variety of patients , interventionists , and clinics . There were , however , difficulties in maintaining usage over time and additions of tailored self-management and peer support components generally did not significantly improve results Background Care management programmes are an effective approach to care for high risk patients with complex care needs result ing from multiple co-occurring medical and non-medical conditions . These patients are likely to be hospitalized for a potentially " avoidable " cause . Nurse-led care management programmes for high risk elderly patients showed promising results . Care management programmes based on health care assistants ( HCAs ) targeting adult patients with a high risk of hospitalisation may be an innovative approach to deliver cost-efficient intensified care to patients most in need . Methods / Design PraCMan is a cluster r and omized controlled trial with primary care practice s as unit of r and omisation . The study evaluates a complex primary care practice -based care management of patients at high risk for future hospitalizations . Eligible patients either suffer from type 2 diabetes mellitus , chronic obstructive pulmonary disease , chronic heart failure or any combination . Patients with a high likelihood of hospitalization within the following 12 months ( based on insurance data ) will be included in the trial . During 12 months of intervention patients of the care management group receive comprehensive assessment of medical and non-medical needs and re sources as well as regular structured monitoring of symptoms . Assessment and monitoring will be performed by trained HCAs from the participating practice s. Additionally , patients will receive written information , symptom diaries , action plans and a medication plan to improve self-management capabilities . This intervention is addition to usual care . Patients from the  control group  receive usual care . Primary outcome is the number of all-cause hospitalizations at 12 months follow-up , assessed by insurance cl aims data . Secondary outcomes are health-related quality of life ( SF12 , EQ5D ) , quality of chronic illness care ( PACIC ) , health care utilisation and costs , medication adherence ( MARS ) , depression status and severity ( PHQ-9 ) , self-management capabilities and clinical parameters . Data collection will be performed at baseline , 12 and 24 months ( 12 months post-intervention ) . Discussion Practice -based care management for high risk individuals involving trained HCAs appears to be a promising approach to face the needs of an aging population with increasing care dem and s . Trial registration Current Controlled Trials IS RCT Background Care management interventions in the German health-care system have been evaluated with promising results , but further research is necessary to explore their full potential in the context of multi-morbidity . Our aim in this trial is to assess the efficacy of a primary care practice network – based care management intervention in improving self-care behaviour among patients with type 2 diabetes mellitus and multiple co-occurring chronic conditions . Methods / Design The study is design ed as a prospect i ve , 18-month , multicentre , investigator-blinded , two-arm , open-label , individual-level , r and omized parallel-group superiority trial . We will enrol 582 patients with type 2 diabetes mellitus and at least two severe chronic conditions and one informal caregiver per patient . Data will be collected at baseline ( T0 ) , at the primary endpoint after 9 months ( T1 ) and at follow-up after 18 months ( T2 ) . The primary outcome will be the differences between the  intervention and control groups  in changes of diabetes-related self-care behaviours from baseline to T1 using a German version of the revised Summary of Diabetes Self-Care Activities ( SDSCA-G ) . The secondary outcomes will be the differences between the intervention and control groups in : changes in scores on the SDSCA-G subscales , glycosylated haemoglobin A level , health-related quality of life , self-efficacy , differences in ( severe ) symptomatic hypoglycaemia , cost-effectiveness and financial family burden . The intervention will be delivered by trained health-care assistants as an add-on to usual care and will consist of three main elements : ( 1 ) three home visits , including structured assessment of medical and social needs ; ( 2 ) 24 structured telephone monitoring contacts ; and ( 3 ) self-monitoring of blood glucose levels after T1 in 3-month intervals . The control group will receive usual care . The confirmatory primary analysis will be performed following the intention-to-treat ( ITT ) principle . The efficacy of the intervention will be quantified using two-level linear regression stratified by type of medical treatment adjusted for baseline values on the SDSCA-G. Secondary analyses will be performed according to the ITT principle . In health economic evaluations , we will estimate the incremental cost-effectiveness ratios . Discussion We hope that the results of this study will provide insights into the efficacy of practice network – based care management among patients with complex health-care needs . Trial registration Current Controlled Trials IS RCT N83908315 ( IS RCT N assigned 25 February 2014 ) Objective To measure whether the benefits of a single education and self management structured programme for people with newly diagnosed type 2 diabetes mellitus are sustained at three years . Design Three year follow-up of a multicentre cluster r and omised controlled trial in primary care , with r and omisation at practice level . Setting 207 general practice s in 13 primary care sites in the United Kingdom . Participants 731 of the 824 participants included in the original trial were eligible for follow-up . Biomedical data were collected on 604 ( 82.6 % ) and question naire data on 513 ( 70.1 % ) participants . Intervention A structured group education programme for six hours delivered in the community by two trained healthcare professional educators compared with usual care . Main outcome measures The primary outcome was glycated haemoglobin ( HbA1c ) levels . The secondary outcomes were blood pressure , weight , blood lipid levels , smoking status , physical activity , quality of life , beliefs about illness , depression , emotional impact of diabetes , and drug use at three years . Results HbA1c levels at three years had decreased in both groups . After adjusting for baseline and cluster the difference was not significant ( difference −0.02 , 95 % confidence interval −0.22 to 0.17 ) . The groups did not differ for the other biomedical and lifestyle outcomes and drug use . The significant benefits in the intervention group across four out of five health beliefs seen at 12 months were sustained at three years ( P<0.01 ) . Depression scores and quality of life did not differ at three years . Conclusion A single programme for people with newly diagnosed type 2 diabetes mellitus showed no difference in biomedical or lifestyle outcomes at three years although there were sustained improvements in some illness beliefs . Trial registration Current Controlled Trials IS RCT N17844016 OBJECTIVE To compare three interventions to reduce diabetes distress ( DD ) and improve self-management among non– clinical ly depressed adults with type 2 diabetes mellitus ( T2DM ) . RESEARCH DESIGN AND METHODS In REDEEM , 392 adults with T2DM and DD were r and omized to computer-assisted self-management ( CASM ) , CASM plus DD-specific problem solving ( CAPS ) , or a computer-administered minimal supportive intervention . Primary outcomes were Diabetes Distress Scale ( DDS ) total , the Emotional Burden ( EB ) and Regimen Distress ( RD ) DDS subscales , and diet , exercise , and medication adherence . RESULTS Significant and clinical ly meaningful reductions in DD ( DDS , EB , and RD ) and self-management behaviors occurred in all three conditions ( P < 0.001 ) , with no significant between-group differences . There was , however , a significant group × baseline distress interaction ( P < 0.02 ) , in which patients with high baseline RD in the CAPS condition displayed significantly larger RD reductions than those in the other two conditions . RD generated the most distress and displayed the greatest distress reduction as a result of intervention . The pace of DD reduction varied by patient age : older patients demonstrated significant reductions in DD early in the intervention , whereas younger adults displayed similar reductions later . Reductions in DD were accompanied by significant improvements in healthy eating , physical activity , and medication adherence , although not by change in HbA1c . CONCLUSIONS DD is malleable and highly responsive to intervention . Interventions that enhance self-management also reduce DD significantly , but DD-specific interventions may be necessary for patients with high initial levels of DD . Future research should identify the minimal , most cost-effective interventions to reduce DD and improve self-management Abstract Background Diabetes is an important contributor to the burden of disease in South Africa and prevalence rates as high as 33 % have been recorded in Cape Town . Previous studies show that quality of care and health outcomes are poor . The development of an effective education programme should impact on self-care , lifestyle change and adherence to medication ; and lead to better control of diabetes , fewer complications and better quality of life . Methods Trial design : Pragmatic cluster r and omized controlled trial Participants : Type 2 diabetic patients attending 45 public sector community health centres in Cape Town Interventions : The intervention group will receive 4 sessions of group diabetes education delivered by a health promotion officer in a guiding style . The control group will receive usual care which consists of ad hoc advice during consultations and occasional educational talks in the waiting room . Objective : To evaluate the effectiveness of the group diabetes education programme Outcomes : Primary outcomes : diabetes self-care activities , 5 % weight loss , 1 % reduction in HbA1c . Secondary outcomes : self-efficacy , locus of control , mean blood pressure , mean weight loss , mean waist circumference , mean HbA1c , mean total cholesterol , quality of life R and omisation : Computer generated r and om numbers Blinding : Patients , health promoters and research assistants could not be blinded to the health centre ’s allocation Numbers r and omized : Seventeen health centres ( 34 in total ) will be r and omly assigned to either control or intervention groups . A sample size of 1360 patients in 34 clusters of 40 patients will give a power of 80 % to detect the primary outcomes with 5 % precision . Altogether 720 patients were recruited in the intervention arm and 850 in the control arm giving a total of 1570 . Discussion The study will inform policy makers and managers of the district health system , particularly in low to middle income countries , if this programme can be implemented more widely . Trial registerPan African Clinical Trial Registry Background Type 2 diabetes ( diabetes ) is a serious threat to public health in the United States and disproportionally affects many racial/ethnic minority groups , including African Americans . Limited access to treatment and high attrition rates further contribute to health disparities in diabetes-related morbidity and mortality among minorities . Greater opportunities for increasing access and decreasing barriers to treatment are needed . Technology-based interventions have potential for accomplishing this goal but evidence of feasibility and potential effectiveness is lacking , especially for population s that traditionally have limited educational attainment and low computer literacy . Objective This paper describes the design and methods of a pilot r and omized clinical trial that will compare the feasibility and potential efficacy of delivering a diabetes self-management intervention via a virtual world vs. a face-to-face format . Methods Study participants ( n=100 ) will be African American women with uncontrolled type 2 diabetes recruited from primary care practice s and affiliated health centers at a large safety net hospital in Massachusetts . Participants will be r and omized into a virtual world-based ( VW ) intervention condition or a face-to-face control condition . Both conditions provide the same theory-based curriculum and equivalent exposure to the self-management program ( eight group sessions ) , and both will be delivered by a single intervention team ( a dietitian and a diabetes educator ) . Assessment s will be conducted at baseline and 4 months . Feasibility will be determined by evaluating the degree to which participants engage in the VW-based intervention compared to face to face ( number of sessions completed ) . Potential efficacy will be determined by comparing change in physiological ( glycemic control ) and behavioral ( self-reported dietary intake , physical activity , blood glucose self-monitoring , and medication adherence ) outcomes between the experimental and control groups . Results The primary outcomes of interest are feasibility of the VW intervention and its potential efficacy on glucose control and diabetes self-management behaviors , compared to the face-to-face condition . Analysis will use a two- sample Kolmogorov-Smirnov test for changes in variable distribution . P values will be calculated using binomial tests for proportions and t tests for continuous variables . Conclusions If the intervention is found to be feasible and promising , it will be tested in a larger RCT AIMS To assess the impact of a French adaptation of the Staged Diabetes Management ( SDM ) programme on glycaemic control of people with Type 2 diabetes in primary care . Secondary endpoints were blood pressure , blood lipids , healthcare costs and quality of life . METHODS Prospect i ve , r and omized controlled study , of 1 years ' duration . General practitioners ( GPs ) were recruited in four separate districts of a French region . They enrolled consecutive patients with Type 2 diabetes . GPs in the intervention group were educated in the SDM programme . GPs in the control group were asked to provide usual care .  Healthcare costs were collected by medical departments of the Health Insurance systems . Quality of life was assessed with the Duke Health Profile . RESULTS Three hundred and forty patients enrolled by 57 GPs completed the study , 192 in the intervention group and 148 in the control group . Patients in the intervention group were managed more adequately in accordance with the guidelines ( P < 0.05 for nine out of 10 items ) . HbA(1c ) decreased by 0.31 % in the intervention group and increased by 0.56 % in the control group , result ing in a difference of 0.87 % by the end of the study ( P = 0.001 ) . Blood pressure and blood lipids did not differ between groups . Occurrence of major complications was low and identical in both groups . Incremental costs during the study in the intervention group were 35 euros per patient per month , and this was not significantly different in comparison with the control group . Quality of life was not affected by the intervention . CONCLUSIONS Educating GPs in the French adaptation of the SDM programme improves glycaemic control in a primary care setting , without significantly increasing healthcare costs Objective . To evaluate a 12-week group-based lifestyle intervention programme for women with prediabetes following gestational diabetes ( GDM ) . Design . A two-group , mixed methods r and omized controlled trial in which 50 women with a history of GDM and abnormal glucose tolerance postpartum were r and omly assigned to intervention ( n = 24 ) or wait control ( n = 26 ) and postintervention qualitative interviews with participants . Main Outcome Measures . Modifiable biochemical , anthropometric , behavioural , and psychosocial risk factors associated with the development of type 2 diabetes . The primary outcome variable was the change in fasting plasma glucose ( FPG ) from study entry to one-year follow-up . Results . At one-year follow-up , the intervention group showed significant improvements over the wait control group on stress , diet self-efficacy , and quality of life . There was no evidence of an effect of the intervention on measures of biochemistry or anthropometry ; the effect on one health behaviour , diet adherence , was close to significance . Conclusions . Prevention programmes must tackle the barriers to participation faced by this population ; home-based interventions should be investigated . Strategies for promoting long-term health self-management need to be developed and tested AIM To evaluate the impact of diabetes education provided to patients with type 2 diabetes mellitus ( T2DM ) in non-controlled studies ( " real-world conditions " ) on quality of care , re source consumption and conditions of employment . METHODS This cross-sectional study and longitudinal follow-up describe the data ( demographic and socioeconomic profiles , clinical characteristics , treatment of hyperglycaemia and associated cardiovascular risk factors , re source consumption ) collected during the second phase ( 2006 ) of the International Diabetes Management Practice s Study ( IDMPS ) . Patients received diabetes education directly from the practice nurse , dietitian or educator , or were referred to ad hoc group-education programmes ; all programmes emphasized healthy lifestyle changes , self-care and active participation in disease control and treatment . Educated vs non-educated T2DM patients ( n=5692 in each group ) , paired by age , gender and diabetes duration , were r and omly recruited for the IDMPS by participating primary -care physicians from 27 countries in Eastern Europe , Asia , Latin America and Africa . Outcome measures included clinical ( body weight , height , waist circumference , blood pressure , foot evaluation ) , metabolic ( HbA(1c ) levels , blood lipid profile ) and biochemical control measures . Treatment goals were defined according to American Diabetes Association guidelines . RESULTS T2DM patients ' education significantly improved the percentage of patients achieving target values set by international guidelines . Educated patients increased their insulin use and self-care performance , had a lower rate of chronic complications and a modest increase in cost of care , and probably higher salaries and slightly better productivity . CONCLUSION Diabetes education is an efficient tool for improving care outcomes without having a major impact on healthcare costs OBJECTIVE Internet-based programs offer potential for practical , cost-effective chronic illness self-management programs . METHODS We report 12-month results of an Internet-based diabetes self-management program , with and without additional support , compared to enhanced usual care in a 3-arm practical r and omized trial . Patients ( n=463 ) were r and omized : 77.3 % completed 12-month follow-up . Primary outcomes were changes in health behaviors of healthy eating , physical activity , and medication taking . Secondary outcomes were hemoglobin A1c , body mass index , lipids , blood pressure , and psychosocial factors . RESULTS Internet conditions  improved health behaviors significantly vs. usual care over the 12-month period ( d for effect size=.09-.16 ) . All conditions improved moderately on biological and psychosocial outcomes .  Latinos , lower literacy , and higher cardiovascular disease risk patients improved as much as other participants . CONCLUSIONS The Internet intervention meets the reach and feasibility criteria for a potentially broad public health impact . However , 12-month magnitude of effects was small , suggesting that different or more intensive approaches are necessary to support long-term outcomes . Research is needed to underst and the linkages between intervention and maintenance processes and downstream outcomes . PRACTICE IMPLICATION S Automated self-management interventions should be tailored and integrated into primary care ; maintenance of patient self-management can be enhanced through links to community re sources 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 Depression is common among people with diabetes , negatively affecting quality of life , treatment adherence and diabetes outcomes . In routine clinical care , diabetes patients have limited access to mental health services and depression therefore often remains untreated . Web-based therapy could potentially be an effective way to improve the reach of psychological care for diabetes patients , at relatively low costs . This study seeks to test the effectiveness of a web-based self-help depression programme for people with diabetes and co-morbid depression . Methods / Design The effectiveness of a web-based self-help course for adults with diabetes with co-morbid depression will be tested in a r and omised trial , using a wait-list controlled design . The intervention consists of an 8-week , moderated self-help course that is tailored to the needs of persons living with diabetes and is offered on an individual basis . Participants receive feedback on their homework assignments by e-mail from their coach .  We aim to include 286 patients ( 143/143 ) , as power analyses showed that this number is needed to detect an effect size of 0.35 , with measurements at baseline , directly after completing the web-based intervention and at 1 , 3 , 4 and 6 months follow-up . Patients in the control condition are placed on a waiting list , and follow the course 12 weeks after r and omisation . Primary outcomes are depressive symptoms and diabetes-specific emotional distress . Secondary outcomes are satisfaction with the course , perceived health status , self-care behaviours , glycaemic control , and days in bed/absence from work . Question naires are administered via the Internet . Discussion The intervention being trialled is expected to help improve mood and reduce diabetes-specific emotional distress in  diabetes patients with depression , with subsequent beneficial effects on diabetes self-care and glycaemic outcomes . When proven efficacious , the intervention could be disseminated to reach large groups of patients with diabetes and concurrent depressive symptoms . Trial registration Current Controlled Trials IS RCT The objective of this study was to evaluate the effect of integrated health management model on the health of older adults with diabetes . The 100 older adults with diabetes who gave informed consent were r and omly allocated 1:1 into management and control groups . The integrated health management model was applied in the former while the latter was only given usual care . This model included the following components : health record establishment , health evaluation and health management ( such as : diet advice , psychological aspects of health , education/skills training on health self-management , regular blood glucose monitoring , long-term diabetes drug monitoring , etc . ) . After 18 months , differences in three categories of variables ( subjective grading items , objective measurement health indices and health service utilization ) between the two groups before and after the intervention were assessed with t-test , χ(2)-test and mixed model analysis . The management group demonstrated improvement on the following variables : health knowledge score , self-evaluated psychological conditions , overall self-evaluated health conditions , diet score , physical activity duration per week , regular blood sugar monitoring , waist-to-hip ratio , diastolic blood pressure and fasting blood sugar , the days of hospital admissions in the preceding 6 months . Mixed model analysis showed that gender , age , self-evaluated health status , self-evaluated psychological status , education level and resident status were important factors affecting health indices . This study demonstrated that integrated health management model was effectiveness in improving the health of older adults  with diabetes Objectives : To evaluate the reach and effectiveness of a  diabetes self-management DVD compared to classroom-based instruction . Methods : A hybrid preference/r and omized design was used with participants assigned to Choice v. R and omized and DVD v. Class conditions . One hundred and eighty-nine adults with type 2 diabetes participated . Key outcomes included self-management behaviours , process measures including DVD implementation and hypothesized mediators and clinical risk factors . Results : In the Choice condition , four times as many participants chose the mailed DVD  as selected Class-based instruction ( 38.8 v. 9.4 % , p<0.001 ) . At the 6-month follow-up , the DVD produced results generally not significantly different than classroom-based instruction , but a combined Class plus DVD condition did not improve outcomes beyond those produced by the classes alone . Discussion : The DVD appears to have merit as an efficient and appealing alternative to brief classroom-based diabetes education , and the hybrid design is recommended to provide estimates of programme reach OBJECTIVES This study attempted to evaluate clinical outcomes and long-term cost-effectiveness of an intervention involving Community Health Workers ( CHW 's , a.k.a . promotoras de salud in Spanish ) in assisting Mexican-American diabetes type-2 patients with controlling their condition . The intervention has been carried out in Hidalgo County , TX which is situated on the U.S.-Mexico border . STUDY DESIGN The design of the study is experimental . The sample ( n = 30 ) was recruited from Mexican-American diabetes patients aged 30 or above . The intervention group received monthly visits from CHW 's , while the control group did not . METHODS Incremental lifetime health outcomes and related expenditures were calculated using the CDC Diabetes Cost-Effectiveness Model ( DCEM ) which is a probabilistic computer simulation model of disease progression and cost-effectiveness for type 2 diabetes patients . The DCEM allows projection of lifetime healthcare costs and Quality -Adjusted Life-Years ( QALYs ) . RESULTS The intervention group showed a significant improvement in glycemic control and cholesterol management after two years of intervention . The intervention is expected to reduce long-term complications , result ing in an increase in residual life-years and quality -adjusted life-years . The incremental cost-effectiveness ratio has been estimated to be $ 13,810 , which is below the level of comparable studies . CONCLUSIONS Intervention has a substantial impact on the medical costs of type 2 diabetes treatment . The estimates presented in this model may be used to analyse the cost-effectiveness of interventions involving CHW 's for type 2 diabetes Background Many community-based self-management programs have been developed for older adults with type-2 diabetes mellitus ( T2DM ) , bolstered by evidence from r and omized controlled trials ( RCTs ) that T2DM can be prevented and managed through lifestyle modifications . However , the evidence for their effectiveness is contradictory and weakened by reliance on single-group design s and /or small sample s. Additionally , older adults with multiple chronic conditions ( MCC ) are often excluded because of recruiting and retention challenges . This paper presents a protocol for a two-armed , multisite , pragmatic , mixed- methods RCT examining the effectiveness and implementation of the Aging , Community and Health Research Unit-Community Partnership Program ( ACHRU-CPP ) , a new 6-month interprofessional , nurse-led program to promote self-management in older adults ( aged 65 years or older ) with T2DM and MCC and support their caregivers ( including family and friends ) . Methods / design The study will enroll 160 participants in two Canadian provinces , Ontario and Alberta . Participants will be r and omly assigned to the control ( usual care ) or program study arm . The program will be delivered by registered nurses ( RNs ) and registered dietitians ( RDs ) from participating diabetes education centers ( Ontario ) or primary care networks ( Alberta ) and program coordinators from partnering community-based organizations . The 6-month program includes three in-home visits , monthly group sessions , monthly team meetings for providers , and nurse-led care coordination . The primary outcome is the change in physical functioning as measured by the Physical Component Summary ( PCS-12 ) score from the short form-12v2 health survey ( SF-12 ) . Secondary client outcomes include changes in mental functioning , depressive symptoms , anxiety , and self-efficacy . Caregiver outcomes include health-related quality of life and depressive symptoms . The study includes a comparison of health care service costs for the intervention and control groups , and a subgroup analysis to determine which clients benefit the most from the program . Descriptive and qualitative data will be collected to examine implementation of the program and effects on interprofessional/team collaboration . Discussion This study will provide evidence of the effectiveness of a community-based self-management program for a complex target population . By study ing both implementation and effectiveness , we hope to improve the uptake of the program within the existing community-based structures , and reduce the research -to- practice gap . Trial registration Clinical Trials.gov , Identifier : NCT02158741 . Registered on 3 June 2014 OBJECTIVE Internet and other interactive technology-based programs offer great potential for practical , effective , and cost-efficient diabetes self-management ( DSM ) programs capable of reaching large numbers of patients . This study evaluated minimal and moderate support versions of an Internet-based diabetes self-management program , compared to an enhanced usual care condition . RESEARCH DESIGN AND METHODS A three-arm practical r and omized trial was conducted to evaluate minimal contact and moderate contact versions of an Internet-based diabetes self-management program , offered in English and Spanish , compared to enhanced usual care .  A heterogeneous sample of 463 type 2 patients was r and omized and 82.5 % completed a 4-month follow-up . Primary outcomes were behavior changes in healthy eating , physical activity , and medication taking . Secondary outcomes included hemoglobin A1c , body mass index , lipids , and blood pressure . RESULTS The Internet-based intervention produced significantly greater improvements than the enhanced usual care condition on three of four behavioral outcomes ( effect sizes [ d ] for healthy eating = 0.32 ; fat intake = 0.28 ; physical activity= 0.19 ) in both intent-to-treat and complete-cases analyses . These changes did not translate into differential improvements in biological outcomes during the 4-month study period . Added contact did not further enhance outcomes beyond the minimal contact intervention . CONCLUSIONS The Internet intervention meets several of the RE- AIM criteria for potential public health impact , including reaching a large number of persons , and being practical , feasible , and engaging for participants , but with mixed effectiveness in improving outcomes , and consistent results across different subgroups . Additional research is needed to evaluate longer-term outcomes , enhance effectiveness and cost-effectiveness , and underst and the linkages between intervention processes and outcomes Objectives : Evaluate the effectiveness of an online self-management programme ( EPP Online ) for Engl and residents with long-term conditions . Methods : A prospect i ve longitudinal study . Data were collected online at baseline , 6 and 12 months . The intervention was an asynchronous 6-week chronic-disease self-management programme offered online . We measured seven health status measures ( health distress , self-rated health , illness intrusiveness , disability , fatigue , pain and shortness of breath ) , four behaviours ( aerobic exercise , stretching exercise , stress management and communications with physician ) , and five utilization measures ( GP visits , pharmacy visits , PT/OT visits , emergency visits and hospitalizations ) . We also measured self-efficacy and satisfaction with the health care system . Results : A total of 568 completed baseline data : 546 ( 81 % ) completed 6 months and 443 ( 78 % ) completed 1 year . Significant improvements ( p<0.01 ) were found at 6 months for all variables except self-rated health , disability , stretching , hospitalizations and nights in hospital . At 12 months only decrease in disability , nights in hospital and hospitalizations were not significant with reduction in visits to emergency departments being marginally significant ( p = 0.012 ) . Both self-efficacy and satisfaction with the health care system improved significantly . Discussion : The peer-led online programme conditions appears to decrease symptoms , improve health behaviours , self-efficacy and satisfaction with the health care system and reducing health care utilization up to 1 year Introduction The potential for telehealth-based interventions to provide remote support , education and improve self-management for long-term conditions is increasingly recognised . This trial aims to determine whether an intervention delivered through an easy-to-use tablet computer can improve the quality of life of patients with chronic obstructive pulmonary disease ( COPD ) by providing personalised self-management information and education . Methods and analysis The EDGE ( sElf management anD support proGrammE ) for COPD is a multicentre , r and omised controlled trial design ed to assess the efficacy of an Internet-linked tablet computer-based intervention ( the EDGE platform ) in improving quality of life in patients with moderate to very severe COPD compared with usual care . Eligible patients are r and omly allocated to receive the tablet computer-based intervention or usual care in a 2:1 ratio using a web-based r and omisation system . Participants are recruited from respiratory outpatient clinics and pulmonary rehabilitation courses as well as from those recently discharged from hospital with a COPD -related admission and from primary care clinics . Participants allocated to the tablet computer-based intervention complete a daily symptom diary and record clinical symptoms using a Bluetooth-linked pulse oximeter . Participants allocated to receive usual care are provided with all the information given to those allocated to the intervention but without the use of the tablet computer or the facility to monitor their symptoms or physiological variables . The primary outcome of quality of life is measured using the St George 's Respiratory Question naire for COPD patients ( SGRQ-C ) baseline , 6 and 12 months . Secondary outcome measures are recorded at these intervals in addition to 3 months . Ethics and dissemination The Research Ethics Committee for Berkshire — South Central has provided ethical approval for the conduct of the study in the recruiting regions . The results of the study will be disseminated through peer review publications and conference presentations . Trial registration Current controlled trials IS RCT N40367841 Background Type 2 diabetes mellitus ( DM2 ) is a disease with high prevalence and significant impact in terms of mortality and morbidity . The increased prevalence of the disease requires the implementation of new strategies to promote patient self-management . The Spanish Diabetes Self-Management Program ( SDSMP ) has proven to be effective in other setting s. The objective of this study is to assess its effectiveness in terms of care for DM2 patients in primary care setting s within the Basque Health Service – Osakidetza ( Spain ) . Method / Design This is a r and omised clinical trial in which patients diagnosed with DM2 , 18–79 years of age , from four health regions within the Basque Health Service will be r and omised into two groups : an intervention group , who will follow the SDSMP , and a control group , who will receive usual care in accordance with the clinical guidelines for DM2 and existing regulations in our region . The intervention consists of 2,5 hour-group sessions once a week for six weeks . The sessions cover target setting and problem solving techniques , promotion of physical exercise , basic knowledge of nutrition , proper use of medication , effective communication with relatives and health professionals , and basic knowledge about DM2 and its complications . This content is complemented by educational material : books , leaflets and CDs . The primary outcome measure will be the change in glycated haemoglobin ( HbA1c ) , and secondary outcome measures will include changes in levels of physical activity and intake of fruit and vegetables , cardiovascular risk , quality of life , self-efficacy , number of consultations and drug prescriptions . The results will be analysed 6 , 12 and 24 months after the intervention . Discussion If the intervention were to be effective , the programme should be spread to the entire diabetic population in the Basque Country and it could also be applied for other diseases . Trial registration Clinical Trials.gov identifier Background Type 2 diabetes can seriously affect patients '  health-related quality of life and their self-rated health . Most often , evaluation of diabetes interventions assess effects on glycemic control with little consideration of quality of life . The aim of the current study was to study the effectiveness of group-based rehabilitation versus individual counselling on health-related quality of life ( HRQOL ) and self-rated health in type 2 diabetes patients . Methods We r and omised 143 type 2 diabetes patients to either a six-month multidisciplinary group-based rehabilitation programme including patient education , supervised exercise and a cooking-course or a six-month individual counselling programme .  HRQOL was measured by Medical Outcomes Study Short Form 36-item Health Survey ( SF-36 ) and self-rated health was measured by Diabetes Symptom Checklist - Revised ( DCS-R ) . Results In both groups , the lowest estimated mean scores of the SF36 question naire at baseline were " vitality " and " general health " . There were no significant differences in the change of any item between the two groups after the six-month intervention period . However , vitality-score increased 5.2 points ( p = 0.12 ) within the rehabilitation group and 5.6 points ( p = 0.03 ) points among individual counselling participants .In both groups , the highest estimated mean scores of the DSC-R question naire at baseline were " Fatigue " and " Hyperglycaemia " . Hyperglycaemic and hypoglycaemic distress decreased significantly after individual counselling than after group-based rehabilitation ( difference -0.3 points , p = 0.04 ) . No between-group differences occurred for any other items . However , fatigue distress decreased 0.40 points within the rehabilitation group ( p = 0.01 ) and 0.34 points within the individual counselling group ( p < 0.01 ) . In the rehabilitation group cardiovascular distress decreased 0.25 points ( p = 0.01 ) . Conclusions A group-based rehabilitation programme did not improve health-related quality of life and self-rated health more than an individual counselling programme . In fact , the individual group experienced a significant relief in hyper- and hypoglycaemic distress compared with the rehabilitation group . However , the positive findings of several items in both groups indicate that lifestyle intervention is an important part of the management of type 2 diabetes patients BACKGROUND A major problem in the dissemination of most interventions found to be efficacious is that they are of limited or unknown generalizability . OBJECTIVE To document the " robustness , " or external validity , of a computer-assisted diabetes self-management program across different patient characteristics , healthcare setting s ( mixed payer vs health maintenance organization ) , intervention staff , and outcomes . STUDY DESIGN A r and omized controlled trial evaluating a computer-assisted behavior change program for adult patients with type 2 diabetes mellitus ( n = 217 ) vs a computerized health risk assessment . METHODS Outcomes were identified using the RE- AIM framework and included program adoption among physicians , reach across patient groups , implementation , and behavioral ( fat intake and physical activity ) and biological ( glycosylated hemoglobin and lipid levels ) effectiveness measures . RESULTS The program achieved 41 % patient participation , variable adoption across healthcare setting s ( 76 % of health maintenance organization physicians vs 18 % of non-health maintenance organization physicians participated ) , good implementation , and improvement in behavioral outcomes . There were few significant interactions between treatment condition and patient characteristics , type of healthcare setting , or interventionist experience on effectiveness measures . CONCLUSIONS Patients and physicians were willing to participate in a computer-assisted dietary and physical activity goal - setting intervention , although participation varied by healthcare setting . Interventionists from different background s successfully delivered the intervention , and the results appear robust across various patient and delivery characteristics BACKGROUND Healthy diet is a core component in prevention and self-management of type 2 diabetes and cardiovascular disease . The long-term efficacy was assessed of a theory-based health education programme ' Ready to Act ' on dietary quality in people with screen-detected dysglycaemia . METHODS Five hundred and nine adults with prediabetes ( impaired glucose tolerance , impaired fasting glycaemia ) or type 2 diabetes were recruited through screening for type 2 diabetes [ the ADDITION ( Anglo-Danish-Dutch Study of Intensive Treatment in People with Screen-Detected Diabetes in Primary Care ) study , DK ] and then r and omly assigned to health education or to a control group ( I = 322 ; C = 187 ) . The intervention group was offered a 12-week programme in health-related action competence including 2 one-to-one and 8 group sessions ( 18 h ) . Dietary quality was measured by the Dietary Quality Score_revised ( 0 - 8 points ) at baseline and at one- and 3-year follow-up . Changes were analysed by multilevel analyses . RESULTS The analysis included data from 444 participants ( 87 % ) . At the 3-year follow-up , the intervention group had significantly increased dietary quality compared with the control group ( net change : 0.39 Dietary Quality Score_revised points , P = 0.04 ) . The intake of unsaturated fats used on bread and for cooking increased in the intervention group compared with the control group at the 3-year follow-up ( net change : 31 g/week ; P = 0.02 ) . A non-significant tendency toward an increased intake of vegetables in the intervention group compared with the control group was seen ( net change : 111 g/week ; P = 0.16 ) . No changes were seen in fish intake . CONCLUSIONS Health education aim ing at action competence improved the long-term dietary quality in a population with dysglycaemia , especially according to the intake of unsaturated fat . The ADDITION trial was registered at Clinical Trials.gov ID no NCT00237549 Introduction Pulmonary Rehabilitation ( PR ) is an evidence -based intervention that has been recommended in guidelines to be available to those who may benefit . However , not all patients with chronic obstructive pulmonary disease ( COPD ) have access to this service . Healthcare services have shown the need for the provision of PR in other forms to enable patient choice and service capacity . There is an increase in evidence for the use of the internet in the management of long-term conditions to provide education and promote self-management . The aim of this study is to see if an interactive web-based PR programme is a feasible alternative compared with conventional PR . Methods and analysis This is a feasibility study design ed to evaluate the efficacy of providing a web-based PR programme to improve patients exercise capacity , quality of life and promote self-management in patients with moderate to severe COPD compared with conventional PR programmes .  Eligible patients will be r and omly allocated to receive either the web-based programme or conventional rehabilitation programme for 7 weeks using an internet-based r and omisation system . Participants will be recruited from PR assessment s , primary care and community rehabilitation programmes . Those r and omised to the web-based programme work through the website which contains all the information that the patients receive in the PR classes . They receive weekly phone calls by a professional to help progress through the course on line . The outcome measures will be recruitment rates and eligibility as well as that st and ard for a PR assessment including measures of exercise capacity , quality of life question naires and physical activity . Ethics and dissemination The research ethics committee for Northampton has provided ethical approval for the conduct of the study . The results of the study will be disseminated through appropriate conference presentations and peer review ed journals . Trial registration number IS RCT N03142263 AIMS To improve patient-centred care by determining the impact of baseline levels of conscientiousness and diabetes self-efficacy on the outcomes of efficacious interventions to reduce diabetes distress and improve disease management . METHODS Adults with Type 2 diabetes with diabetes distress and self-care problems ( N = 392 ) were r and omized to one of three distress reduction interventions : computer-assisted self-management ; computer-assisted self-management plus problem-solving therapy ; and health education . The baseline assessment included conscientiousness and self-efficacy , demographics , diabetes status , regimen distress , emotional burden , medication adherence , diet and physical activity . Changes in regimen distress , emotional burden and self-care between baseline and 12 months were recorded and ancova models assessed how conscientiousness and self-efficacy qualified the significant improvements in distress and management outcomes . RESULTS Participants with high baseline conscientiousness displayed significantly larger improvements in medication adherence and emotional burden than participants with low baseline conscientiousness . Participants with high baseline self-efficacy showed greater improvements in diet , physical activity and regimen distress than participants with low baseline self-efficacy . The impact of conscientiousness and self-efficacy were independent of each other and occurred across all three intervention groups . A significant interaction indicated that those with both high self-efficacy and high conscientiousness at baseline had the biggest improvement in physical activity by 12 months . CONCLUSIONS Both broad personal traits and disease-specific expectations qualify the outcomes of efficacious interventions . These findings reinforce the need to change from a one-size-fits-all approach to diabetes interventions to an approach that crafts clinical interventions in ways that fit the personal traits and skills of individual people AIMS To evaluate the outcomes of an established programme to teach patients to match their insulin dose to their carbohydrate intake . RESEARCH DESIGN AND METHODS A prospect i ve observational study in Australia ( Newcastle , NSW ) of 137 consecutive patients with type 1 ( n=82 ) or type 2 diabetes ( n=55 ) over two successive years . Four educational principles were used to teach intensive insulin management and diabetes self-care skills including : carbohydrate counting and insulin dose adjustment , exercise , appropriate treatment of hypoglycaemia and hyperglycaemia , managing sickness , problem solving , communication with health professionals , goal setting , and the importance of support . Outcomes included changes at 4 and 12 months in HbA1c , self-efficacy measured by a diabetes empowerment scale ( DES ) , diabetes specific quality of life ( ADDQoL ) , and problem solving . Both intention to treat and efficacy analyses were performed . RESULTS Diabetes-related quality of life and diabetes problem solving skills improved significantly . Excluding 16 people who failed to adopt intensive insulin management and 24 who started with an HbA1c less than 7 % , intention to treat analysis showed the average HbA1c fell from 8.7 % initially to 8.1 % at 12 months and the number of people with an HbA1c of less than 8 % rose from 67 ( 48.9 % ) before the program to 86 ( 62.8 % ) afterwards . CONCLUSIONS An intensive diabetes self-management program led to improvements in HbA1c , empowerment , and quality of life that were largely sustained at 1 year . This is all the more remarkable given that the intervention was once only , entailed no long-term follow-up , and took place in normal clinical operations The Diabetes Control and Complications Trial ( DCCT ) and the Kumamoto study [ 1 , 2 ] showed that near-normal glycemic control reduces the development and progression of microvascular and neuropathic complications by approximately 50 % in type 1 and type 2 diabetes mellitus . Additional analyses [ 3 - 5 ] indicate that therapy to achieve near normalization of blood glucose levels is cost-effective compared with other treatments . Thus , the American Diabetes Association has recommended that all persons with diabetes attempt to achieve near normalization of blood glucose levels [ 6 ] . This recommendation is not routinely followed in medical practice . In a 1989 national survey of physician practice behaviors in the United States , 64 % of physicians agreed that achieving target HbA1c values is very important but only 18 % reported that they ordered HbA1c tests every 2 to 3 months for patients with type 1 diabetes [ 7 ] . Although 98 % agreed that patient education improves glucose control , only 55 % reported that they routinely used a dietitian or a diabetes educator in patient care . Studies indicate that bringing clinical practice into line with scientific knowledge can be difficult . Methods used to achieve diabetes control in clinical trials are re source intensive . The American Diabetes Association currently recommends that patients with diabetes see their primary care physicians two to four times per year . Data from the National Health Interview Survey , a nationally representative survey [ 8 ] , indicate that most patients with diabetes are seen by nonspecialists and that 69 % of physician visits last less than 15 minutes . Algorithms for diabetes care exist but may be complex and difficult for physicians to follow , given patient load , diversity of patients seen , lack of information systems , and time constraints . Simple , low-cost methods of translating guidelines into clinical care are required . One solution may be to make greater use of personnel other than physicians . Nurse case management was an integral part of intensive therapy in the DCCT and has proven to be effective in reducing smoking and cholesterol levels after acute myocardial infa rct ion [ 3 , 9 ] . A nonr and omized study [ 10 ] of more than 700 patients with diabetes in a health maintenance organization suggests that nurse case management may be effective in improving metabolic control . Other studies [ 11 , 12 ] show a strong association between algorithm-directed nurse interventions and improved glycemic control . To our knowledge , no r and omized , controlled clinical trial of nurse case management in diabetes has yet been published . In a 12-month r and omized , controlled trial , we compared a nurse case management model of diabetes care with usual diabetes management in a primary care setting . Methods Patients Our study was approved by the institutional review board of the Prudential Center for Health Care Research , and all patients gave written informed consent . Participants were recruited from two of the largest clinics within the Jacksonville Health Care Group , which is the largest provider of primary care services for the Prudential HealthCare HMO plan of Jacksonville , Florida . The Jacksonville Health Care Group is a group of 43 primary care physicians who provide care in eight clinics to more than 75 000 Prudential HealthCare plan members . Potential study participants were identified through a data base used to support quality -improvement activities . Prudential HealthCare HMO members who had diabetes were included in the data base if they had visited a physician for diabetes ( International Classification of Diseases , 9th Revision , codes 250.0 to 250.9 ) , had had a hospital cl aim processed for diabetes , had been seen by the utilization management nurse , or had been referred to an ophthalmologist for a diabetic retinal examination . This data base is up date d regularly . A list with each member 's name , address , telephone number , medical record number , member identification number , age , sex , physician , and clinic was generated by merging the data from the data base with enrollment information . In addition , a list of members who may have had diabetes was created by using pharmacy data . Adult members with diabetes who were potential study participants each received a recruitment call and were invited to schedule an appointment with a research assistant to discuss participation in the study . We made a total of 14 calls at different times and on different days before coding a member as unavailable . After consent was given and the eligibility assessment was completed , baseline information was obtained and an HbA1c test was ordered if the result of one given within the previous 60 days was not available . Patients were ineligible for the study if they had a recent HbA1c value less than 7.0 % ; had uncontrolled hypertension ( blood pressure > 180/110 mm Hg ) ; had unstable angina ( class 4 ) ; had had a myocardial infa rct ion in the past 3 months ; had had two or more episodes of seizures ; had alcoholism or drug abuse documented in the chart ; had late-stage complications of diabetes or other chronic conditions , such as severe immunodeficiency or cirrhosis ; were pregnant or were planning to become pregnant in the next 12 months ; or were unable to perform self-management . Patients were r and omly assigned in blocks to either the nurse case management ( intervention ) group or the usual care group . R and omization was based on a 1:1 allocation ratio and a block size of three . Each block contained six patients , three in each study group . This r and omization scheme ensured that the desired allocation ratio-one intervention patient to one usual care patient-was maintained after sequential enrollment of every sixth patient . Outcome Measures Change in HbA1c value was the primary outcome measure . Decreased HbA1c values correlate directly with reduced risk for diabetes-related microvascular and neuropathic complications in type 1 and type 2 diabetes [ 1 , 3 ] . We also assessed health-related quality of life by using four generic questions developed by the Centers for Disease Control and Prevention for the Behavioral Risk Factor Surveillance System ( BRFSS ) [ 13 , 14 ] . These questions evaluate key conceptual domains of health-related quality of life : 1 ) patient-perceived general health status , 2 ) patient-perceived physical dysfunction during the previous 30 days , 3 ) patient-perceived mental dysfunction during the previous 30 days , and 4 ) patient-perceived functional incapacity during the previous 30 days for either mental or physical reasons . The BRFSS quality -of-life measures have been vali date d in a national sample of adults in the United States [ 15 ] . Patient-perceived health was found to be a good proxy indicator for chronic disease conditions . The other three domains further characterize general health functioning and quality of life [ 15 ] . In this analysis , we report findings related to the patient-perceived general health status domain . Intervention and Follow-up The nurse case manager was a registered nurse and a certified diabetes educator . She was trained to follow a set of detailed management algorithms under the direction of a board-certified family medicine physician and an endocrinologist who were responsible for all diabetes management decisions for patients in the intervention group but were not primary care providers for these patients . The algorithms were specific for type of diabetes and were developed by a multidisciplinary team on which endocrinology , family medicine , nursing , pharmacy , health services research , and epidemiology were represented . The algorithms progressively moved a patient toward improvement of glycemic control through adjustments in medication , meal planning , and reinforcement of exercise ( Figure 1 ) . Figure 1 . Algorithm for management of type 2 diabetes mellitus . Patients assigned to receive nurse case management met with the nurse for an initial assessment , were instructed about a blood glucose monitoring schedule , and returned for a follow-up visit 2 weeks later . The initial visit with the nurse averaged 45 minutes . At the 2-week follow-up visit , the nurse review ed the patient 's blood glucose log ; explained the algorithm step to which the patient had been assigned ; and used this information as the baseline for subsequent medication adjustments , meal planning , and exercise reinforcement . Patients receiving nurse case management  were also referred to a 5-week , 12-hour diabetes education program that included individual counseling by a dietitian , individual counseling by an exercise therapist , and group diabetes education classes . Subsequent in-person follow-up visits occurred quarterly . Patients in the nurse case management group  who were taking insulin  received weekly follow-up telephone calls . After the nurse review ed the blood glucose log and discussed glucose values with the patient , medication regimens were adjusted as needed and meal planning and exercise were reinforced . Patients treated with oral agents or diet and exercise  received follow-up telephone calls every 2 weeks . The nurse case manager met at least biweekly with the family medicine physician and the endocrinologist to review patient progress , medication adjustments , and other issues related to diabetes care . All medication adjustments or changes were communicated to the patients ' regular primary care physicians . Patients assigned to receive usual care were given blood glucose meters and strips , were encouraged to discuss enrollment in the diabetes education class with their physicians if they had not done so in the past year , and continued to receive diabetes care and follow-up from their primary care physicians . The 5-week diabetes education program is a st and ard , free-of-charge benefit for all HMO members with diabetes . All Jacksonville Health Care Group primary care physicians participate in an annual diabetes care seminar and undergo regular peer review of their adherence to published diabetes care st and ards . Tests to Evidence for the effectiveness of patient education programmes in changing individual self-management behaviour is equivocal . More distal elements of personal social relationships and the availability of social capital at the community level may be key to the mobilisation of re sources needed for long-term condition self-management to be effective . Aim To determine how the social networks of people with long-term conditions ( diabetes and heart disease ) are associated with health-related outcomes and changes in outcomes over time . Methods Patients with chronic heart disease ( CHD ) or diabetes ( n = 300 ) r and omly selected from the disease registers of 19 GP practice s in the North West of Engl and . Data on personal social networks collected using a postal question naire , alongside face-to-face interviewing . Follow-up at 12 months via postal question naire using a self-report grid for network members identified at baseline . Analysis Multiple regression analysis of relationships between health status , self-management and health-economics outcomes , and characteristics of patients ' social networks . Results Findings indicated that : ( 1 ) social involvement with a wider variety of people and groups supports personal self-management and physical and mental well-being ; ( 2 ) support work undertaken by personal networks exp and s in accordance with health needs helping people to cope with their condition ; ( 3 ) network support substitutes for formal care and can produce substantial saving in traditional health service utilisation costs . Health service costs were significantly ( p<0.01 ) reduced for patients receiving greater levels of illness work through their networks . Conclusions Support for self-management which achieves desirable policy outcomes should be construed less as an individualised set of actions and behaviour and more as a social network phenomenon . This study shows the need for a greater focus on harnessing and sustaining the capacity of networks and the importance of social involvement with community groups and re sources for producing a more desirable and cost-effective way of supporting long term illness management Adults with type 2 diabetes mellitus often struggle with their antihyperglycemic medication regimens . To improve medication management , providers must ensure that their patients underst and potential benefits , harms , and burdens of available options and elicit patients ' preferences and barriers to taking medications . Patients who are actively involved in treatment decision making tend to be more satisfied with their health care , be more adherent to treatment , and have improved clinical outcomes ( 13 ) . Such discussion s , however , can be too time-consuming for clinic visits . For inner-city low-income African American and Latino adults , low health literacy and limited English proficiency are often additional barriers ( 4 ) that reduce the exchange of information and decrease patient participation during primary care visits ( 58 ) . This contributes to less optimal treatment decisions and lower patient satisfaction , leading to poor medication adherence and outcomes ( 3 , 911 ) . There is therefore an urgent need for cost-effective approaches to enable low-re source health systems to help these high-risk population s gain information and decision support so that they can more actively participate in and improve satisfaction with their treatment decision making . Since 2000 , the REACH ( Racial and Ethnic Approaches to Community Health 2010 ) Detroit Partnership , a coalition of community , health system , and academic partners , has used community-based participatory research principles to guide development , implementation , and evaluation of interventions to meet this need among African American and Latino adults with diabetes in Detroit , Michigan . These interventions have built on evidence that community health workers ( CHWs ) are effective in improving diabetes outcomes , particularly among racial and ethnic minority communities ( 12 ) . CHW interventions train community members to work as bridges between their ethnic , cultural , or geographic communities and health care providers ( 13 ) . Two cohorts of participants in our previous CHW-led diabetes self-management support interventions  improved hemoglobin A1c ( HbA1c ) levels and diabetes distress compared with usual care ( 14 , 15 ) . An important next step in increasing the potential effect of CHWs and other lay health care workers is to develop and test effective tools they can use to better present evidence -based information to patients and to help patients make better self-management decisions ( 16 ) . Little is known about the effectiveness of different approaches for nontraditional care providers , such as CHWs , to deliver health information to ethnic minority and low-literacy population s ( 17 ) . By definition , CHWs and other lay workers do not have medical expertise and thus rely on effectively sharing printed educational and support material s with patients as part of their coaching and counseling efforts . Decision aids can increase satisfaction with treatment decisions and result in treatments that better reflect patients ' preferences ( 18 , 19 ) . There is also evidence that tailored health messages are more effective than generic group messages ( 20 , 21 ) , including for patients with diabetes ( 22 , 23 ) . Tailoring individualizes information and behavior change strategies to reach each person based on characteristics unique to that person derived from an individual assessment and related to the outcome of interest ( 24 ) . Software programs that are being developed to automatically embed tailored content into portable e-health Web applications show promise in improving health behaviors and outcomes ( 25 , 26 ) . To date , however , most e-health applications have been design ed for use by patients with relatively high literacy and the skills to navigate them ( 27 ) . Do more sophisticated , tailored , interactive e-health tools increase the effectiveness of CHW outreach with underserved patients compared with reliance on printed educational material s alone ? We addressed this question by developing and evaluating a personally tailored , interactive diabetes medication decision aid ( iDecide [ in English ] or iDecido [ in Spanish ] ) design ed for CHWs to deliver on tablet computers with 3 G wireless access to African American and Latino adults with diabetes and low health literacy . We then evaluated the effectiveness of iDecide in improving key diabetes outcomes compared with CHW delivery of the same evidence -based information , without tailoring , through print consumer booklets developed by the Agency for Healthcare Research and Quality ( AHRQ ) . Methods Setting This study was developed and implemented by using community-based participatory research principles ( 28 ) in partnership with the REACH Detroit Partnership and the Community Health and Social Services Center ( CHASS ) , a federally qualified health center in Southwest Detroit serving more than 13000 patients with 47099 visits in 2012 ( 29 ) . The University of Michigan and CHASS institutional review boards approved the study . Content of AHRQ Consumer Guides The AHRQ guides ( Pills for Type 2 Diabetes and Premixed Insulin for Type 2 Diabetes ) ( 30 , 31 ) provide information on diabetes and summarize the effectiveness of currently available medication classes  ( oral and insulin ) on HbA1c . They also provide information on administration methods , costs , medication adverse effects , risks for diabetes complications , suggested questions to discuss with health care providers , and prompts to make notes of any questions for the doctor . The booklets include pictures of patients and tables and graphs summarizing information . Content of iDecide The development process and content of the iDecide program have been described in detail elsewhere ( 32 ) . Briefly , we used community-based participatory research and user-centered design ( 33 , 34 ) principles to iteratively develop and refine the iDecide tool . iDecide is available in English and Spanish , can be delivered via tablet computers , and enables navigation by the CHW and participant to selectively explore issues most important to the participant . The iDecide program is organized into 4 main sections and includes the same content as the AHRQ consumer guides . However , its information is presented in a more graphical style suited to patients with low literacy . Table 1 summarizes key differences between the presentation of information in iDecide and the printed material s. The first section illustrates , through animations , how diabetes affects the way glucose is processed in the body and how different medication classes , foods , and physical activity affect blood glucose . The second section includes pictographs showing participants ' own risk for diabetes complications ( tailored according to their baseline HbA1c ) and enabling participants to explore how their risk for different complications changes with their HbA1c levels . In the third section , participants review their current diabetes medications and barriers to taking the medications they had reported on the baseline survey . This section includes an interactive issue card approach to help elicit patient preferences and priorities about different medication characteristics ( for example , cost , adverse effects , effects on weight , and dosing schedules ) ( 22 , 35 ) . The fourth section prompts participants to set goals and develop specific action plans to address identified barriers or other concerns and identify specific questions and concerns to discuss with their doctor about their medications or making lifestyle changes . Personal information from the baseline assessment is interwoven throughout the program ( high-depth tailoring within sentences ) . Motivational interviewingbased , tailored discussion prompts encourage autonomy-supportive CHWpatient interactions at key points with open-ended questions and values exploration to help participants discover their motivation , overcome barriers to change , and develop an action plan ( 36 ) . Table 1 . Comparison of Content and Mode of Delivery Between the iDecide Study Group and the Printed Material s Group Recruitment and R and omization From September 2011 to August 2012 , potentially eligible participants were identified from a computer-generated list of CHASS patients with physician-diagnosed type 2 diabetes . Inclusion criteria required a HbA1c value greater than 7.5 % in the previous 6 months or expressed concerns about current diabetes medications during the screening assessment . Exclusion criteria were age younger than 21 years , terminal health conditions , self-reported alcohol or drug abuse , and conditions ( such as blindness and dementia ) that would impede meaningful participation . Pregnant women and individuals who reported that they could not be contacted by telephone were also excluded . Introductory letters were sent in timed batches . Research staff then telephoned patients and screened them for eligibility . Interested eligible patients met with research staff , who facilitated completion of written informed consent , administered baseline surveys in English or Spanish , and measured HbA1c and blood pressure . Participants received a stipend of $ 20 after each assessment . Within 1 to 14 days , participants were scheduled for a visit with a CHW ( at home , the clinic , or another agreed-upon place ) . At the beginning of the CHW visits , participants were registered into the iDecide program and r and omly assigned by the computer program , through use of a r and om-sequence algorithm , into 1 of 2 study groups . There were no differences between the steps to participate in either study group . Patients , research staff , and CHWs were blinded to r and omization results through completion of all baseline measures up to the start of the intervention . Data assessors remained blinded to group assignment throughout the study . CHW Intervention for Both Study Groups All participants received an initial one-on-one , face-to-face session with a CHW and a copy of the printed material s to take home . The iDecide sessions lasted approximately 2 hours , and the sessions using printed material s lasted OBJECTIVE Because of other competing priorities ,  physical activity ( PA ) is seldom addressed in a consistent way in either primary care or diabetes education . This 8-week pilot study evaluated the short-term benefits of an Internet-based supplement to usual care that focused on providing support for sedentary patients with type 2 diabetes to increase their PA levels . RESEARCH DESIGN AND METHODS A total of 78 type 2 diabetic patients ( 53 % female , average age 52.3 years ) were r and omized to the Diabetes Network ( D-Net ) Active Lives PA Intervention or an Internet information-only condition .  The intervention condition received goal - setting and personalized feedback , identified and developed strategies to overcome barriers , received and could post messages to an on-line " personal coach , " and were invited to participate in peer group support areas . Key outcomes included minutes of PA per week and depressive symptomatology . RESULTS There was an overall moderate improvement in PA levels within both intervention and control conditions , but there was no significant improvement in regard to condition effects . There was substantial variability in both site use and outcomes within the intervention and control conditions . Internal analyses revealed that among intervention participants , those who used the site more regularly derived significantly greater benefits , whereas those in the control condition derived no similar benefits with increased program use . CONCLUSIONS Internet-based self-management interventions for  PA and other regimen areas have great potential to enhance the care of diabetes and other chronic conditions . We conclude that greater attention should be focused on methods to sustain involvement with Internet-based intervention health promotion programs over time Objective This study is aim ed at assessing the effectiveness of a simple outpatient diabetes self-management education programme . Methods In the study , 60 patients with type 2 diabetes mellitus were r and omly allocated into the control group ( n = 30 ) and intervention group ( n = 30 ) . Regular and 2-session health education programmes were provided . The summary of diabetes self-care activity measure , problem areas in the diabetes scale , fasting blood glucose , postpr and ial 2 h blood glucose , and HbA1c were measured before and after the intervention to assess the effects of this 2-session diabetes education programme . Results The total mean score of the summary of diabetes self-care activities measure was 17.60 ± 6.63 points . The problem areas in the diabetes scale revealed that the total mean score was 29.82 ± 15.22 points ; 27 % of the patients had diabetes-related distress , while 9 % suffered from severe emotional distress . Compared with the control group , scores of the summary of diabetes self-care activities measure and problem areas in the diabetes scale , fasting blood glucose , postpr and ial 2 h blood glucose , and HbA1c were significantly improved in the intervention group after the intervention ( P < 0.01 ) . Conclusion This study showed that the 2-session diabetes education programme could effectively improve the level of self-reported self-management , psychological distress , and glycemic control in patients with type 2 diabetes mellitus BACKGROUND Type 1 diabetes ( T1D ) in children and young people is increasing worldwide with a particular increase in children under the age of 5 years . Fewer than one in six children and young people achieve glycosylated fraction of haemoglobin ( HbA1c ) values in the range identified as providing best future outcomes . There is an urgent need for clinic-based pragmatic , feasible and effective interventions that improve both glycaemic control and quality of life ( QoL ) . The intervention offers both structured education , to ensure young people know what they need to know , and a delivery model design ed to motivate self-management . OBJECTIVE To assess the feasibility of providing a clinic-based structured educational group programme incorporating psychological approaches to improve long-term glycaemic control , QoL and psychosocial functioning in a diverse range of young people . DESIGN The study was a pragmatic , cluster r and omised control trial with integral process and economic evaluation . SETTING Twenty-eight paediatric diabetes services across London , south-east Engl and and the Midl and s. R AND OMISATION Minimised by clinic size , age ( paediatric or adolescent ) and specialisation ( district general hospital clinic or teaching hospital/tertiary clinic ) . ALLOCATION Half of the sites were r and omised to the intervention arm and half to the control arm . Allocation was concealed until after clinics had consented and the first participant was recruited . Where possible , families were blind to allocation until recruitment finished . PARTICIPANTS Forty-three health-care practitioners ( 14 teams ) were trained in the intervention . The study recruited 362 children aged 8 - 16 years , diagnosed with T1D for > 12 months , with a mean 12-month HbA1c level of ≥ 8.5 % . INTERVENTION Two 1-day workshops taught intervention delivery . A detailed manual and re sources were provided . The intervention consists of four group education sessions led by a paediatric diabetes specialist nurse with another team member . OUTCOMES The primary outcome was glycaemic control , assessed at the individual level using venous HbA1c values , measured at baseline , 12 and 24 months . Secondary outcomes were directly and indirectly related to diabetes management , including hypoglycaemic episodes , hospital admissions , diabetes regimen , knowledge , skills and responsibility for diabetes management , intervention compliance , clinic utilisation , emotional and behavioural adjustment , and general and diabetes-specific QoL. PROCESS EVALUATION Question naires , semistructured interviews , informal discussion following observation sessions , fieldwork notes and case note review were used to collect qualitative and quantitative data from key stakeholder groups at specific time points in the trial . STATISTICAL ANALYSES Primary and secondary analyses were intention-to-treat comparisons of outcomes at 12 and 24 months , using analysis of covariance with a r and om effect for clinic . Prespecified subgroup analyses based on age , gender , initial HbA1c value and socioeconomic status were estimated from models that included an interaction term . The economic analysis compared long-term costs and predicted quality -adjusted life-years ( QALYs ) . RESULTS The intervention did not improve HbA1c at 12 months [ intervention effect 0.11 ; 95 % confidence interval ( CI ) -0.28 to 0.50 ; p = 0.584 ] or 24 months ( intervention effect 0.03 ; 95 % CI -0.36 to 0.41 ; p = 0.891 ) . A total of 298/362 patients ( 82.3 % ) provided blood sample s at 12-month follow-up , and 284/362 ( 78.5 % ) provided blood sample s at 24-month follow-up . Follow-up question naires were completed by 307 patients ( 85.3 % ) at 12 months and by 295 patients ( 81.5 % ) at 24 months . Intervention group parents at 12 months ( 95 % CI 0.74 ; 0.03 to 1.52 ) and young people at 24 months ( 0.85 ; 95 % CI 0.03 to 1.61 ) had higher scores on the diabetes family responsibility question naire . Young people reported reduced happiness with body weight at 12 months ( -0.56 ; 95 % CI -1.03 to -0.06 ) . Only 68 % of groups were run . Of the 180 families recruited , 96 ( 53 % ) attended at least one module . Reasons for low uptake included difficulties organising groups , and work and school commitments . Young people with higher HbA1c levels were less likely to attend . Parents and young people who attended groups described improved family relationships , improved knowledge and underst and ing , greater confidence and increased motivation to manage diabetes . Twenty-four months after the intervention , nearly half of the young people reported that the groups had made them want to try harder and that they had carried on trying . A high- quality , complex , pragmatic trial of structured education can be delivered alongside st and ard care in NHS diabetes clinics . Health-care providers benefited from behaviour change skill training and can deliver pragmatic aspects of a National Institute for Health and Care Excellence (NICE)-compliant structured education programme after relatively brief training . The process evaluation provides insight into aspects of the model , and highlights strengths and aspects that may have contributed to the failure to influence primary and secondary outcomes . Current NHS practice dominates CASCADE ( Child and Adolescent Structured Competencies Approach to Diabetes Education ) in that it achieves the same number of QALYs at a lower cost . The mean cost of providing the intervention was £ 5098 per site or £ 683 per child . Members of paediatric diabetes services trained to deliver the CASCADE structured education package using behaviour change techniques did not improve glycaemic control in patients compared with control subjects 1 and 2 years after the intervention . The training workshops for practitioners were well evaluated ; however , more intensive training was needed . The intervention cost £ 683 per patient but was not cost-effective because it did not improve metabolic control . CONCLUSIONS A high- quality , complex , pragmatic trial of structured education can be successfully conducted alongside st and ard care in NHS diabetes clinics . Pragmatic components of a NICE-compliant structured education programme can be successfully delivered following a relatively brief 2-day training while paediatric health-care professionals benefit from training in behaviour change skills . The study provides invaluable information on barriers and opportunities regarding future , similar interventions . A low dropout rate and good attendance for the subgroup that attended the intervention suggests there might be improved uptake if offered to young people with lower HbA1c . Testing whether this approach can be more successful with a robust ongoing supervisory element should be a target of further research . TRIAL REGISTRATION Current Controlled Trials IS RCT N52537669 . FUNDING This project was funded by the NIHR Health Technology Assessment programme and will be published in full in Health Technology Assessment ; Vol . 18 , No. 20 . See the NIHR Journals Library website for further project information OBJECTIVE To assess the effectiveness of a culturally sensitive , structured education programme ( CSSEP ) on biomedical , knowledge , attitude and practice measures among Arabs with type two diabetes . RESEARCH DESIGN S AND METHODS A total of 430 patients with type II diabetes mellitus living in Doha , Qatar were enrolled in the study . They were r and omized to either intervention ( n = 215 ) or a control group  ( n = 215 ) . A baseline and one-year interval levels of biomedical variables including HbA1C , lipid profile , urine for microalbuminuria ; in addition to knowledge , attitude and practice ( KAP ) scores were prospect ively measured . The intervention was based on theory of empowerment , health belief models and was culturally sensitive in relation to language ( Arabic ) , food habits and health beliefs . It consisted of four educational sessions for each group of patients ( 10 - 20 patients per session ) , lasting for 3 - 4 h. The first session discussed diabetes pathophysiology and complications ; while the second session discussed healthy life style incorporating the Idaho plate method ; and the third session dealt with exercise benefits and goal setting and the fourth session concentrated enhancing attitude and practice using counselling techniques . Outcomes were assessed at base line and 12 months after intervention . RESULTS After 12 months participation in the intervention was shown to have led to a statistically significant reduction in HbA1C in the ( CSSEP ) group ( -0.55 mmol/L , P = 0.012 ) , fasting blood sugar ( -0.92 mmol/L , P = 0.022 ) , body mass index ( 1.70 , P = 0.001 ) and albumin/creatinine ratio ( -3.09 , P < 0.0001 ) but not in the control group . The intervention group also had improvement in Diabetes knowledge ( 5.9 % , P < 0.0001 ) , attitude ( 6.56 % , P < 0.0001 ) , and practice ( 6.52 % , P = 0.0001 ) . CONCLUSION This study demonstrates the effectiveness of culturally sensitive , structured , group-based diabetes education in enhancing biomedical and behavioural outcomes in Diabetic patients Aims Type 2 diabetes mellitus ( T2DM ) , a serious and prevalent chronic disease , is traditionally associated with older age . However , due to the rising rates of obesity and sedentary lifestyles , it is increasingly being diagnosed in the younger population . Sedentary ( sitting ) behaviour has been shown to be associated with greater risk of cardio-metabolic health outcomes , including T2DM . Little is known about effective interventions to reduce sedentary behaviour in younger adults at risk of T2DM . We aim ed to investigate , through a r and omised controlled trial ( RCT ) design , whether a group-based structured education workshop focused on sitting reduction , with self-monitoring , reduced sitting time . Methods Adults aged 18–40 years who were either overweight ( with an additional risk factor for T2DM ) or obese were recruited for the Sedentary Time ANd Diabetes ( ST AND ) RCT . The intervention programme comprised of a 3-hour group-based structured education workshop , use of a self-monitoring tool , and follow-up motivational phone call . Data were collected at three time points : baseline , 3 and 12 months after baseline . The primary outcome measure was accelerometer-assessed sedentary behaviour after 12 months . Secondary outcomes included other objective ( activPAL ) and self-reported measures of sedentary behaviour and physical activity , and biochemical , anthropometric , and psycho-social variables . Results 187 individuals ( 69 % female ; mean age 33 years ; mean BMI 35 kg/m2 ) were r and omised to intervention and control groups . 12 month data , when analysed using intention-to-treat analysis ( ITT ) and per- protocol analyses , showed no significant difference in the primary outcome variable , nor in the majority of the secondary outcome measures . Conclusions A structured education intervention design ed to reduce sitting in young adults at risk of T2DM was not successful in changing behaviour at 12 months . Lack of change may be due to the brief nature of such an intervention and lack of focus on environmental change . Moreover , some participants reported a focus on physical activity rather than reductions in sitting per se . The habitual nature of sedentary behaviour means that behaviour change is challenging . Trial Registration Controlled-Trials.com IS RCT The objective of this study was to evaluate the value of an intensive telephone follow-up as an additional component of a diabetes disease management program already shown to be effective in improving glycemic control , adherence with American Diabetes Association ( ADA ) st and ards of care , and health-related quality of life ( HRQOL ) . The study involved a r and omized controlled trial . The intervention group received a series of 12 weekly phone calls reinforcing base education and self-management skills .  Five hundred and seven consenting patients , age 18 years or older , with type 1 or type 2 diabetes mellitus referred to the hospital- based disease management program who had telephones and were able to complete surveys in English or Spanish were enrolled . Outcomes were evaluated at 3 and 12 months follow- up . Adherence to ADA st and ards of care , specifically annual eye exams , physician foot exams , foot self-exams , and pneumonia vaccination were significantly better with the added telephone intervention , but there were no differences between the groups on glycemic control , HRQOL , or patient satisfaction . The effectiveness of the disease management program was replicated with sustained improvement in glycemic control , HRQOL , and adherence to ADA st and ards . The additional telephone intervention further improved adherence to ADA guidelines for self-care and medical care but did not affect glycemic control or HRQOL Self-management has been described as the cornerstone of care for diabetes . Many self-management studies are limited by poor methodology and poor descriptions of the intervention . The current study developed a theoretically based self-management programme for patients with type 2 diabetes , which was evaluated via a r and omized controlled trial . At immediate post-intervention and three-month follow-up the intervention group showed significant improvement relative to controls on self-management behaviours , quality of life and illness beliefs . A trend towards improved HbA1c was also observed . Documentation in a manual and development of a training programme for facilitators ensures the programme is replicable BACKGROUND Reducing the impact of chronic disease in minority ethnic groups is an important public health challenge . Lay-led education may overcome cultural and language barriers that limit the effectiveness of professionally-led programmes . We report the first r and omised trial of a lay-led self-management programme - the Chronic Disease Self-Management Programme ( CDSMP ) ( Expert Patient Programme ) - in a south Asian group . AIM To determine the effectiveness of a culturally-adapted lay-led self-management programme for Bangladeshi adults with chronic disease . DESIGN OF STUDY R and omised controlled trial . SETTING Tower Hamlets , east London . METHOD We recruited Bangladeshi adults with diabetes , cardiovascular disease , respiratory disease or arthritis from general practice s and r and omised them to the CDSMP or waiting-list control .  Self-efficacy ( primary outcome ) , self-management behaviour , communication with clinician , depression scores , and healthcare use were assessed by blinded interviewer-administered question naires in Sylheti before r and omisation and 4 months later . RESULTS Of the 1363 people invited , 476 ( 34 % ) agreed to take part and 92 % ( 439/476 ) of participants were followed up . The programme improved self-efficacy ( difference : 0.67 , 95 % confidence interval [ CI ] = 0.08 to 1.25 ) and self-management behaviour ( 0.53 ; 95 % CI = 0.01 to 1.06 ) . In the 51 % ( 121/238 ) of intervention participants attending three or more of the 6-weekly education sessions the programme led to greater improvements in self-efficacy ( 1.47 ; 95 % CI = 0.50 to 1.82 ) and self-management behaviour ( 1.16 ; 95 % CI = 0.50 to 1.82 ) , and reduced HADS depression scores ( 0.64 ; 95 % CI = 0.07 to 1.22 ) . Communication and healthcare use were not significantly different between groups . The programme cost pound123 ( 181 ) per participant . CONCLUSION A culturally-adapted CDSMP improves self-efficacy and self-care behaviour in Bangladeshi patients with chronic disease . Effects on health status were marginal . Benefits were limited by moderate uptake and attendance The prevalence of type 2 diabetes continues to increase in minority and underserved patients , who are also more likely to have poorer control of diabetes and related risk factors for complications . Although the Look AHEAD trial has demonstrated improved risk factor control among overweight or obese diabetes patients who received an intensive lifestyle intervention  , translating such findings into accessible programs is a major public health challenge . The purpose of this paper is to report the design and baseline characteristics of the Lifestyle Interventions for the Treatment of Diabetes study ( LIFT Diabetes ) . The overall goal is to test the impact of a community-based lifestyle weight loss ( LWL ) intervention adapted from Look AHEAD on cardiovascular disease risk at 12-months and 24-months among minority and lower income diabetes patients . Secondary outcomes include body weight , physical activity , medication use , cost , re source utilization , and safety . The primary hypothesis being tested is that the  LWL  will result in 10 % relative reduction in CVD risk compared to the DSM . We have r and omized 260 overweight or obese adults with diabetes one of two 12-month interventions : a LWL condition delivered by community health workers or a diabetes self-management ( DSM ) education condition . The baseline demographic characteristics indicate that our sample is predominantly female , obese , low income , and ethnic minority . Translating evidence -based , lifestyle strategies , and targeting minority and underserved patients , will yield , if successful , a model for addressing the burden of diabetes and may favorably impact health disparities Background Self-management support for people with type 2 diabetes is essential in diabetes care . Thus , mobile health technology with or without low-intensity theory-based health counseling could become an important tool for promoting self-management . Objectives The aim was to evaluate whether the introduction of technology-supported self-management using the Few Touch Application ( FTA ) diabetes diary with or without health counseling improved glycated hemoglobin ( HbA1c ) levels , self-management , behavioral change , and health-related quality of life , and to describe the sociodemographic , clinical , and lifestyle characteristics of the participants after 4 months . Methods A 3-armed r and omized controlled trial was conducted in Norway during 2011 - 2013 . In the 2 intervention groups , participants were given a mobile phone for 1 year , which provided access to the FTA diary , a self-help tool that recorded 5 elements : blood glucose , food habits , physical activity , personal goal setting , and a look-up system for diabetes information . One of the intervention groups was also offered theory-based health counseling with a specialist diabetes nurse by telephone for 4 months from baseline . Both intervention groups and the  control group were provided usual care according to the national guidelines . Adults with type 2 diabetes and HbA1c ≥7.1 % were included ( N=151 ) . There were 3 assessment points : baseline , 4 months , and 1 year . We report the short-term findings after 4 months . HbA1c was the primary outcome and the secondary outcomes were self-management ( Health Education Impact Question naire , heiQ ) , behavioral change ( diet and physical activity ) , and health-related quality of life ( SF-36 question naire ) . The data were analyzed using univariate methods ( ANOVA ) , multivariate linear , and logistic regression . Results Data were analyzed from 124 individuals ( attrition rate was 18 % ) . The groups were well balanced at baseline . There were no differences in HbA1c between groups after 4 months , but there was a decline in all groups . There were changes in self-management measured using the health service navigation item in the heiQ , with improvements in the FTA group compared to the control group ( P=.01 ) and in the FTA with health counseling group compared with both other groups ( P=.04 ) . This may indicate an improvement in the ability of patients to communicate health needs to their health care providers . Furthermore , the FTA group reported higher scores for skill and technique acquisition at relieving symptoms compared to the control group ( P=.02 ) . There were no significant changes in any of the domains of the SF-36 . Conclusions The primary outcome , HbA1c , did not differ between groups after 4 months . Both of the intervention groups had significantly better scores than the control group for health service navigation and the FTA group also exhibited improved skill and technique acquisition Objective : Supporting patients ’ self care could have a major effect on the management of long-term conditions , which has led to worldwide interest in effective self care interventions . In Engl and , self care support is being developed through the “ Expert Patients Programme ” , which provides lay-led generic courses to improve patients ’ self care skills . However , the clinical and cost effectiveness of such courses remains unclear . Methods : Two-arm pragmatic r and omised controlled trial design with waiting list control in community setting s in Engl and . 629 patients with a wide range of self-defined long-term conditions were studied . The lay-led self care support group involved 6-weekly sessions to teach self care skills . Primary outcomes were self-efficacy , reported energy and routine health services utilisation at 6 months . A cost-effectiveness analysis was also conducted . Results : Patients receiving immediate course access reported considerably greater self-efficacy and energy at 6-month follow-up , but reported no statistically significant reductions in routine health services utilisation over the same time period . The cost-effectiveness analysis showed that patients receiving immediate course access reported considerably greater health related quality of life , and a small reduction in costs . If a quality adjusted life year was valued at £ 20 000 ( $ 39 191 ; € 30 282 ) , there was a 70 % probability that the intervention was cost effective . Conclusions : Lay-led self care support groups are effective in improving self-efficacy and energy levels among patients with long-term conditions , and are likely to be cost effective over 6 months at conventional values of a decision-maker ’s willingness to pay . They may be a useful addition to current services in the management of long-term conditions Context Many patients have both diabetes and depression . Some hypothesize that treating depression might improve diabetes outcomes . Contribution In this r and omized trial , 12 months of depression care management for depressed patients with diabetes improved depression-related outcomes and increased the frequency of exercise . However , care management did not affect diet , diabetes medication adherence , glucose testing , or glycemic control . Caution s The study sample had reasonably good diabetes control at baseline . Whether patients with poorly controlled diabetes would benefit from depression care is not known . The Editors Major depression and dysthymic disorder affect 5 % to 10 % of older adults seen in primary care setting s ( 1 - 3 ) .  Late-life depression  is often chronic or recurrent ( 4 - 6 ) and is associated with substantial suffering , functional impairment , and diminished health-related quality of life ( 7 ) . Diabetes mellitus affects 7.8 % of all adults and almost 1 in 5 of those age 60 years and older ( 8) . Individuals with diabetes mellitus have a 2-fold higher rate of major depression than those without diabetes ( 9 , 10 ) . Depression adversely affects the course of coexisting medical illness , contributing to increased symptom burden , functional impairment , and mortality ( 11 , 12 ) . For patients with diabetes mellitus , depression is associated with decreased glycemic control and increased number of micro- and macrovascular complications ( 13 , 14 ) . The mechanism of effect is not understood but may be related to depression-induced abnormalities in neuroendocrine and neurotransmitter function or decreased self-care behaviors ( 15 - 20 ) . Integrating evidence -based depression care for persons with diabetes may improve both depression and diabetes outcomes . Three small r and omized , controlled trials have studied the effect of treatment for  depression on affective and glycemic outcomes in patients with depression and diabetes mellitus ( 21 - 23 ) . These studies have consistently shown improvements in affective outcomes , but effects on glycemic control have been mixed . Primary care physicians are well positioned to provide integrated care for depression and diabetes mellitus but face many barriers . Controlled trials report that  treatment for depression  is efficacious in approximately 70 % of persons who complete treatment compared with 30 % of those who receive placebo ( 24 ) . However , these results are difficult to replicate in routine primary care practice . Barriers to high- quality care include suboptimal recognition ; inconsistent treatment with lack of close follow-up and monitoring ; and organizational barriers , such as brief visits , poor integration with specialty mental health care , competing clinical priorities , and lack of decision support systems ( 25 - 27 ) . Simple interventions , such as depression screening and physician education , have little impact on these barriers and patient outcomes ( 28 - 30 ) . Treatment models that use a depression specialist working collaboratively with primary care physicians have shown clinical ly important improvement in patient outcomes ( 31 - 37 ) . We recently reported robust effects of such a model for older adults with major depression or dysthymia ( 37 ) . In this preplanned analysis , we evaluate the effects on affective and diabetes-specific outcomes . If effective care for depression also benefits adherence to self-care regimens , functional status , and other medical illness outcomes , it would add powerful quality -of-care and economic incentives for the dissemination and maintenance of these models . In addition , if effective care for depression improves self-care behaviors , it may also positively affect other chronic medical illnesses with important self-care components . For this prespecified subgroup analysis , we focused on older adults with clinical depression and coexisting diabetes mellitus . We hypothesized that the collaborative care intervention would improve affective symptoms , functional status , self-care behaviors , and glycemic control . In addition , we hypothesized that effects on glycemic control would be greatest for patients with baseline hemoglobin A1c values of 8.0 % or greater . Methods The Improving MoodPromoting Access to Collaborative Treatment ( IMPACT ) study is a multisite r and omized , controlled trial of a collaborative care intervention program for late-life depression in primary care ( 37 , 38 ) . Institutional review boards at participating sites approved study protocol s , and all participants gave written informed consent . Patients Seven study sites representing 8 diverse health care organizations with a total of 18 primary care clinics in 5 states participated in the study . From July 1999 to August 2001 , depressed older adults were recruited through referrals from primary care practitioners and other clinic staff or through systematic depression screening with a 2-item depression screener adapted from the Primary Care Evaluation of Mental Disorders ( 39 ) . Of the 2190 patients referred to the study , 308 ( 14 % ) declined the initial eligibility screening or additional interviews , 54 ( 3 % ) had incomplete initial screenings , and 202 ( 9 % ) were ineligible because they were younger than 60 years of age or they did not plan to use the participating clinic over the coming 12 months . Of the 32908 patients approached for screening , 5246 ( 16 % ) declined the initial screening or follow-up interviews . A total of 1791 ( 5 % ) of the initial screenings were incomplete and 23233 ( 71 % ) of those screened were not eligible because they did not have one of the core depression symptoms ( 95 % ) or because of logistic reasons such as lack of transportation or access to a telephone ( 5 % ) . The remaining 1626 ( 74 % ) of those referred and 2638 ( 8 % ) of those screened completed a computer-assisted structured clinical interview for Diagnostic and Statistical Manual of Mental Disorders , fourth edition ( DSM-IV ) , to assess whether patients met research diagnostic criteria for major depression or dysthymia ( 40 ) . Inclusion criteria were age 60 years or older , plans to use one of the participating clinics as the main source of general medical care in the coming year , and a diagnosis of current major depression or dysthymic disorder according to the structured clinical interview for DSM-IV . Otherwise eligible persons were excluded because of a current drinking problem ( a score of 2 on the CAGE question naire ) ( 41 ) , a history of bipolar disorder or psychosis ( 38 ) , ongoing treatment with a psychiatrist , or severe cognitive impairment defined by a score less than 3 on a 6-item cognitive screener ( 42 ) . We identified 2102 eligible older adults with major depression or dysthymic disorder , of whom 1801 ( 86 % ) enrolled in the study . As part of the structured baseline interview , enrolled patients were asked Has a doctor or another health care worker diagnosed you with or treated you for high blood sugar or diabetes in the past 3 years ? The 417 patients who endorsed this question are the focus of the diabetes-specific analyses . After the baseline interview , we r and omly assigned participants to the IMPACT intervention or usual care . The r and omization was stratified by recruitment method ( screening or referral ) and clinic . R and omization information was contained in a set of numbered , sealed envelopes for each stratum that were used sequentially for newly enrolled patients at each clinic ( 38 ) . Diagnoses were communicated to enrolled patients and their primary care physicians . Intervention Patients in the intervention group received a 20-minute educational videotape and a booklet about late-life depression and were encouraged to have an initial visit with a depression care manager at the primary care clinic ( 43 , 44 ) . Care managers were nurses or psychologists who were trained for the study as a depression clinical specialist ( 38 , 45 ) . During the initial visit , the depression clinical specialist conducted a clinical and psychosocial history , review ed the educational material s , and discussed patient preferences for  depression treatment ( antidepressant medications or psychotherapy ) . New patients and patients needing treatment plan adjustments were discussed with a supervising team psychiatrist and a liaison primary care physician during a weekly team meeting . The depression clinical specialist then worked with the patient and his or her regular primary care provider to establish a treatment plan according to an evidence -based treatment algorithm ( 38 ) . The IMPACT algorithm suggested an initial choice of an antidepressant ( usually a selective serotonin reuptake inhibitor ) or a course of Problem-Solving Treatment in Primary Care ( PST-PC ) , which consisted of 6 to 8 brief sessions of structured psychotherapy for depression , delivered by the depression clinical specialist in primary care ( 46 - 49 ) . For patients who were already receiving antidepressant medications but who were still depressed , the recommendation for partial responders was to increase the dose or augment the antidepressant with a trial of PSTPC ; the recommendation for nonresponders was to switch to a different medication or use a trial of PSTPC . Depression clinical specialists also encouraged patients to increase behavioral activation and referred them to additional health or social services , as clinical ly indicated . The intervention did not specifically address diabetes mellitus or other coexisting medical illnesses . As care managers , depression clinical specialists attempted to follow patients for up to 12 months ; they monitored treatment response with the Primary Care Evaluation of Mental Disorders Patient Health Question naire ( 50 ) and a Web-based clinical information system ( 51 ) . During the acute treatment phase , in-person or telephone follow-up contacts were suggested at least every other week . Patients who recovered from depression ( 50 % reduction in the Patient Health Question naire score and <3 of 9 symptoms of major depression ) were engaged in developing a relapse prevention plan and were then Aims /hypothesisThe aim of this study was to measure the efficacy of motivational interviewing ( MI ) compared with usual care on changes in glycaemic control and competence of diabetes self-management in patients with diabetes mellitus . Methods Patients were eligible if they had type 1 or 2 diabetes mellitus , were over 18 years of age and had participated in a 4 day group education programme offered at a diabetes clinic at a university hospital in Denmark . Exclusion criteria included pregnancy , severe debilitating disease and cognitive deficit . Out of 469 patients who attended the group education programme , 349 patients were r and omised to either a usual care control group or an intervention group , which received up to five individual counselling sessions in 1 year based on MI , in addition to usual care . A r and omised parallel design was used and open-label allocation was done by r and om permuted blocks , with allocation concealment by sequentially numbered , sealed , opaque envelopes . The primary outcome was glycated haemoglobin ( HbA1c ) . Analysis regarding measurements of glycated haemoglobin ( HbA1c ) and competence of self-management ( using the Problem Areas in Diabetes Scale [ PAID ] and Perceived Competence for Diabetes Scale [ PCDS ] ) was based on 298 participants followed for a 24 month period . Data were collected at the Department of Endocrinology at Odense University Hospital . Our hypotheses were that MI could : ( 1 ) reduce HbA1c levels ; ( 2 ) increase self-efficacy ; and ( 3 ) increase diabetes self-care , compared with usual care . Results Out of the 176 included in the control group and 173 in the intervention group , 153 and 145 were analysed in the groups , respectively . When using the baseline value as covariate there were no significant differences in change score between the two study groups with regard to mean level of HbA1c ( 0.131 , p = 0.221 ) , PAID scores ( −1.793 , p = 0.191 ) or PCDS scores ( 0.017 , p = 0.903 ) at the 24 month follow-up , using a mixed effects regression model . The patients in the intervention group showed significantly higher levels of perceived competence in dealing with diabetes compared with the control group ( mean change score = −0.387 , p = 0.002 ) following 1 year of intervention . Conclusion /interpretationWe were unable to demonstrate any benefit , over or above usual care , of MI in patients with diabetes who have just completed a diabetes education programme , and who have well-regulated diabetes . Trial registration Clinical Trials NCT00555854 . Funding The National Board of Health , Funen County , Danish Association of Diabetes , Odense University Hospital , University of Southern Denmark and TRYG Fonden AIM The aim of this research is to examine the 6-month effects of an Internet-based guided self-help intervention for comorbid depressive symptoms in people with diabetes . METHODS Participants ( n = 260 ) with Type 1 or 2 diabetes and elevated depressive symptoms [ Center for Epidemiological Studies Depression Scale ( CES-D ) ≥ 23 ] were r and omly assigned to a guided Internet-based self-help intervention or a control condition ( treatment as usual + online psychoeducation about depression ) . The primary outcome was a change in depressive symptom severity ( CES-D ) from baseline to 6-month follow-up . The secondary outcomes included numbers of people achieving treatment response ( reliable change of depressive symptoms ) and remission ( CES-D ≤ 16 ) , as well as the effects on glycaemic control , diabetes-related emotional distress and diabetes acceptance . Repeated measures analysis of variance examined between-group differences using intent-to-treat principles . RESULTS Both conditions showed improvements in depression severity : intervention condition , d = 1.48 [ 95 % confidence interval ( 95 % CI ) : 1.21 to 1.76 ] ; control condition d = 0.55 ( 95 % CI : 0.30 to 0.80 ) . Changes were significantly greater in the intervention condition with a large between-group effect size ( d = 0.83 , 95 % CI : 0.57 to 1.08 ) . Accordingly , effects on response [ relative risk ( RR ) = 2.60 ( 95 % CI : 2.01 to 3.36 ) , P < 0.001 ] and remission [ RR = 3.36 ( 95 % CI : 2.98 to 5.44 ) , P < 0.001 ] were in favour of the intervention group , as were differences in change in diabetes emotional distress ( d = 0.50 , 95 % CI : 0.04 to 0.54 ) , and physical and mental functioning [ Short Form Health Survey ( SF-12 ) Physical d = 0.27 ( 95 % CI : 0.01 to 0.51 ) and SF-12 Mental d = 0.68 ( 95 % CI : 0.11 to 0.40 ) ] . The intervention group was not superior with regard to glycaemic control , diabetes self-management and diabetes acceptance . CONCLUSIONS The trial indicates that Internet-based guided self-help treatments for  depression in people with diabetes can have sustained effects on depressive symptoms , well-being and emotional distress associated with diabetes BACKGROUND Computerized decision support systems ( CDSSs ) are believed to enhance patient care and reduce healthcare costs ; however the current evidence is limited and the cost-effectiveness remains unknown . OBJECTIVE To estimate the long-term cost-effectiveness of a CDSS linked to evidence -based treatment recommendations for type 2 diabetes . METHODS Using the Ontario Diabetes Economic Model , changes in factors ( eg , HbA1c ) from a r and omized controlled trial were used to estimate cost-effectiveness . The cost of implementation , development , and maintenance of the core data set , and projected diabetes-related complications were included . The base case assumed a 1-year treatment effect , 5 % discount rate , and 40-year time horizon . Univariate , one-way sensitivity analyses were carried out by altering different parameter values . The perspective was the Ontario Ministry of Health and costs were in 2010 Canadian dollars . RESULTS The cost of implementing the intervention was $ 483,699 . The one-year intervention reduced HbA1c by 0.2 and systolic blood pressure by 3.95 mm Hg , but increased body mass index by 0.02 kg/m² , result ing in a relative risk reduction of 14 % in the occurrence of amputation . The model estimated that the intervention result ed in an additional 0.0117 quality -adjusted life year ; the incremental cost-effectiveness ratio was $ 160,845 per quality -adjusted life-year . CONCLUSION The web-based prototype decision support system slightly improved short-term risk factors . The model predicted moderate improvements in long-term health outcomes . This disease management program will need to develop considerable efficiencies in terms of costs and processes or improved effectiveness to be considered a cost-effective intervention for treating patients with type 2 diabetes Background Diabetes is now a global epidemic , but most cases are now in low- and middle-income countries . Diabetes self-management education ( DSME ) is key to enabling patients to manage their chronic condition and can reduce the occurrence of costly and devastating complications . However , there is limited evidence on the effectiveness of different DSME programmes in re source limited setting s. Methods We conducted an unblinded , parallel-group , individually-r and omised controlled trial at the University of Calabar Teaching Hospital ( Nigeria ) to evaluate whether an intensive and systematic DSME programme , using structured guidelines , improved glycaemic control compared to the existing ad hoc patient education ( clinical practice was unchanged ) . Eligible patients ( ≥18 years , HbA1c > 8.5 % and physically able to participate ) were r and omly allocated by permuted block r and omisation to participate for six months in either an intensive or conventional education group . The primary outcome was HbA1c ( % ) at six-months . Results We r and omised 59 participants to each group and obtained six-month HbA1c outcomes from 53 and 51 participants in the intensive and conventional education groups , respectively . Intensive group participants had a mean six-month HbA1c ( % ) of 8.4 ( 95 % CI : 8 to 8.9 ) , while participants in the conventional education group had a mean six-month HbA1c ( % ) of 10.2 ( 95 % CI : 9.8 to 10.7 ) . The difference was statistically ( P < 0.0001 ) and clinical ly significant , with intensive group participants having HbA1c outcomes on average -1.8 ( 95 % CI : -2.4 to -1.2 ) percentage points lower than conventional group participants . Results were robust to adjustment for a range of covariates and multiple imputation of missing outcome data . Conclusions This study demonstrates the effectiveness of a structured , guideline -based DSME intervention in a LMIC setting versus a pragmatic comparator . The intervention is potentially replicable at other levels of the Nigerian healthcare system and in other LMICs , where nurses/diabetes educators can run the programme . Trial Registration Pan African Clinical Trial Registry BACKGROUND Internet technology has been proven to be a successful tool for the management of patients with multiple medical conditions . The purpose of this study was to demonstrate the feasibility of monitoring glucose control in indigent women with gestational diabetes mellitus ( GDM ) over the Internet . METHODS Women with GDM were r and omized to either the Internet group ( n = 32 ) or the control group ( n = 25 ) . Patients in the Internet group were provided with computers and /or Internet access if needed . A website was established for documentation of glucose values and communication between the patient and the health care team . Women in the control group maintained paper logbooks , which were review ed at each prenatal visit . Maternal feelings of diabetes self-efficacy were assessed at study entry and again before delivery . RESULTS Women in the Internet group accessed the system and sent on average 21.8 ( + /- 16.9 ) sets of data . There was no difference between the two groups in regards either fasting or post-pr and ial blood glucose values , although more women in the Internet group received insulin therapy ( 31 % vs. 4 % ; P < 0.05 ) . There were also no significant differences in pregnancy and neonatal outcomes between the two groups . Women in the Internet group demonstrated significantly higher feelings of self-efficacy at the study 's end . CONCLUSIONS The benefit of monitoring blood glucose in indigent women with GDM via the Internet was limited by their infrequent use of the telemedicine system . Although system use was not associated with improved pregnancy outcomes , women in the telemedicine group did experience enhanced feelings of diabetes psychosocial self-efficacy Background Many type 2 diabetes mellitus patients face difficulties self-managing their illness , which can lead to high levels of diabetes-related distress . Diabetes distress may be decreased by peer support , as peers underst and and have dealt with similar problems , and can help motivate each other . A recent systematic review concluded that evidence of benefits of peer support in patients with type 2 diabetes mellitus is too inconsistent due to weak theoretical foundation of the interventions . This study describes the design of a trial evaluating the effectiveness of a group-based , peer support programme with a strong theoretical foundation on diabetes-related distress in type 2 diabetes patients . Methods This is a parallel group r and omised controlled trial of a six session group-based peer support intervention , delivered by peer leaders and group psychotherapists , compared with one educational meeting on diabetes .  At least 152 patients with a type 2 diabetes duration of three years or more and between 50 and 70 years of age , recruited via their general practitioner , will be r and omised to receive the peer support intervention or one educational meeting . The intervention is developed in line with three key stages of research development of the Medical Research Council framework . The primary outcome measure for this study is diabetes-related distress . Secondary outcomes include self-management behaviour , well-being and health-related quality of life . Perceived social support is a process measure . Outcomes will be measured one month before , and 6 , and 12 months after the intervention by means of self-reported question naires . Analysis will be on an intention-to-treat basis . Discussion This article contains a description of the design of a study that will investigate the effect of a group-based , peer support intervention on diabetes-related distress in type 2 diabetes patients . The intervention was developed in recognition of the limited evidence , and the importance of a theoretical foundation and its implementation . Findings will contribute to knowledge in the field of peer support and patient-important outcomes in type 2 diabetes patients .Trial registration Dutch Trial Registry : Background The benefit of self-monitoring of blood glucose ( SMBG ) in people with type 2 diabetes on diet or oral agents other than sulphonylureas  remains uncertain . Trials of interventions incorporating education about self-monitoring of blood glucose have reported mixed results . A recent systematic review concluded that SMBG was not cost-effective . However , what was unclear was whether a cheaper method of self-monitoring ( such as urine glucose monitoring ) could produce comparable benefit and patient acceptability for less cost . Methods / Design The DESMOND SMBG trial is comparing two monitoring strategies ( blood glucose monitoring and urine testing ) over 18 months when incorporated into a comprehensive self-management structured education programme . It is a multi-site cluster r and omised controlled trial , conducted across 8 sites ( 7 primary care trusts ) in Engl and , UK involving individuals with newly diagnosed Type 2 diabetes . The trial has 80 % power to demonstrate equivalence in mean HbA1c ( the primary end-point ) at 18 months of within ± 0.5 % assuming 20 % drop out and 20 % non-consent . Secondary end-points include blood pressure , lipids , body weight and psychosocial measures as well as a qualitative sub- study . Practice s were r and omised to one of two arms : participants attend a  DESMOND programme incorporating a module on self-monitoring of either urine or blood glucose . The programme is delivered by accredited educators who received specific training about equipoise . Biomedical data are collected and psychosocial scales completed at baseline , and 6 , 12 , and 18 months post programme . Qualitative research with participants and educators will explore views and experiences of the trial and preferences for methods of monitoring . Discussion The DESMOND SMBG trial is design ed to provide evidence to inform the debate about the value of self-monitoring of blood glucose in people with newly diagnosed type 2 diabetes . Strengths include a setting in primary care , a cluster design , a health economic analysis , a comparison of different methods of monitoring while controlling for other components of training within the context of a quality assured structured education programme and a qualitative sub- study .Trial registration IS RCT N : IS RCT N95696668 ABSTRACT Background : People with type 2 diabetes frequently have a variety of related and unrelated chronic conditions . These additional conditions have implication s for patient education , treatment burden and disease management . Objectives : The aim of this study was to examine the nature of multimorbidity , and its impact on GP visits , polypharmacy and glycaemic control as measured by HbA1c , in a cohort of patients with type 2 diabetes attending general practice in Irel and . Methods : A cohort of 424 patients with type 2 diabetes enrolled in a cluster r and omized controlled trial based in Irish general practice was examined . Patient data included : medical conditions , HbA1c , health service utilization , socio-economic status and number of prescribed medications . Results : 90 % of patients had at least one additional chronic condition and a quarter had four or more additional chronic conditions . 66 % of patients had hypertension ; 25 % had heart disease ; and 16 % had arthritis . General practitioner visits and polypharmacy increased significantly with increasing numbers of chronic conditions . When comparing patient self-report with medical records , patients who reported a higher proportion of their conditions had better glycaemic control with a significantly lower HbA1c score . Conclusion : There was a high prevalence of multimorbidity in these patients with type 2 diabetes and the results suggest that glycaemic control is related to patients ’ awareness of their chronic conditions . The variety of conditions emphasizes the complexity of illness management in this group and the importance of maintaining a generalist and multidisciplinary approach to their clinical care Background : The benefits of self-monitoring blood glucose levels are unclear in patients with type 2 diabetes mellitus who do not use insulin , but there are considerable costs . We sought to determine the cost effectiveness of self-monitoring for patients with type 2 diabetes not using insulin . Methods : We performed an incremental cost-effectiveness analysis of the self-monitoring of blood glucose in adults with type 2 diabetes not taking insulin . We used the United Kingdom Prospect i ve Diabetes Study ( UKPDS ) model to forecast diabetes-related complications , corresponding quality -adjusted life years and costs . Clinical data were obtained from a systematic review comparing self-monitoring with no self-monitoring .  Costs and utility decrements were derived from published sources . We performed sensitivity analyses to examine the robustness of the results . Results : Based on a clinical ly modest reduction in hemoglobin A1C of 0.25 % ( 95 % confidence interval 0.15–0.36 ) estimated from the systematic review , the UKPDS model predicted that self-monitoring performed 7 or more times per week reduced the lifetime incidence of diabetes-related complications compared with no self-monitoring , albeit at a higher cost ( incremental cost per quality -adjusted life year $ 113 643 ) . The results were largely unchanged in the sensitivity analysis , although the incremental cost per quality -adjusted life year fell within widely cited cost-effectiveness thresholds when testing frequency or the price per test strip was substantially reduced from the current levels . Interpretation : For most patients with type 2 diabetes not using insulin , use of blood glucose test strips for frequent self-monitoring ( ≥ 7 times per week ) is unlikely to represent efficient use of finite health care re sources , although periodic testing ( e.g. , 1 or 2 times per week ) may be cost-effective . Reduced test strip price would likely also improve cost-effectiveness We assessed the effectiveness of a brief structured diabetes education programme based on the concept of self-efficacy on self-care and glycaemic control using single-blind study design . One hundred and sixty-four participants with poorly controlled diabetes from two setting s were r and omized using computer-generated list into control ( n = 82 ) and intervention ( n = 82 ) groups , of which 151 completed the study . Monthly interventions over 12 weeks addressed the self-care practice s of diet , physical activity , medication adherence and self-monitoring of blood glucose ( SMBG ) . These self-care practice s were assessed at Weeks 0 and 12 using pre- and post- question naires in both groups together with glycated haemoglobin A1c ( HbA1c ) and diabetes knowledge . In the intention-to-treat analysis ( n = 164 ) , the intervention group improved their SMBG ( P = < 0.001 ) , physical activity ( P = 0.001 ) , HbA1c ( P = 0.03 ) , diabetes knowledge ( P = < 0.001 ) and medication adherence . At Week 12 , HbA1c difference adjusted for SMBG frequency , medication adherence and weight change remained significant ( P = 0.03 ) compared with control group . For within group comparisons , diabetes knowledge ( P = < 0.001 ) , HbA1c level ( P = < 0.001 ) , SMBG ( P = < 0.001 ) and medication adherence ( P = 0.008 ) improved from baseline in the intervention group . In the control group , only diabetes knowledge improved ( P = < 0.001 ) . These findings can contribute to the development of self-management diabetes education in Malaysia Objectives .The objective of this work was to evaluate the reach , effectiveness , adoption , and implementation of a brief behavioral dietary intervention and 2 supplemental components of diabetes self-management support : telephone follow-up calls and community re sources enhancement . Design and Subjects . This was a 2 × 2 r and omized , controlled trial investigating the incremental effects of telephone follow-up and community re sources enhancement with 320 adult type 2 diabetes out patients . Methods .Key outcomes included behavioral ( dietary patterns , fat intake ) , physiologic ( HbA1C , lipids ) , and quality -of-life/patient satisfaction measures and were collected at baseline and 3- and 6-month follow-up . Results .Despite high reach ( 76 % patient participation ) , excellent adoption ( all 12 primary care practice s approached participated ) , and good implementation , there were few outcome differences among treatment conditions . There was significant improvement across conditions in most outcomes in each category at both follow-ups . Conclusions .A brief , computer-assisted , dietary goal – setting intervention basic treatment condition was moderately successful in producing dietary improvements but less so in producing biologic or quality -of-life outcomes . Additions of follow-up phone calls or a community re sources enhancement component did not produce incremental improvements over this basic intervention OBJECTIVES To determine whether treating depression decreases mortality from various chronic medical conditions . DESIGN Long-term follow-up of multisite- practice r and omized controlled trial ( Prevention of Suicide in Primary Care Elderly : Collaborative Trial ) . SETTING Twenty primary care practice s r and omized to intervention or usual care . PARTICIPANTS Individuals aged 60 and older identified through depression screening of r and om patients ( N=1,226 ) . INTERVENTION For 2 years , a depression care manager worked with primary care physicians in intervention practice s to provide algorithm-based care for depression . MEASUREMENTS Mortality risk based on a median follow-up of 98 months ( range 0.8 - 116.4 months ) through 2008 ; chronic medical conditions ascertained through self-report . RESULTS For heart disease , persons with major depression were at greater risk of death , whether in usual-care or intervention practice s. Older adults with major depression and diabetes mellitus in practice s r and omized to the intervention condition ( hazard ratio=0.47 , 95 % confidence interval=0.24 - 0.91 ) were less likely to die . For other medical conditions , the point estimates for risk of death in persons with major depression were all in the direction of indicating lower risk in intervention practice s but did not reach statistical significance . CONCLUSION Older adults with depression and medical comorbidity pose a significant clinical and public health challenge . Evidence was found of a statistically significant intervention effect on mortality for diabetes mellitus in persons with major depression Intensification of insulin therapy in the Diabetes Control and Complications Trial led to an improvement in the quality of diabetes care , which was accompanied , however , by a threefold increase in the risk of severe hypoglycaemia . The present trial , a long-term evaluation of a structured 5-day treatment and teaching programme ( DTTP ) for intensified insulin therapy , was performed to clarify factors determining HbA1c , the incidence of severe hypoglycaemia , diabetes knowledge and quality of life .  Ninety-four Type 1 diabetic patients were examined at baseline and 4 years after participation in a DTTP .  Comparison of baseline data with measurements at the 4-year follow-up examination showed that relative HbA1c (= HbA1c/mean normal ) improved ( 1.9 + /- 0.51 vs 1.55 + /- 0.3 * , p < 0.001 , * excluding 4 patients with diabetes manifestation at baseline ) and that frequencies of daily insulin injections ( 3.73 + /- 1.23 vs 4.9 + /- 0.69 * , p < 0.001 ) and weekly blood glucose self-tests ( 6.6 + /- 10.1 vs 25.5 + /- 8.7 * , p < 0.001 ) increased , whereas the incidence of severe hypoglycaemia ( intravenous glucose , glucagon injection ) remained stable ( 0.19 vs 0.24 , p = 0.48 ) . Patients with less diabetes knowledge  had higher HbA1c levels and a higher incidence of severe hypoglycaemia . In the group of patients with severe hypoglycaemia , certain crucial gaps in diabetes knowledge were identified concerning the effects of physical activity , nutrition and long-term complications of diabetes . In multivariate analysis . The most important factor associated with HbA1c was diabetes knowledge which , however , was not influenced by educational level or other factors . Interventions , such as the identification of psychosocial factors which may interact with diabetes knowledge , quality of life and successful self-management of diabetes by patients , are needed to improve the efficacy of DTTPs and to prevent severe side effects such as hypoglycaemia DIABETES MELLITUS EXACTS AN ENORMOUS TOLL IN the United States by decreasing quality of life and causing death and disability , all at a huge economic cost . Yet simple diagnostic criteria and effective treatment choices that prevent or delay the onset of costly diabetes complications are readily available to health care professionals . It is time for health care professionals and patients with diabetes to take action together to reduce premature morbidity and mortality from diabetes-caused disease . The National Diabetes Education Program is the first joint diabetes initiative of the National Institutes of Health and the Centers for Disease Control and Prevention and involves public and private partnerships to promote early diagnosis and improve the treatment and outcomes for patients with type 1 and type 2 diabetes mellitus . It is estimated that in the United States , type 2 diabetes can be present for up to 9 to 12 years before initial clinical diagnosis . Microvasculardiseaseprogressesduringthis time , causing 15 % to 20 % of patients to have retinopathy and 5 % to 10%tohaveproteinuriaat the timeofdiagnosis . Patients with type 2 diabetes have high rates of hypertension , dyslipidemia , and obesity , major reasons for their 2to 4-fold higher rates ofcardiovasculardisease . Type2diabetes isoccurring increasingly in younger people . Although every patient can be expected to benefit from any increment in improved glycemic control , blood glucose control is more effective in preventing the initial development of microvascular complications than inpreventing theprogressionofcomplicationsonce theyhave become established . This finding underscores the need for aggressive treatment as soon as type 2 diabetes is diagnosed . Diabetes accounts for almost $ 100 billion in direct medical costs and indirect expenditures attributable to diabetes each year . Further , while patients with diabetes represented 4.5 % of the US population in 1992 , they accounted for 15 % of total US health care expenditures and 27 % of Medicare expenditures . There is a marked correlation between glycemic control of diabetes as measured by glycosylated hemoglobin ( HbA1c ) testing and the cost of medical care . Medical care charges increase significantly for every 1 % increase in HbA1c level above 7 % . In 1994 , excess expenditures for patients with diabetes in a managed care setting totaled $ 282.7 million or $ 3494 per person—2.4 times the cost for control subjects . Nearly 38 % of the total excess was spent treating the long-term complications of diabetes , predominantly coronary heart disease and end-stage renal disease . Because of its high and increasing prevalence , type 2 diabetes contributes a significant portion of these costs . There is substantial evidence that the human and economic burden of diabetes can be reduced significantly by early , aggressive therapeutic intervention . The Diabetes Control and Complications Trial and the United Kingdom Prospect i ve Diabetes Study ( UKPDS ) demonstrated that intensive blood glucose control for patients with type 1 and type 2 diabetes significantly reduced the risk for retinopathy , nephropathy , and neuropathy . Lowering blood pressure in a subset of UKPDS patients to a mean of 144/82 mm Hg reduced the risk of strokes , diabetes-related deaths , heart failure , microvascular complications , and vision OBJECTIVE To determine if a patient-centered , computer-assisted diabetes care intervention increased perceived autonomy support , perceived competence ( from self-determination theory ) , and if these constructs mediated the effect of the intervention on ADA/NCQA recommended diabetes care outcomes . DESIGN A r and omized controlled trial of 866 adult type 2 diabetes patients in heterogeneous primary care setting s in Colorado . MAIN OUTCOME MEASURES Perceived autonomy support , perceived competence , patient satisfaction , glycemic control ( HbA1c ) , ratio of total to HDL cholesterol , diabetes distress , and depressive symptoms . RESULTS The computer-assisted intervention increased patient perception of autonomy support relative to a computer-based control condition ( p = .05 ) . Change in perceived competence partially mediated the effects of increased autonomy support on the change in lipids , diabetes distress , and depressive symptoms . The construct of autonomy support was found to be separate from that of patient satisfaction . CONCLUSIONS A patient-centered , computer-assisted intervention was effective in improving diabetes self-management outcomes , in part , because it increased patients ' perception that their autonomy was supported which changed perceived competence . These findings support the self-determination model for health behavior change and the chronic care model and support the further study of the use of these technologies to motivate patients to improve their health outcomes Background The rising prevalence of chronic conditions constitutes a major burden for patients and healthcare systems and is predicted to increase in the upcoming decades . Improving the self-management skills of patients is a strategy to steer against this burden . This could lead to better outcomes and lower healthcare costs . Health coaching is one method for enhancing the self-management of patients and can be delivered by phone . The effects of telephone-based health coaching are promising , but still inconclusive . Economic evaluations and studies examining the transferability of effects to different healthcare systems are still rare . Aim of this study is to evaluate telephone-based health coaching for chronically ill patients in Germany . Methods / Design The study is a prospect i ve r and omized controlled trial comparing the effects of telephone-based health coaching with usual care during a 4-year time period . Data are collected at baseline and after 12 , 24 and 36 months . Patients are selected based on one of the following chronic conditions : diabetes , coronary artery disease , asthma , hypertension , heart failure , COPD , chronic depression or schizophrenia . The health coaching intervention is carried out by trained nurses employed by a German statutory health insurance . The frequency and the topics of the health coaching are manual-based but tailored to the patients ’ needs and medical condition , following the concepts of motivational interviewing , shared decision-making and evidence -based-medicine . Approximately 12,000 insurants will be enrolled and r and omized into intervention and control groups . Primary outcome is the time until hospital readmission within two years after enrolling in the health coaching , assessed by routine data . Secondary outcomes are patient-reported outcomes like changes in quality of life , depression and anxiety and clinical values assessed with question naires . Additional secondary outcomes are further economic evaluations like health service use as well as costs and hospital readmission rates . The statistical analyses includes intention-to-treat and as-treated principles . The recruitment will be completed in September 2014 . Discussion This study will provide evidence regarding economic and clinical effects of telephone-delivered health coaching . Additionally , this study will show whether health coaching is an adequate option for the German healthcare system to address the growing burden of chronic diseases . Trial registration German Clinical Trials Register ( Deutsches Register Klinischer Studien ; DRKS ) DRKS00000584 Context Patient self-management is an essential component of asthma care , and the Internet is a medium to potentially support patients in self-management . Contribution This r and omized trial compared Internet-based asthma self-management with usual care and found modest improvements in asthma control and lung function with the Internet intervention , but found no reduction in exacerbations and changes in asthma-related quality of life that were less than clinical ly significant at 12 months . Implication Although Internet-based self management can improve some asthma outcomes , the improvements were small and the program did not reduce the number of exacerbations . The Editors Asthma is a chronic disorder of the airways that is characterized by recurring respiratory symptoms , variable airflow obstruction , airway hyperresponsiveness , and underlying inflammation ( 1 , 2 ) . Recent clinical guidelines for the management of asthma distinguish 4 essential components of asthma care : assessment and monitoring , patient education , control of environmental and comorbid factors that affect asthma , and drug treatment . With appropriate medical care , well-informed and empowered patients can control their asthma and live full , active lives ( 1 , 2 ) . However , despite the availability of monitoring tools and effective therapy , asthma control is suboptimal in many patients worldwide , and long-term management falls far short of the goals set in the guidelines ( 3 ) . Self-monitoring , education , and specific medical care are important aspects in improving the lives of patients with asthma ( 1 , 2 ) . However , many patients with mild or moderate persistent asthma do not attend checkups regularly or visit their physician with symptoms of the disease ( 4 ) . In addition , in practice , both patients and their health care providers are reluctant to use written self-management plans ( 5 ) . Internet technology is increasingly seen as an appealing tool to support self-management for patients with chronic disease in remote and underserved population s ( 68 ) . However , to date , studies on Internet-based asthma self-management show only short-term improvements in asthma control , lung function , and quality of life ( 911 ) . Long-term studies on the effect of Internet-based self-management , including all its essential features , are not available . Therefore , we developed a guided self-management tool for adult patients with asthma that included Internet-based home monitoring and treatment advice ( action plan ) , online education , and remote Web communication with a specialized asthma nurse . The goal of our study was to assess the long-term clinical effectiveness of  Internet-based self-management education  compared with usual physician-provided care alone . Methods Design Overview We conducted a 12-month , multicenter , nonblinded , r and omized , controlled trial . We r and omly assigned patients to Internet-based self-management ( Internet group ) as an adjunct to usual care or to usual physician-provided care alone ( usual care group ) . The Internet-based self-management program included weekly asthma control monitoring and treatment advice , online and group education , and remote Web communications with a specialized asthma nurse . The intervention continued for 12 months after enrollment . The Medical Ethics Committee of the Leiden University Medical Center , Leiden , the Netherl and s , approved the study . Setting and Participants We recruited patients from 37 general practice s ( 69 general practitioners ) in the Leiden and The Hague area and the Outpatient Clinic of the Department of Pulmonology at the Leiden University Medical Center from September 2005 to September 2006 . Inclusion criteria were physician-diagnosed asthma coded according to the International Classification of Primary Care in the electronic medical record ( 12 ) , age 18 to 50 years , prescription of inhaled corticosteroids for at least 3 months in the previous year , no serious comorbid conditions that interfered with asthma treatment , access to the Internet at home , and mastery of the Dutch language . We excluded patients who were receiving maintenance oral glucocorticosteroid treatment .  On the basis of diagnosis , age , prescribed asthma medication , and comorbid conditions , we sent eligible patients an invitation letter followed by 1 reminder letter after 2 to 4 weeks if they did not respond to the first . We continued this process until a total of 200 patients had entered the study ( September 2006 ) . All participants gave written consent . R and omization and Intervention In a 2-week baseline period before r and omization , we collected data on patient demographic characteristics , asthma-related quality of life , symptom control , lung function , and medication level . We provided basic education about core information on asthma , action of medications , and inhaler technique instructions to all patients . We trained all participants to measure FEV1 daily with a h and -held electronic spirometer ( PiKo-1 , Ferraris Respiratory , Hertford , United Kingdom ) and to report the highest value of 3 measurements in the morning before taking medication ( 2 , 13 ) . They were shown how to report these values on a personal page on a secure Web application by using a login password ( or how to report by mobile telephone text message ) . Patients were also asked to report their nighttime and daytime asthma symptom scores on this Internet page or by text message . We asked all participants to complete the Asthma Control Question naire on their personal Internet page each week ( 14 ) . We did not give any patients feedback about lung function or asthma control . After the 2-week baseline period , we r and omly assigned participants to either the Internet group or the usual care group . We stratified according to care provider ( primary vs. subspecialty care ) and asthma control at baseline ( 15 ) . We r and omly assigned patients to the 2 groups ( 1:1 ratio ) by using a computer-generated , permuted-block scheme . Allocation took place by computer after collection of the baseline data , ensuring concealment of allocation . The Internet-based self-management program consisted of the 4 principal components of asthma self-management and was accessed through the specially design ed Web site , which allowed monitoring through the Web site ( or text message on a mobile telephone ) , use of an Internet-based treatment plan , online education , and Web communications with a specialized asthma nurse ( 16 ) . Patients monitored their asthma weekly by completing an electronic version of the Asthma Control Question naire on the Web site and instantly received feedback on the current state of their asthma control along with advice on how to adjust their treatment according to a predefined algorithm and treatment plan ( Table 1 and Appendix Figures 1 , 2 , 3 , 4 , and 5 ) . Depending on the scores su bmi tted , patients received 4 types of self-treatment advice . When 4 consecutive Asthma Control Question naire scores were 0.5 or less , patients were advised to decrease treatment according to treatment plan . When 2 consecutive scores were greater than 0.5 but less than 1.0 , patients were advised to increase treatment according to treatment plan . When 1 score was 1.0 or more but less than 1.5 , patients were advised to immediately increase treatment according to treatment plan . Finally , when 1 score was 1.5 or more , patients were advised to immediately increase treatment and contact the asthma nurse . Table 1 . Treatment Plan Appendix Figure 1 . Algorithm based on consecutive ACQ scores to adjust medical treatment . * ACQ = Asthma Control Question naire . At entry of the algorithm , the evaluation period is bypassed . The evaluation period starts after treatment was stepped up . The optimal control period starts after 1 ACQ score 0.5 and ends after 1 ACQ score > 0.5 . Appendix Figure 2 . Screen shot of daily lung function and symptom monitoring . Appendix Figure 3 . Screen shot of feedback on daily lung function and symptom monitoring . Appendix Figure 4 . Screen shot of weekly Asthma Control Question naire monitoring . Appendix Figure 5 . Screen shot of feedback on Asthma Control Question naire , treatment advice according to personalized treatment plan , and results of past 6 months . We advised no medication changes during the 4 weeks after treatment was stepped up ( evaluation period ) . In addition to weekly assessment s , patients could optionally report daily symptoms and lung function and were able to contact our asthma nurse though the Web or by telephone . Thus , any acute deterioration warranting a visit to the general practitioner or hospital could be detected ( Appendix Figures 2 and 3 ) . We aim ed to empower patients to use the Internet-based self-management tool and to develop a patientprovider partnership in asthma care ( 2 ) . Self-management education consisted of both Web-based and face-to-face , group-based education . Web-based education included asthma information , news , frequently asked questions , and interactive communication with a respiratory nurse specialist . We scheduled 2 group-based education sessions , which lasted 45 to 60 minutes , for patients in the  Internet-based self-management group  within 6 weeks after entering the trial . Both sessions included exploration of a patient 's interests and previous knowledge ( negotiating an agenda and patient-centered education ) , personalized feedback , and empowerment of self-management ( self-efficacy and implementing a plan for change ) ( 2 , 17 ) . The first educational session also included pathophysiology of asthma , information on the  Web-based action plan  , and information and review of inhalation technique .  The second educational session gave information about the mechanisms and side effects of medication and explained trigger avoidance . Patients in the usual care group received asthma care according to the Dutch general practice guidelines on asthma management in adults , which recommend a medical review and treatment adjustment every 2 to 4 weeks in unstable asthma and medical review once or twice AIMS Education is an essential part of the management of patients with Type 2 diabetes , but the long-term effects are unclear and not well investigated in primary care . METHODS Fifty-four patients ( 39 - 75 years ) treated with maximal dosages of oral hypoglycaemic agents , needing to start insulin ( HbA(1c ) > or = 7.0 % ) , were r and omly allocated to a 6-month educational programme by a diabetes nurse ( DN group ) or usual care ( UC group ) . Main outcome measures were HbA(1c ) , number of patients with HbA(1c ) < 7.0 % , and number of patients treated with insulin 18 months after baseline . RESULTS Six weeks after the intervention HbA(1c ) levels had improved from 8.2 ( 1.1 ) to 7.2 ( 1.3 ) in the DN group , and from 8.8 ( 1.5 ) to 8.4 ( 1.7 ) in the UC group . Adjusted for baseline values , at 6 weeks HbA(1c ) improved 0.7 % ( 95 % confidence interval 0.1 , 1.4 ) more in DN than in UC . Of the patients in DN , 60 % reached HbA(1c ) < 7.0 % compared with 17 % in UC ( P < 0.01 ) . However , at 18 months there were no significant differences for HbA(1c ) , number of patients with HbA(1c ) < 7.0 % , or number treated with insulin . CONCLUSIONS Education was effective in improving glycaemic control and in delaying the need for insulin therapy in patients treated with maximal oral hypoglycaemic therapy . The reduced effect after 1 year was probably due to the discontinuation of the educational programme . Short-term education should not be offered without regular reinforcements integrated into st and ard diabetes care Background The childhood obesity epidemic is one of the foremost UK health priorities . Childhood obesity tracks into adult life and places individuals at considerable risk for diabetes , cardiovascular disease , liver disease and other morbidities . There is widespread need for paediatric lifestyle programmes as change may be easier to accomplish in childhood than later in life . Study Design / Method The study will evaluate the management of adolescent obesity by conducting a Medical Research Council complex intervention phase III efficacy r and omised clinical trial of the Healthy Eating Lifestyle Programme within primary care . The study tests a community delivered multi-component intervention design ed for adolescents developed from best practice as identified by National Institute for Health and Clinical Excellence . The hospital based pilot reduced body mass index and improved health-related quality of life . Subjects will be individually r and omised to receiving either the Healthy Eating Lifestyle Programme ( 12 fortnightly family sessions ) or enhanced st and ard care . Baseline and follow up assessment s will be undertaken blind to allocation status . A health economic evaluation is also being conducted.200 obese young people ( 13 - 17 years , body mass index > 98th centile for age and sex ) will be recruited from primary care within the greater London area . The primary hypothesis is that a motivational and solution-focused family-based weight management programme delivered over 6 months is more efficacious in reducing body mass index in obese adolescents identified in the community than enhanced st and ard care . The primary outcome will be body mass index at the end of the intervention , adjusted for baseline body mass index , age and sex . The secondary hypothesis is that the Healthy Eating Lifestyle Programme is more efficacious in improving quality of life and psychological function and reducing waist circumference and cardiovascular risk factors in obese adolescents than enhanced st and ard care assessed at 6 and 12 months post baseline assessment .Improvement in quality of life predicts on-going lifestyle change and maximises the chances of long-term weight reduction . We will explore whether improvement in QOL may be intermediate on the pathway between the intervention and body mass index change . Trial registration IS RCT N : IS RCT Patient empowerment through self-management education is central to improving the quality of diabetes care and preventing Type 2 Diabetes .  Although national programs exist , there is no EU-wide strategy for diabetes self-management education , and patients with limited literacy face barriers to effective self-management . The Diabetes Literacy project , initiated with the support of the European Commission , aims to fill this gap . The project investigates the effectiveness of diabetes self-management education , targeting people with or at risk of Type 2 Diabetes in the 28 EU Member States , as part of a comprehensive EU-wide diabetes strategy . National diabetes strategies in the EU , US , Taiwan , and Israel are compared , and diabetes self-management programs inventorized . The costs of the diabetes care pathway are assessed on a per person basis at national level . A comparison is made of the (cost)-effectiveness of different methods for diabetes self-management support , and the moderating role of health literacy , organization of the health services , and implementation fidelity of education programs are considered . Web-based material s are developed and evaluated by r and omized trials to evaluate if interactive internet delivery can enhance self-management support for people with lower levels of health literacy . The 3-year project started in December 2012 . Several literature review s have been produced and protocol development and research design are in the final stages . Primary and secondary data collection and analysis take place in 2014 . The results will inform policy decisions on improving the prevention , treatment , and care for persons with diabetes across literacy levels OBJECTIVE The primary objective of this study was to assess and compare the knowledge of diabetes mellitus possessed by patients with diabetes and healthy adult volunteers in Penang , Malaysia . METHOD A cross-sectional study was conducted from 20 February 2006 to 31 March 2006 . We r and omly selected 120 patients with diabetes mellitus from a diabetic clinic at the General Hospital Penang , Malaysia and 120 healthy adults at a shopping complex in Penang . Each participant was interviewed face-to-face by a pharmacist using a vali date d question naire , and they were required to answer a total of 30 questions concerning knowledge about diabetes mellitus using Yes , No or Unsure as the only response . RESULTS The results showed that patients with diabetes mellitus were significantly more knowledgeable than the healthy volunteers about risk factors , symptoms , chronic complications , treatment and self-management , and monitoring parameters . Educational level was the best predictive factor for diabetes mellitus and public awareness . CONCLUSION Knowledge about diabetes mellitus should be improved among the general population . PRACTICE IMPLICATION S This study has major implication s for the design of an educational programme for diabetics and a health promotion programme as a primary prevention measure for the healthy population in general , and especially for those at high risk . The results could be useful in the design of future studies for evaluating patients ' and the general public 's knowledge about diabetes mellitus Purpose With growing numbers of people at risk for diabetes and cardiovascular disease , diabetes educators report increasing referrals for intervention in prevention of these conditions . Diabetes educators have expertise in diabetes self-management education ; however , they are generally not prepared for delivery of chronic disease primary prevention . The purpose of this project was to determine if individuals at risk for diabetes who participate in an intervention delivered by trained diabetes educators in existing diabetes self-management education community-based programs can reduce risk factors for diabetes and cardiovascular disease . Methods Diabetes educators in 3 outpatient-hospital programs ( urban , suburban , and rural ) received training and support for implementation of the Group Lifestyle Balance program , an adaptation of the Diabetes Prevention Program lifestyle intervention , from the Diabetes Prevention Support Center of the University of Pittsburgh . Adults with prediabetes and /or the metabolic syndrome were eligible to enroll in the program with physician referral . With use of existing diabetes educator networks , recruitment was completed via on-site physician in-services , informative letters , and e-mail contact as well as participant-directed newspaper advertisement . Results Eighty-one participants enrolled in the study ( 71 women , 10 men ) .  Mean overall weight loss was 11.3 lb ( 5.1 % , P < .001 ) ; in addition , significant decreases were noted in fasting plasma glucose , low-density lipoprotein cholesterol , triglycerides , and blood pressure . Conclusions These results suggest that the Group Lifestyle Balance program delivered by diabetes educators was successful in reducing risk for diabetes and cardiovascular disease in high-risk individuals . Furthermore , diabetes educators , already integrated within the existing health care system , provide yet another re source for delivery of primary prevention programs in the community 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 BACKGROUND Despite extensive efforts and advances in evidence -based diabetes management , poor glycaemic control still remains a challenge in many countries . There is a paucity of research addressing the needs of patients with poorly controlled type 2 diabetes , or exploring the effectiveness of empowerment-based interventions in this vulnerable population . OBJECTIVES To evaluate the effectiveness of a patient-centred , empowerment-based programme on  glycaemic control and self-management behaviours among patients with poorly controlled type 2 diabetes . DESIGN A prospect i ve multi-centre , single-blind , r and omised controlled trial . SETTING S AND PARTICIPANTS Adult patients with poorly controlled type 2 diabetes [ Haemoglobin A1c ( HbA1c ) ≥7.5 % in the recent six months ] were recruited from two tertiary hospitals in Xi'an city , China . METHODS A total of 242 eligible patients were recruited and r and omly assigned to the intervention or attentional control groups after baseline measurement . Participants in the intervention group received a 6-week patient-centred , empowerment-based self-management programme , which is theoretically grounded on the principles of the Empowerment Process Model- setting personally meaningful goals , taking action towards goals and reflecting on the impact of action plans . Those in the attentional control group received health education classes and post-discharge follow-up . Outcome measures included glycaemic control ( measured by HbA1c ) and self-management behaviours . Data were collected at baseline , and at 8th and 20th week after enrolment . Intervention effect were analysed using the generalised estimating equation model on the basis of the intention-to-treat principle . RESULTS Compared with the attention control group , the intervention group showed a non-significant HbA1c reduction of 0 . 476 % ( Cohen 's d effect size=0.31 , p=0.162 ) . The intervention group exhibited significant improvements in general diet management at the 8th-week ( β=0.740 ; p=0.013 ) , specific diet management at 8th-week ( β=0.646 ; p=0.022 ) and 20th-week ( β=0.517 ; p=0.043 ) , and blood glucose self-monitoring at both the 8th- ( β=0.793 ; p=0.009 ) and 20th-week ( β=0.739 ; p=0.017 ) follow-ups . No intervention-related adverse events were observed . CONCLUSIONS Findings indicate that the patient-centred , empowerment-based self-management intervention program did not induce a significant HbA1c reduction . Whereas this intervention yields improvements in diet management and blood glucose self-monitoring among patients with poorly controlled type 2 diabetes This pilot study evaluated an innovative diabetes symptom awareness and self-management educational program for Mexican Americans , a fast growing minority population experiencing a diabetes epidemic . Patients with diabetes need assistance interpreting and managing symptoms , which are often annoying and potentially life-threatening . A repeated measures r and omized controlled trial was conducted with 72 Mexican Americans aged 25 - 75 years with type 2 diabetes . Experimental condition participants received eight weekly , in-home , one-on-one educational and behavior modification sessions with a registered nurse focusing on symptom awareness , glucose self-testing and appropriate treatments , followed by eight biweekly support telephone sessions . Wait-listed control condition participants served as comparisons at three time points . Hierarchical linear modeling was used to evaluate the effects of the intervention between- and within groups on psychosocial , behavioral and clinical outcomes .  Participants were predominantly female , middle-aged , moderately acculturated and in poor glycemic control . Experimental group participants ( n = 39 ) significantly improved glycemic control , blood pressure , symptoms , knowledge , self-efficacy , empowerment and quality of life . Post intervention focus groups reported satisfaction with the symptom focus . Addressing symptoms led to clinical and psychosocial improvements . Symptoms seem to be an important motivator and a useful prompt to engage patients in diabetes self-management behaviors to relieve symptoms and prevent complications Background Universal screening using the International Association of Diabetes and Pregnancy Study Groups ( IADPSG ) criteria has identified a prevalence of gestational diabetes mellitus ( GDM ) of 12.4 % in women living in Irel and . Women with prior GDM are at increased risk of developing type 2 diabetes later in life . A number of risk factors linked to the development of type 2 diabetes are potentially modifiable through lifestyle and behaviour changes , and medical management . No previous Irish studies have adequately investigated the efficacy of lifestyle intervention programmes in reducing these risk factors in women with prior GDM . Through a two-group , parallel r and omised controlled trial ( RCT ) , this study aims to assess the clinical impact , cost-effectiveness and psychological experience of the Croí MyAction intensive lifestyle modification programme for women with prior GDM . Methods / Design A total of 54 women with a history of GDM and persistent post-partum glucose dysfunction ( impaired glucose tolerance ( IGT ) or impaired fasting glucose ( IFG ) ) , are r and omly assigned to a  control arm ( n = 27 ) or to the Croí MyAction intervention group ( n = 27 ) . The control arm receives usual health care advice - written information on diet and lifestyle changes for reducing diabetes risks and visits with general practitioners as required . The intervention group receives usual health care as per the control group in addition to attending a 12-week intensive lifestyle modification programme known as Croí MyAction . Croí MyAction involves 2.5 hour sessions once per week ( for 12 weeks ) comprising a group exercise programme , group health promotion or education seminars , and one-to-one meetings with a multidisciplinary health care team to personalise risk factor reductions . R and omisation and allocation to the intervention arms is carried out by an independent research er , ensuring that the allocation sequence is concealed from study research ers until the interventions are assigned . The primary analysis is based on glucose dysfunction , comparing a mean reduction in fasting plasma glucose ( FPG ) levels on a 75 gram oral glucose tolerance test ( OGTT ) in the two groups at a one-year , post-intervention follow-up . The trial is funded by the Irish Health Research Board ( HRB ) . Ethics approval was obtained on 27 March 2012 from the Clinical Research Ethics Committee , Galway University Hospitals , Health Service Executive of Irel and ( Ref : C.A.691).Trial registration Current Controlled Trials IS RCT N41202110 OBJECTIVE In this secondary analysis , we examined whether older adults with diabetes ( aged 60–75 years ) could benefit from self-management interventions compared with younger adults . Seventy-one community-dwelling older adults and 151 younger adults were r and omized to attend a structured behavioral group , an attention control group , or one-to-one education . RESEARCH DESIGN AND METHODS We measured A1C , self-care ( 3-day pedometer readings , blood glucose checks , and frequency of self-care ) , and psychosocial factors ( quality of life , diabetes distress , frustration with self-care , depression , self-efficacy , and coping styles ) at baseline and 3 , 6 , and 12 months postintervention . RESULTS Both older ( age 67 ± 5 years , A1C 8.7 ± 0.8 % , duration 20 ± 12 years , 30 % type 1 diabetes , 83 % white , 41 % female ) and younger ( age 47 ± 9 years , A1C 9.2 ± 1.2 % , 18 ± 12 years with diabetes , 59 % type 1 diabetes , 82 % white , 55 % female ) adults had improved A1C equally over time . Importantly , older and younger adults in the group conditions improved more and maintained improvements at 12 months ( older structured behavioral group change in A1C −0.72 ± 1.4 % , older control group −0.65 ± 0.9 % , younger behavioral group −0.55 ± 1.2 % , younger control group −0.43 ± 1.7 % ) . Furthermore , frequency of self-care , glucose checks , depressive symptoms , quality of life , distress , frustration with self-care , self-efficacy , and emotional coping improved in older and younger participants at follow-up . CONCLUSIONS The findings suggest that , compared with younger adults , older adults receive equal glycemic benefit from participating in self-management interventions . Moreover , older adults showed the greatest glycemic improvement in the two group conditions . Clinicians can safely recommend group diabetes interventions to community-dwelling older adults with poor glycemic control Background Coronary Heart Disease and Cerebrovascular Disease share many predisposing , modifiable risk factors ( hypertension , abnormal blood lipids and lipoproteins , cigarette smoking , physical inactivity , obesity and diabetes mellitus ) . Lifestyle interventions and pharmacological therapy are recognised as the cornerstones of secondary prevention . Cochrane review has proven the benefits of programmes incorporating exercise and lifestyle counselling in the cardiac disease population . A Cochrane review highlighted as priority , the need to establish feasibility and efficacy of exercise based interventions for Cerebrovascular Disease . Methods A single blind r and omised controlled trial is proposed to examine a primary care cardiac rehabilitation programme for adults post transient ischemic attack ( TIA ) and stroke in effecting a positive change in the primary outcome measures of cardiac risk scores derived from Blood Pressure , lipid profile , smoking and diabetic status and lifestyle factors of habitual smoking , exercise and healthy eating participation . Secondary outcomes of interest include health related quality of life as measured by the Hospital Anxiety and Depression Scale , the Stroke Specific Quality of Life scale and WONCA COOP Functional Health Status charts and cardiovascular fitness as measured by a sub-maximal fitness test .  A total of 144 patients , over 18 years of age with confirmed diagnosis of ischaemic stroke or TIA , will be recruited from Dublin community stroke services and two tertiary T.I.A clinics . Exclusion criteria will include oxygen dependence , unstable cardiac conditions , uncontrolled diabetes , major medical conditions , claudication , febrile illness , pregnancy or cognitive impairment . Participants will be block-statified , r and omly allocated to one of two groups using a pre-prepared computer generated r and omisation schedule . Both groups will receive a two hour education class on  risk reduction  post stroke  .  The intervention group will receive a 10 week programme of supervised aerobic exercises ( twice weekly ) and individually tailored brief intervention lifestyle counselling . Both groups will be tested on week one and week ten of the programme . Follow-up at 1 year will assess longer term benefits . Analysis will test for significant changes in the key variables indicated . Discussion Application of the Cardiac Rehabilitation paradigm to patients with ischaemic stroke or TIA has not been explored despite the obvious overlap in aetiology . It is hoped the anticipated improvement in vascular risk factors and fitness result ing from such a programme will enhance health and social gain in this population .Trial Registration Current Controlled Trials ISCTRN90272638 BACKGROUND & OBJECTIVES Community health workers ( CHWs ) may be an important mechanism to provide diabetes self-management to disadvantaged population s. We describe the design and baseline results of a trial evaluating a home-based CHW intervention . METHODS & RESEARCH DESIGN Peer Support for Achieving Independence in Diabetes ( Peer-AID ) is a r and omized , controlled trial evaluating a home-based CHW-delivered diabetes self-management intervention versus usual care . The study recruited participants from 3 health systems .  Change in A1c measured at 12 months is the primary outcome . Changes in blood pressure , lipids , health care utilization , health-related quality of life , self-efficacy and diabetes self-management behaviors at 12 months are secondary outcomes . RESULTS A total of 1438 patients were identified by a medical record review as potentially eligible , 445 patients were screened by telephone for eligibility and 287 were r and omized . Groups were comparable at baseline on socio-demographic and clinical characteristics . All participants were low-income and were from diverse racial and ethnic background s. The mean A1c was 8.9 % , mean BMI was above the obese range , and non-adherence to diabetes medications was high . The cohort had high rates of co-morbid disease and low self-reported health status . Although one-third reported no health insurance , the mean number of visits to a physician in the past year was 5.7 . Trial results are pending . CONCLUSIONS Peer-AID recruited and enrolled a diverse group of low income participants with poorly controlled type 2 diabetes and delivered a home-based diabetes self-management program . If effective , replication of the Peer-AID intervention in community based setting s could contribute to improved control of diabetes in vulnerable population BACKGROUND Diabetes is a chronic disease , with high prevalence across many nations , which is characterized by elevated level of blood glucose and risk of acute and chronic complication . The Kingdom of Saudi Arabia ( KSA ) has one of the highest levels of diabetes prevalence globally . It is well-known that the treatment of diabetes is complex process and requires both lifestyle change and clear pharmacologic treatment plan . To avoid the complication from diabetes , the effective behavioural change and extensive education and self-management is one of the key approaches to alleviate such complications . However , this process is lengthy and expensive . The recent studies on the user of smart phone technologies for diabetes self-management have proven to be an effective tool in controlling hemoglobin ( HbA1c ) levels especially in type-2 diabetic ( T2D ) patients . However , to date no reported study addressed the effectiveness of this approach in the in Saudi patients . This study investigates the impact of using mobile health technologies for the self-management of diabetes in Saudi Arabia . METHODS In this study , an intelligent mobile diabetes management system ( SAED ) , tailored for T2D patients in KSA was developed . A pilot study of the SAED system was conducted in Saudi Arabia with 20 diabetic patients for 6 months duration . The patients were r and omly categorized into a control group who did not use the SAED system and an intervention group whom used the SAED system for their diabetes management during this period . At the end of the follow-up period , the HbA1c levels in the patients in both groups were measure together with a diabetes knowledge test was also conducted to test the diabetes awareness of the patients . RESULTS The results of SAED pilot study showed that the patients in the intervention group were able to significantly decrease their HbA1c levels compared to the control group . The SAED system also enhanced the diabetes awareness amongst the patients in the intervention group during the trial period . These outcomes confirm the global studies on the effectiveness of smart phone technologies in diabetes management . The significance of the study is that this was one of the first such studies conducted on Saudi patients and of their acceptance for such technology in their diabetes self-management treatment plans . CONCLUSIONS The pilot study of the SAED system showed that a mobile health technology can significantly improve the HbA1C levels among Saudi diabetic and improve their disease management plans . The SAED system can also be an effective and low-cost solution in improving the quality of life of diabetic patients in the Kingdom considering the high level of prevalence and the increasing economic burden of this disease ABSTRACT BACKGROUND Churches may provide a familiar and accessible setting for chronic disease self-management education and social support for Latinos with diabetes . OBJECTIVE We assessed the impact of a multi-faceted church-based diabetes self-management intervention on diabetes outcomes among Latino adults . DESIGN This was a community-based , r and omized controlled , pilot study .SUBJECTSOne-hundred adults with self-reported diabetes from a Midwestern , urban , low-income Mexican-American neighborhood were included in the study . INTERVENTIONS Intervention participants were enrolled in a church-based diabetes self-management program that included eight weekly group classes led by trained lay leaders . Enhanced usual care participants attended one 90-minute lecture on diabetes self-management at a local church . OUTCOME MEASURES The primary outcome was change in glycosylated hemoglobin ( A1C ) . Secondary outcomes included changes in low-density lipoproteins ( LDL ) , blood pressure , weight , and diabetes self-care practice s . KEY RESULTS Participants ’ mean age was 54 ± 12 years , 81 % were female , 98 % were Latino , and 51 % were uninsured . At 3 months , study participants in both arms decreased their A1C from baseline ( −0.32 % , 95 % confidence interval [ CI ] : -0.62 , -0.02 % ) . The difference in change in A1C , LDL , blood pressure and weight from baseline to 3-month and 6-month follow-up was not statistically significant between the intervention and enhanced usual care groups . Intervention participants reported fewer days of consuming high fat foods in the previous week ( −1.34 , 95 % CI : -2.22 , -0.46 ) and more days of participating in exercise ( 1.58 , 95 % CI : 0.24 , 2.92 ) compared to enhanced usual care from baseline to 6 months . CONCLUSIONS A pilot church-based diabetes self-management intervention did not reduce A1C , but result ed in decreased high fat food consumption and increased participation in exercise among low-income Latino adults with diabetes .  Future church-based interventions may need to strengthen linkages to the healthcare system and provide continued support to participants to impact clinical outcomes Background Diabetes is becoming a very important health issue in rapidly developing nations and there is an urgent need to improve overall diabetes self-management education in these countries . Although e-health is an emerging theme , only a few successful web-based studies on diabetes self-management have been reported . Purpose We describe the development , implementation , and process evaluation of an Internet-delivered dietary intervention program ( myDIDeA ) for diabetic patients in a developing country . MethodS pecific dietary components to be included in the intervention module were first identified through a comprehensive review of literature and guidelines . The lesson plans and the study website were then developed based on the evidence , Transtheoretical Model ’s Stages of Change and user-centered design approach . Finally , the effectiveness of the website was tested through a r and omized-controlled trial to promote dietary change in patients with type 2 diabetes . The participants in the intervention group ( n = 66 ) were given access to myDIDeA for 6 months . Process evaluation in form of intervention adherence and program reception were conducted at post intervention . Results The response rate for the process evaluation was 89 % . On average , each participant logged in at least once for each lesson plan and spent almost 12 min on the site . The participants ’ content satisfaction , acceptability , and usability scores were satisfactory . The primary outcome of the trial , Dietary Knowledge , Attitude , and Behavior score was strongly correlated with content satisfaction ( r = 0.826 , p < 0.001 ) , acceptability ( r = 0.793 , p < 0.001 ) and usability of the website ( r = 0.724 , p < 0.001 ) , and moderately correlated with frequency of log-in ( r = 0.501 , p < 0.05 ) and duration spent in the website ( r = 0.399 , p < 0.05 ) . Conclusion The process evaluation of myDIDeA demonstrates its feasibility , and future studies should identify the possibility of extending the use of Internet-based intervention programs to other health behaviors and issues related to self-management of chronic conditions . In addition , interactivity , peer support via social media , and other means to stimulate the interest of participants can be explored Introduction : Diabetes is a chronic disease associated with high morbidity and mortality , which represents a major public health concern . Interventions that can enhance patient care and reduce clinic visits will not only relieve some of this burden , they will also improve patient QOL and wellbeing . Aims : This review assesses the evidence for the use of insulin glargine in type 1 and type 2 diabetes mellitus . Evidence review : Once-daily insulin glargine has a prolonged , peakless activity profile , making it a c and i date as a long-acting ( basal ) insulin . In combination with bolus insulin to cover pr and ial glucose surges , it facilitates a more physiologic approach to patient management . Evidence from large , r and omized , controlled clinical trials in patients with type 1 diabetes has confirmed its effectiveness and tolerability relative to neutral protamine hagedorn ( NPH ) insulin , with a tendency toward causing less hypoglycemia . In patients with type 2 diabetes requiring insulin therapy , once-daily insulin glargine has proven to be clinical ly superior to NPH insulin in terms of providing at least as effective glycemic control , but with significantly fewer episodes of nocturnal hypoglycemia . A variety of economic analyses have confirmed the cost effectiveness of insulin glargine in type 1 and type 2 diabetes and in particular it was shown to be significantly superior to NPH insulin . Clinical value : Insulin glargine has established itself as a first-line choice in patients with type 1 diabetes , including children ( > 6 years ) and adolescents , and is a recommended treatment option . In patients with type 2 diabetes it is clearly associated with less hypoglycemia than NPH insulin , and this may help overcome one of the major barriers to starting insulin therapy in this class of patient . Thus , insulin glargine is a valuable addition to the therapeutic armamentarium available to physicians and it has the potential to significantly improve the quality of life of patients with diabetes Chronic hepatitis C ( HCV ) infection afflicts millions of people worldwide . While antiviral treatments are effective for some patients , many either can not or choose not to receive antiviral treatment . Education about behavioural changes like alcohol avoidance and symptom management , in contrast , is universally recommended , particularly in HCV-infected persons from disadvantaged groups where liver risk factors are most prevalent .  Self-management interventions are one option for fostering improved HCV knowledge and health-related quality of life ( HRQOL ) .  One hundred and thirty-two patients with VA with HCV ( mean age of 54.6 , 95 % men , 41 % ethnic minority , 83 % unmarried , 72 % unemployed/disabled , 48 % homeless in last 5 years ) were r and omized to either a 6-week self-management workshop or an information-only intervention . The weekly 2-h self-management sessions were based on cognitive-behavioural principles and were adapted from an existing self-management programme that has been efficacious with other chronic diseases . HCV-specific modules were added . Outcomes including HRQOL , HCV knowledge , self-efficacy , depression , energy and health distress were measured at baseline and 6 weeks later . Data were analysed using ANOVA . When compared to the information-only group , participants attending the self-management workshop improved more on HCV knowledge ( P < 0.001 ) , HCV self-efficacy ( P = 0.011 ) , and SF-36 energy/vitality ( P = 0.040 ) . Similar trends were found for SF-36 physical functioning ( P = 0.055 ) and health distress ( P = 0.055 ) . Attending the self-management programme improved disease knowledge and HRQOL 6 weeks later in this disadvantaged population . The intervention can improve the health of  people with hepatitis C , independent of antiviral therapy . Future research will study longer-term outcomes , effects on antiviral treatment and costs 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 AIMS The Families , Adolescents and Children 's Teamwork Study ( FACTS ) is a family-centred structured education programme for children and adolescents with Type 1 diabetes . It aims to integrate group-based diabetes education into routine care , enhance parental responsibility for self management and improve glycaemic control . METHODS A r and omized wait-list control group study allocated participants to either the immediate ( four educational sessions during year 1 ) or delayed intervention ( four educational sessions during year 2 ) . In both groups , glycated haemoglobin ( HbA1c ) was measured 3-monthly and participants completed the  Paediatric Quality of Life Inventory ( PedsQL ) , Problem Areas in Diabetes Scale ( PAID ) and Diabetes Family Responsibility Question naire ( DFRQ ) before and after the intervention . RESULTS Intention-to-treat analysis showed no significant difference in HbA1c or parental responsibility between participants r and omized to the immediate or delayed programme . However , during 12 months ' follow-up , families who attended > or = 2 sessions reported increased parental involvement ( P = 0.01 ) , and in children/adolescents who attended > or = 2 sessions HbA1c fell by 0.29 % compared with an increase of 0.11 % in non-attenders ( P = 0.04 ) . CONCLUSION This family-centred education programme has been integrated into paediatric diabetes care with potential benefits on parental involvement and glycaemic control , but further study is warranted before routine application into clinical care Introduction We investigated the experience of individuals diagnosed with type 2 diabetes mellitus ( T2DM ) who participated in an intervention in which the key elements were the provision of a smartphone and self-monitoring software .  The interviews focused on use of a smartphone and the effects on motivation for health behavior change . Methods This was a qualitative evaluation of participants in a larger T2DM self-management r and omized controlled trial ( RCT ) conducted at the Black Creek Community Health Centre ( BCCHC ) in Toronto , Canada ( Clinical Trials.gov Identifier : NCT02036892 ) . The study is based on semi-structured interviews ( n = 11 ) that were audio taped and analyzed with a thematic analytic approach . The RCT compared the effectiveness of six months of smartphone-based self-monitoring and health coaching with a control group who received health coaching without internet or smartphone-based assistance . Results Qualitative data analyses result ed in derivation of four major themes that describe participant experience : ( a ) ‘ smartphone and software ’ , describes smartphone use in relation to health behavior change ; ( b ) ‘ health coach ’ describes how client/health coach relationships were assisted by smartphone use ; ( c ) ‘ overall experience ’ describes perceptions of the overall intervention ; and ( d ) ‘ frustrations in managing chronic conditions ’ describes difficulties with the complexities of T2DM management from a patient perspective . Discussion Findings suggest that interventions with T2DM assisted by smartphone software and health coaches actively engage individuals in improved hemoglobin A1c ( HbA1c ) control BACKGROUND Type 2 diabetes is an individual health challenge requiring ongoing self-management . Remote patient reporting of relevant health parameters and linked automated feedback via mobile telephone have potential to strengthen self-management and improve outcomes . This research involved development and evaluation of a mobile telephone-based remote patient reporting and automated telephone feedback system , guided by health behavior change theory , aim ed at improving self-management and health status in individuals with type 2 diabetes . SUBJECTS AND METHODS This research comprised a r and omized controlled trial . Inclusion criteria were diagnosis of type 2 diabetes , elevated glycosylated hemoglobin ( HbA1c ) levels ( range , 6.5 - 11 % ) or use of oral diabetes medication , and 30 - 70 years of age . Intervention subjects ( n=24 ) participated in remote patient reporting of health status parameters and linked health behavior change feedback . Control participants ( n=24 ) received st and ard of care including diabetes education and healthcare provider counseling . Patients were followed for approximately 10 months . RESULTS Intervention participants achieved , compared with controls and controlling for baseline , a significantly greater mean reduction in HbA1c of -0.40 % ( 95 % confidence interval [ CI ] -0.67 % to -0.14 % ) versus 0.036 % ( 95 % CI -0.23 % to 0.30 % ) ( P<0.03 ) and significantly greater weight reduction of -2.1 kg ( 95 % CI -3.6 to -0.6 kg ) versus 0.4 kg ( 95 % CI -1.1 to 1.9 kg ) . Nonsignificant trends for greater intervention compared with control improvement in systolic and diastolic blood pressure were observed . CONCLUSIONS Sophisticated information technology platforms for remote patient reporting linked with theory-based health behavior change automated feedback have potential to improve patient outcomes in type 2 diabetes and merit scaled-up research efforts Background Diabetes is a chronic medical condition accompanied by a considerable health-related quality of life ( HRQL ) burden . The purpose of this analysis was to use generic measures of HRQL to describe HRQL deficits associated with varying degrees of severity of type 2 diabetes . Methods The R AND -12 physical and mental health composites ( PHC and MHC , respectively ) and Health Utilities Index Mark 3 ( HUI3 ) were self-completed by 372 subjects enrolled in a prospect i ve , controlled study of an intervention to improve care for individuals with type 2 diabetes in rural communities . Analysis of covariance was used to assess differences in HRQL according to disease severity and control of blood glucose . Disease severity was defined in terms of treatment intensity , emergency room visits and absenteeism from work specifically attributable to diabetes . To control for potential confounding , the analysis was adjusted for important sociodemographic and clinical characteristics . Results The PHC and MHC were significantly lower for individuals treated with insulin as compared to diet alone ( PHC : 41.01 vs 45.11 , MHC : 43.23 vs 47.00 , p < 0.05 ) . Individuals treated with insulin had lower scores on the vision , emotion and pain attributes of the HUI3 than individuals managed with oral medication or diet . The PHC , MHC , pain attribute and overall score on the HUI3 captured substantial decrements in HRQL associated with absenteeism from work due to diabetes , while the burden associated with emergency room utilization for diabetes was seen in the PHC and HUI3 pain attribute . Conclusions We concluded that generic measures of HRQL captured deficits associated with more severe disease in type 2 diabetes Background In Shanghai there are 1.2 million people with hypertension , many of whom have difficulty in affording medical treatment . Community based , anti-hypertensive clubs have been created to provide health education but education alone is often ineffective . Lifestyle change programmes have shown some potential for reducing blood pressure but in previous trials have required specialist staff and extensive contact . We have previously demonstrated that self-management programmes delivered by health professionals , such as a nurse who has had short training in self-management techniques can change health behaviour and reduce symptoms . This study was design ed to evaluate the benefits of a simple , cognitive-behavioural , self-management programme for hypertension based around a hypertension manual and delivered in the setting of a community anti-hypertensive club in Shanghai . Method The method was a pragmatic r and omised controlled trial with an intention-to-treat analysis . Adult patients with mild-to-moderate primary hypertension , waiting to join a neighbourhood anti-hypertension club , were r and omised to the self-management programme or to an information only control procedure . They attended the group treatment sessions on 4 occasions over 5 weeks for education combined with goal setting for lifestyle change and an introduction to exercise . The main outcome measures were : changes in blood pressure ; blood total cholesterol ; diet ; activity level and health related quality of life 1 month and 4 months after the end of treatment . Results A total of 140 adults with mild-to-moderate primary hypertension took part . All of the main outcomes showed beneficial changes . Four months after the end of treatment the mean blood pressure differences between groups were systolic 10.15 mm Hg ( P < 0.001 , 95 % CI 7.25–13.05 ) , and diastolic 8.29 mmHg ( P < 0.001 , 95 % CI 6.71–9.88 ) . Patients in the intervention group also had significantly reduced weight , lowered blood total cholesterol , increased physical activity and improved quality of life . Conclusion Patients with mild-to-moderate primary hypertension attending a 5 week , group and manual based , cognitive-behavioural self-management programme , delivered through a voluntary club in Shanghai experienced a significant reduction in blood pressure . Trial registration Current Controlled Trials IS RCT
There were three reported  deaths out of 3578 participants .Computer-based  diabetes self-management interventions currently have limited effectiveness .
Current interventions do not show adequate evidence for improving depression , health-related quality of life or weight .
AUTHORS ' CONCLUSIONS Computer-based diabetes self-management interventions to manage type 2 diabetes appear to have a small beneficial effect on blood glucose control and the effect was larger in the mobile phone subgroup .
There is no evidence to show benefits in other biological outcomes or any cognitive , behavioural or emotional outcomes
BACKGROUND Diabetes is one of the commonest chronic medical conditions , affecting around 347 million adults worldwide .
Structured patient education programmes reduce the risk of diabetes-related complications four-fold .
Internet-based self-management programmes have been shown to be effective for a number of long-term conditions , but it is unclear what are the essential or effective components of such programmes .
If computer-based self-management interventions improve outcomes in type 2 diabetes , they could potentially provide a cost-effective option for reducing the burdens placed on patients and healthcare systems by this long-term condition .
OBJECTIVES To assess the effects on health status and health-related quality of life of computer-based diabetes self-management interventions for adults with type 2 diabetes mellitus .