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Effectiveness of short message service-based intervention (SMS) on self-care in type 2 diabetes: A feasibility study. EMPOWER: a randomized trial using community health workers to deliver a lifestyle intervention program in African American women with Type 2 diabetes: design, rationale, and baseline characteristics. A randomized trial of regular standardized telephone contact by a diabetes nurse educator in adolescents with poor diabetes control. Randomized controlled trial of a family-oriented self-management program to improve self-efficacy, glycemic control and quality of life among Thai individuals with Type 2 diabetes. Literacy and health outcomes: a cross-sectional study in 1002 adults with diabetes Web-based comprehensive information system for self-management of diabetes mellitus. Dosage effects of diabetes self-management education for Mexican Americans: the Starr County Border Health Initiative. Prospective Randomized Controlled Trial to Evaluate Effectiveness of Registered Dietitian–Led Diabetes Management on Glycemic and Diet Control in a Primary Care Setting in Taiwan Health and Psychosocial Outcomes of a Telephonic Couples Behavior Change Intervention in Patients With Poorly Controlled Type 2 Diabetes: A Randomized Clinical Trial Challenges and lessons learned in the development and implementation of a couples-focused telephone intervention for adults with type 2 diabetes: the Diabetes Support Project Peer-Led, Empowerment-Based Approach to Self-Management Efforts in Diabetes (PLEASED): A Randomized Controlled Trial in an African American Community Diabetes management in a health maintenance organization. Efficacy of care management using cluster visits. Intensive telephone follow-up to a hospital-based disease management model for patients with diabetes mellitus. 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Rationale and design: telephone-delivered behavioral skills interventions for Blacks with type 2 diabetes A Low-Intensity Mobile Health Intervention With and Without Health Counseling for Persons With Type 2 Diabetes, Part 1: Baseline and Short-Term Results From a Randomized Controlled Trial in the Norwegian Part of RENEWING HEALTH A Self-Management Intervention for African Americans With Comorbid Diabetes and Hypertension: A Pilot Randomized Controlled Trial Computer-assisted intervention improves patient-centered diabetes care by increasing autonomy support. Efficacy of self-monitoring blood glucose as a key component of a chronic care model versus usual care in type 2 diabetes patients treated with oral agents: results of a randomized trial Is Self-Monitoring of Blood Glucose Appropriate for All Type 2 Diabetic Patients? A randomized trial of a primary care-based disease management program to improve cardiovascular risk factors and glycated hemoglobin levels in patients with diabetes. Explaining engagement in self-monitoring among participants of the DESMOND Self-monitoring Trial: a qualitative interview study. Do automated calls with nurse follow-up improve self-care and glycemic control among vulnerable patients with diabetes? A randomized controlled trial of telephone calls to young patients with poorly controlled type 1 diabetes. Impact of a goal setting and decision support telephone coaching intervention on diet, psychosocial, and decision outcomes among people with type 2 diabetes. Supported self-management for adults with type 2 diabetes and a learning disability (OK-Diabetes): study protocol for a randomised controlled feasibility trial Imbedding Interdisciplinary Diabetes Group Visits Into a Community-Based Medical Setting The OnTrack Diabetes Web-Based Program for Type 2 Diabetes and Dysphoria Self-Management: A Randomized Controlled Trial Protocol An Internet-Based Program to Improve Self-Management in Adolescents With Type 1 Diabetes Correlates of Medication Nonadherence Among Latinos With Type 2 Diabetes Motivational Enhancement Therapy with and without Cognitive Behavior Therapy to Treat Type 1 Diabetes Poor Cognitive Function and Risk of Severe Hypoglycemia in Type 2 Diabetes The Cholesterol, Hypertension, And Glucose Education (CHANGE) study: results from a randomized controlled trial in African Americans with diabetes. 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Glycemia treatment strategies in the Action to Control Cardiovascular Risk in Diabetes (ACCORD) trial. Integrating an Automated Diabetes Management System Into the Family Management of Children With Type 1 Diabetes Diabetes self-management education improves quality of care and clinical outcomes determined by a diabetes bundle measure Texas-Mexico Border Intervention by Promotores for Patients With Type 2 Diabetes Clinical Inertia Contributes to Poor Diabetes Control in a Primary Care Setting Impact of MyCareTeam for poorly controlled diabetes mellitus. A Randomized Controlled Trial of Cognitive Behavioral Therapy for Adherence and Depression (CBT-AD) in Patients With Uncontrolled Type 2 Diabetes
This study compared an activation intervention to passive education in a r and omized attention-control trial of 232 patients with type 2 diabetes . The activation intervention was based on Exp and ing Patient Involvement in Care ( EPIC ) trials , and was compared to time-matched passive education viewing of ADA video-tapes . Patient demographics and clinical characteristics of their diabetes were assessed with question naires , active involvement was assessed via ratings of taped interactions between patients and providers , and serum sample s were analyzed for HbA1c . Patients in the activation condition were rated as more actively involved in discussion s of diabetes self-management , and rated active involvement was predictive of improvement in glycemic control . No effect of the activation intervention was found on HbA1c . Thus , the activation intervention increased the active involvement of patients with type 2 diabetes in visits with practitioners , and active involvement led to improved glycemic control . However , the activation intervention did not improve glycemic control directly OBJECTIVE This study evaluated the Diabetes Outpatient Intensive Treatment ( DOIT ) program , a multiday group education and skills training experience combined with daily medical management , followed by case management over 6 months . Using a r and omized control design , the study explored how DOIT affected glycemic control and self-care behaviors over a short term . The impact of two additional factors on clinical outcomes were also examined ( frequency of case management contacts and whether or not insulin was started during the program ) . RESEARCH DESIGN AND METHODS Patients with type 1 and type 2 diabetes in poor glycemic control ( A1c > 8.5 % ) were r and omly assigned to DOIT or a second condition , entitled EDUPOST , which was st and ard diabetes care with the addition of quarterly educational mailings . A total of 167 patients ( 78 EDUPOST , 89 DOIT ) completed all baseline measures , including A1c and a question naire assessing diabetes-related self-care behaviors . At 6 months , 117 patients ( 52 EDUPOST , 65 DOIT ) returned to complete a follow-up A1c and the identical self-care question naire . RESULTS At follow-up , DOIT evidence d a significantly greater drop in A1c than EDUPOST . DOIT patients also reported significantly more frequent blood glucose monitoring and greater attention to carbohydrate and fat contents ( ACFC ) of food compared with EDUPOST patients . An increase in ACFC over the 6-month period was associated with improved glycemic control among DOIT patients . Also , the frequency of nurse case manager follow-up contacts was positively linked to better A1c outcomes . The addition of insulin did not appear to be a significant contributor to glycemic change . CONCLUSIONS DOIT appears to be effective in promoting better diabetes care and positively influencing glycemia and diabetes-related self-care behaviors . However , it dem and s significant time , commitment , and careful coordination with many health care professionals . The role of the nurse case manager in providing ongoing follow-up contact seems important Background Persistently poor glycemic control in adult type 1 diabetes patients is a common , complex , and serious problem initiating significant damage to the cardiovascular , renal , neural , and visual systems . Currently , there is a plethora of low-cost and free diabetes self-management smartphone applications available in online stores . Objective The aim of this study was to examine the effectiveness of a freely available smartphone application combined with text-message feedback from a certified diabetes educator to improve glycemic control and other diabetes-related outcomes in adult patients with type 1 diabetes in a two-group r and omized controlled trial . Methods Patients were recruited through an online type 1 diabetes support group and letters mailed to adults with type 1 diabetes throughout Australia . In a 6-month intervention , followed by a three-month follow-up , patients ( n=72 ) were r and omized to usual care ( control group ) or usual care and the use of a smartphone application ( Glucose Buddy ) with weekly text-message feedback from a Certified Diabetes Educator ( intervention group ) . All outcome measures were collected at baseline and every three months over the study period . Patients ’ glycosylated hemoglobin levels ( HbA1c ) were measured with a blood test and diabetes-related self-efficacy , self-care activities , and quality of life were measured with online question naires . Results The mean age of patients was 35.20 years ( SD 10.43 ) ( 28 male , 44 female ) , 39 % ( 28/72 ) were male , and patients had been diagnosed with type 1 diabetes for a mean of 18.94 years ( SD 9.66 ) . Of the initial 72 patients , 53 completed the study ( 25 intervention , 28 control group ) . The intervention group significantly improved glycemic control ( HbA1c ) from baseline ( mean 9.08 % , SD 1.18 ) to 9-month follow-up ( mean 7.80 % , SD 0.75 ) , compared to the control group ( baseline : mean 8.47 % , SD 0.86 , follow-up : mean 8.58 % , SD 1.16 ) . No significant change over time was found in either group in relation to self-efficacy , self-care activities , and quality of life . Conclusions In adjunct to usual care , the use of a diabetes-related smartphone application combined with weekly text-message support from a health care professional can significantly improve glycemic control in adults with type 1 diabetes . Trial Registration Australian New Zeal and Clinical Trials Registry : ACTRN12612000132842 ; https://www.anzctr.org.au/Trial/ Registration /Trial Review .aspx?ACTRN=12612000132842 ( Archived by WebCite at http://www.webcitation.org/6Kl4jqn5u ) OBJECTIVE To evaluate whether assessment of barriers to self-care and strategies to cope with these barriers in older adults with diabetes is superior to usual care with attention control . The American Diabetes Association guidelines recommend the assessment of age-specific barriers . However , the effect of such strategy on outcomes is unknown . RESEARCH DESIGN AND METHODS We r and omized 100 subjects aged ≥69 years with poorly controlled diabetes ( A1C > 8 % ) in two groups . A geriatric diabetes team assessed barriers and developed strategies to help patients cope with barriers for an intervention group . The control group received equal amounts of attention time . The active intervention was performed for the first 6 months , followed by a “ no-contact ” period . Outcome measures included A1C , Tinetti test , 6-min walk test ( 6MWT ) , self-care frequency , and diabetes-related distress . RESULTS We assessed 100 patients ( age 75 ± 5 years , duration 21 ± 13 years , 68 % type 2 diabetes , 89 % on insulin ) over 12 months . After the active period , A1C decreased by −0.45 % in the intervention group vs. −0.31 % in the control group . At 12 months , A1C decreased further in the intervention group by −0.21 % vs. 0 % in control group ( linear mixed-model , P < 0.03 ) . The intervention group showed additional benefits in scores on measures of self-care ( Self-Care Inventory-R ) , gait and balance ( Tinetti ) , and endurance ( 6MWT ) compared with the control group . Diabetes-related distress improved in both groups . CONCLUSIONS Only attention between clinic visits lowers diabetes-related distress in older adults . However , communication with an educator cognizant of patients ’ barriers improves glycemic control and self-care frequency , maintains functionality , and lowers distress in this population AIMS Care management may improve the quality of diabetes care by enhancing contact between high-risk patients and their providers . This prospect i ve , longitudinal , r and omized trial sought to investigate whether telephone or online care management improves diabetes-related outcomes over time compared with usual care supplemented with Internet access and training . SUBJECTS AND METHODS One hundred fifty-one adult subjects with type 2 diabetes mellitus and an elevated hemoglobin A1c ( A1c ) level ( ≥8.5 % ) were r and omly assigned to  online care management ( n=51 ) , telephone-based care management ( n=51 ) , or Web training ( n=49 ) groups . Online and telephone participants interacted with a care manager through a diabetes education and care management Web site and by telephone , respectively . The Web training group was provided with online diabetes self-management re sources but no care management support . The primary outcome measure was A1c measured every 3 months for a year . RESULTS A1c declined significantly and substantially in all groups over 12 months . A1c declined linearly at a rate of 0.32 % ( P<0.0001 ) per quarter for the online group , 0.36 % ( P<0.0001 ) for the telephone group , and 0.41 % for the Web training group ( P<0.0001 ) . The rate of change over time did not differ significantly among groups . The groups converged at 12 months with average absolute A1c difference of -1.5 % . The number of interactions with care providers was not significantly associated with the change in A1c . Blood pressure , weight , lipid levels , and diabetes distress did not differ among groups over time . CONCLUSIONS Online , telephone-based care management , and Web training for diabetes patients with elevated A1c were each associated with a substantial improvement in A1c over a 1-year period . Internet access and training alone may be as effective as care management in patients with poorly controlled diabetes OBJECTIVE Examine influences of diabetes-specific social support ( D-SS ) and depressive symptoms on glycemic control over time , among adults r and omized to a diabetes self-management education and support ( DSME/S ) intervention or usual care .  METHODS Data were from 108 African-American and Latino participants in a 6-month intervention trial . Multivariable linear regression models assessed associations between baseline D-SS from family and friends and depressive symptoms with changes in HbA1c . We then examined whether baseline D-SS or depression moderated intervention-associated effects on HbA1c . RESULTS Higher baseline D-SS was associated with larger improvements in HbA1c ( adjusted ΔHbA1c -0.39 % for each + 1-point D-SS , p=0.02 ) , independent of intervention-associated HbA1c decreases . Baseline depressive symptoms had no significant association with subsequent HbA1c change . Neither D-SS nor depression moderated intervention-associated effects on HbA1c . CONCLUSIONS AND PRACTICE IMPLICATION S Diabetes self-management education and support programs have potential to improve glycemic control for participants starting with varying levels of social support and depressive symptoms . Participants starting with more support for diabetes management from family and friends improved HbA1c significantly more over 6 months than those with less support , independent of additional significant DSME/S intervention-associated HbA1c improvements . Social support from family and friends may improve glycemic control in ways additive to 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 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 Native Hawaiians and other Pacific Isl and ers ( NH/PI ; e.g. , Samoan and Chuukese ) have higher type 2 diabetes prevalence compared to other groups in Hawai‘i . Partners in Care ( PIC ) , a culturally tailored , community-based , diabetes self-management education intervention ( DSME ) , is effective at improving participants ' glycemic control and self-care behaviors . Maintenance of improvements is challenging . Diabetes-related social support groups ( SSG ) are a promising maintenance component for DSME . This study examined the effects of a diabetes-specific SSG component relative to a control group , after the receipt of the 3-month PIC intervention , which was delivered to 47 adult NH/PI with type 2 diabetes . Participants were then r and omized to either a 3-month , 6-session SSG or a control group .  Hemoglobin A1c ( HbA1c ) , blood pressure , triglycerides , cholesterol , and diabetes self-management knowledge and behaviors were assessed at baseline , 3 months , and 6 months . Results indicated significant improvements in HbA1c , diabetes-related self-management knowledge , and behaviors from baseline to 3-month assessment . However , no differences between the SSG and control group from 3-month to 6-month assessment suggest that all participants were able to maintain initial improvements . The SSG group had a significant decrease in systolic blood pressure from 3-month to 6-month assessment while the control group did not . Study limitations and future directions are discussed Purpose The purpose of the study was to investigate the effects of a family-based self-management support intervention for adults with type 2 diabetes ( T2DM ) . Methods Using a 2-group , experimental repeated measures design , 157 dyads ( participant with T2DM and family member ) were r and omly assigned to an intervention ( education , social support , home visits , and telephone calls ) or a wait list control group . Data were collected at baseline , postintervention ( 3 months ) , and 6 months postintervention . A series of 2 × 3 repeated measures ANOVAs were used to test the hypotheses with interaction contrasts to assess immediate and sustained intervention effects . Results Significant changes over time were reported in diet self-management , exercise self-management , total self-management , diabetes self-efficacy for general health and total diabetes self-efficacy , physician distress , regimen distress , interpersonal distress , and total distress . There were likewise sustained effects for diet self-management , total self-management , diabetes self-efficacy for general health , total self-efficacy , physician distress , regimen distress , and interpersonal distress . Conclusions Results support and extend prior research documenting the value of culturally relevant family-based interventions to improve diabetes self-management and substantiate the need for intensive , longer , tailored interventions to achieve glycemic control Objective : To assess quality of life ( QoL ) and glycemic control in adolescents with type 1 diabetes and to investigate the impact of an educational program . Methods : A quasiexperimental study with nonr and omized experimental and control groups was conducted in which a total of 503 adolescents with type 1 diabetes completed a question naire using the Diabetes Quality of Life Instrument for Youth . Adolescents were then assigned to experimental and control groups . The experimental group was subjected to four 120-minute sessions of an educational program over a period of 4 months . Extracted medical chart data included the duration of diabetes , insulin dosage , and most recent hemoglobin A1c levels . Analysis of covariance was used to detect the impact of intervention . Results : The overall mean QoL score ( % ) was 76.51 ± 9.79 , with good QoL in 38 % of all adolescents . Poorer QoL was significantly associated with older age ( P < 0.001 ) , more hospital admissions in the last 6 months ( P = 0.006 ) , higher levels of depression ( P < 0.001 ) , poor self-esteem ( P < 0.001 ) , and poor self-efficacy ( P < 0.001 ) . There was significant deterioration in all domains of QoL in the experimental group after intervention . However , this deterioration was significantly less severe than in the control group . Between-group effects on total knowledge , adherence to exercise , glucose monitoring , treatment , self-efficacy , family contribution to management , glycemic control , and satisfaction with life were significantly in favor of the experimental group . Conclusion : Education intervention for adolescents with type 1 diabetes could be a safeguard against possible deterioration in QoL and glycemic control over time OBJECTIVE To test whether adding mobile application coaching and patient/provider web portals to community primary care compared with st and ard diabetes management would reduce glycated hemoglobin levels in patients with type 2 diabetes . RESEARCH DESIGN AND METHODS A cluster-r and omized clinical trial , the Mobile Diabetes Intervention Study , r and omly assigned 26 primary care practice s to one of three stepped treatment groups or a control group ( usual care ) . A total of 163 patients were enrolled and included in analysis . The primary outcome was change in glycated hemoglobin levels over a 1-year treatment period . Secondary outcomes were changes in patient-reported diabetes symptoms , diabetes distress , depression , and other clinical ( blood pressure ) and laboratory ( lipid ) values . Maximal treatment was a mobile- and web-based self-management patient coaching system and provider decision support . Patients received automated , real-time educational and behavioral messaging in response to individually analyzed blood glucose values , diabetes medications , and lifestyle behaviors communicated by mobile phone . Providers received quarterly reports summarizing patient ’s glycemic control , diabetes medication management , lifestyle behaviors , and evidence -based treatment options . RESULTS The mean declines in glycated hemoglobin were 1.9 % in the maximal treatment group and 0.7 % in the usual care group , a difference of 1.2 % ( P = 0.001 ) over 12 months . Appreciable differences were not observed between groups for patient-reported diabetes distress , depression , diabetes symptoms , or blood pressure and lipid levels ( all P > 0.05 ) . CONCLUSIONS The combination of behavioral mobile coaching with blood glucose data , lifestyle behaviors , and patient self-management data individually analyzed and presented with evidence -based guidelines to providers substantially reduced glycated hemoglobin levels over 1 year Purpose The purpose of this study was to examine the impact of family and friends on the management of persons with diabetes  and their willingness to be involved in a culturally tailored program . Methods This qualitative study was based within a larger quasi-experimental study that focused on the impact of a culturally tailored group intervention compared with individual st and ard diabetes education on the outcomes of self-management and glycemic control among rural African Americans with type 2 diabetes . Twenty-one participants were r and omly assigned to an individual education group or a culturally tailored intervention group . Family members/ peers ( n = 6 ) attended invited group sessions to obtain information about diabetes and family/peer support . The facilitator of the invited group sessions used a guide to help with group discussion s. The investigators used an iterative approach to enhance the examination of the responses from the discussion guide , thus identifying recurring themes within the participants ' responses . Results The data revealed that family and friends made a difference in the diabetes management of individuals with dia- betes . Although family and friends may have been helpful at times , they also created moments of problems and an environment that made it more difficult to care for diabetes . The data also revealed that diabetes is hard to manage and control . Participants reported that taking medications and being aware of types of foods to keep a well-maintained glucose level were often challenging . Conclusions These findings confirm that family and peers greatly influence diabetes management among rural African Americans . The study 's results will help health care providers underst and the importance of involving family members and friends in the treatment and diabetes management of individuals with type 2 diabetes , particularly within rural African American communities where re sources are limited OBJECTIVE : To determine the impact of clinical pharmacists involved in direct patient care on the glycemic control of patients with type 2 diabetes mellitus . DESIGN : Eligible patients included those with type 2 diabetes who received insulin or were initiated on insulin therapy by the pharmacists and were willing to perform self-monitoring of blood glucose . The pharmacists provided diabetes education , medication counseling , monitoring , and insulin initiation and /or adjustments . All initial patient interactions with the pharmacists were face-to-face . Thereafter , patient – pharmacist interactions were either face-to-face or telephone contacts . SETTING : Two primary care clinics in a university-affiliated Veterans Affairs Medical Center . PARTICIPANTS : Study subjects were patients with type 2 diabetes who were referred to the pharmacists by their primary care providers for better glycemic control . OUTCOME MEASURES : Primary outcome variables were changes from baseline in glycosylated hemoglobin , fasting blood glucose , and r and om blood glucose measurements . Secondary outcomes were the number and severity of symptomatic episodes of hypoglycemia , and the number of emergency room visits or hospitalizations related to diabetes . Twenty-three veterans aged 65 ± 9.4 years completed the study . Fifteen ( 65 % ) patients were initiated on insulin by the pharmacists ; 8 ( 35 % ) were already using insulin . Patients were followed for a mean ± SD of 27 ± 10 weeks . Glycosylated hemoglobin , fasting blood glucose concentrations , and r and om blood glucose concentrations significantly decreased from baseline by 2.2 % ( p = 0.00004 ) , 65 mg/dL ( p < 0.01 ) , and 82 mg/dL ( p = 0.00001 ) , respectively . Symptomatic hypoglycemic episodes occurred in 35 % of patients . None of these episodes required physician intervention . CONCLUSIONS : This study demonstrates that pharmacists working as members of interdisciplinary primary care teams can positively impact glycemic control in patients with type 2 diabetes requiring insulin Purpose The purpose of the study was to test the feasibility and efficacy of a diabetes self-management and education program for Chinese Americans in a support group format . The rationale for the study was to create culturally appropriate diabetes education and management programs in response to the growing diabetes prevalence among Chinese Americans . The investigators hypothesized that participants will have improved diabetes knowledge and practice s , hemoglobin A1C , and social support . The study objectives were at least : 50 % will have significant improvements in diabetes knowledge and practice activities , 30 % of participants will have significant improvements in A1C , and 50 % will report a gain in emotional support . Methods The program consisted of 12 90-minute diabetes education and support group sessions offered in a medical office setting . The sample included 23 Chinese Americans with either type 1 or type 2 diabetes . Using a single-group , pre-post test design , A1C and diabetes knowledge were assessed at baseline and 6 months . Data were collected through clinical assessment s and written question naires . Results The results indicated high attendance and statistically significant increases in glycemic control and diabetes knowledge . Statistically insignificant differences were shown in diabetes management practice s. Secondary outcomes assessed participants ’ perceived diabetes management and emotional and social support . Conclusions Diabetes Self-Management : A Cultural Approach ( DSMCA ) support group model demonstrates that a culturally tailored support group utilizing a community-based participatory research approach is an effective format to improve diabetes self-management skills among Chinese Americans . The program can be adapted for other ethnic population s. The efficacy of the intervention can be further tested in larger r and omized trials Background : In order to optimize care and improve outcomes in people with diabetes , adequate access to health care facilities and re sources for self-management is required . Methods : Data on 3369 individuals with type 2 diabetes who received education at 7 diabetes centers were collected prospect ively between June 2005 and January 2007 . The driving distances of subjects who were in good control [ hemoglobin A1c ( A1C ) > 7.0 % ] were compared with the driving distances of those who were not ( A1C > 7.0 % ) . The association between A1C and improvement in A1C with travel burden was tested . Results : The mean distance subjects traveled to visit their center was 13.3 miles . The results indicated that residing more than 10 miles from the diabetes management center [ odds ratio ( OR ) = 1.91 , p < .0001 ] , being younger ( OR = 0.99 , p = .00015 ) , and having a longer duration of diabetes ( OR = 1.03 , p = .0007 ) were significant contributors to a A1C > 7 % adjusted for individual- and community-level factors . In addition , those who lived within 10 miles of their center were 2.5 times more likely to have improved their A1C values between their first and last Office visits . Conclusion : Health care providers should be aware of travel burden as a potential barrier to glycemic control . In the future , it may be useful to minimize driving distance for individuals with diabetes , perhaps by improved public transportation , more diabetes center locations in rural areas , telemedicine , or home visits 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 PURPOSE To evaluate the effects of a collaborative case management intervention for patients with poorly controlled type 2 diabetes on glycemic control , intermediate cardiovascular outcomes , satisfaction with care , and re source utilization . METHODS We conducted a r and omized controlled trial at two Department of Veterans Affairs Medical Centers involving 246 veterans with diabetes and baseline hemoglobin A(1C ) ( HbA(1C ) ) levels > or=7.5 % . Two nurse practitioner case managers worked with patients and their primary care providers , monitoring and coordinating care for the intervention group for 18 months through the use of telephone contacts , collaborative goal setting , and treatment algorithms . Control patients received educational material s and usual care from their primary care providers . RESULTS At the conclusion of the study , both case management and control patients remained under poor glycemic control and there was little difference between groups in mean exit HbA(1C ) level ( 9.3 % vs. 9.2 % ; difference = 0.1 % ; 95 % confidence interval : -0.4 % to 0.7 % ; P = 0.65 ) . There was also no evidence that the intervention result ed in improvements in low-density lipoprotein cholesterol level or blood pressure control or greater intensification in medication therapy . However , intervention patients were substantially more satisfied with their diabetes care , with 82 % rating their providers as better than average compared with 64 % of patients in the control group ( P = 0.04 ) . CONCLUSION An intervention of collaborative case management did not improve key physiologic outcomes for high-risk patients with type 2 diabetes . The type of patients targeted for intervention , organizational factors , and program structure are likely critical determinants of the effectiveness of case management . Health systems must underst and the potential limitations before expending substantial re sources on case management , as the expected improvements in outcomes and downstream cost savings may not always be realized BACKGROUND type 2 diabetes mellitus continues to increase in prevalence worldwide . Many factors have been cited as contributing to compliance , such as family and social support , education , number of tablets per dose , frequency of administration and health care provider communication . Toward these goals , the present study was developed to measure the effect offactors on glycemic control such as diabetes education by pharmacists , a diabetes disease booklet and special medication containers . MATERIAL AND METHOD A total of 360 volunteers with type 2 DM patients were recruited , participants were simple r and omized to control 180 and intervention 180 patients . Which intervention categorized to 4 groups ; all intervention groups received diabetes drug counseling by a pharmacist , one group received plus a diabetes booklet , one received plus special medical containers and the last group received all of them . The interventions were done at the 1st time of visit . Both the control and intervention groups were monitored for fasting plasma glucose and HbA1c at 0 , 3 , 6 months and glycemic level in both groups was compared . RESULTS After 3 months , mean fasting plasma glucose and HbA1c decreased wiih the intervention group vs. control group ( 152.36 + /- 39.73 to 131.52 + /- 35.22 mg% ) and ( 150.16 + /- 41.78 to 153.98 + /- 47.95 mg% ) respectively ; ( p < 0.001 ) . HbA1c level 8.16 + /- 1.44 to 7.72 + /- 1.26 vs 8.01 + /- 1.51 to 8.38 + /- 1.46 respectively ; ( p < 0.001 ) . After 6 months , mean fasting plasma glucose and HbA1c decreased with the intervention group vs. control group ( 152.36 + /- 39.73 to 145.20 + /- 46.07 mg% ) and ( 150.16 + /- 41.78 to 159.16 + /- 54.90 mg% ) respectively ; ( p < 0.013 ) . HbA1c level 8.16 + /- 1.44 to 7.91 + /- 1.27 vs. 8.01 + /- 1.51 to 8.80 + /- 1.36 respectively ; ( p < 0.001 ) . The most favorable glycemic outcome was the group that received all of the interventions ; mean FPG was reduced from 147.46 + /- 36.07 to 125.38 + /- 31.12 mg% ( p < 0.000 ) in 1nd visit ( 3 months later ) and still reducing effect on the 2nd visit ( 6 month later ) mean FPG from 147.46 + /- 36.07 to 130.21 + /- 33.96 mg% ( p < 0.016 ) also the same way in HbA 1c level . The group that received only drug counseling by pharmacist had no significant reduction in FPG and HbA1c . ( p > 0.05 ) . CONCLUSION Drug counseling by a pharmacist has little beneficial effect on diabetes management outcome compared to the diabetes booklet and special drug container . To improve glycemic control of type 2 DM is to integrate self-management in daily life , wide a variety of education , drug taken behavior and health care provider available communication produce improvement in patient management and is somewhat better when used in combination BACKGROUND Although maintaining nearly normal glycemia delays onset and slows progression of diabetes complications , many patients with diabetes and their physicians struggle to achieve glycemic targets . The best methods to support patients as they follow diabetes prescriptions and recommendations are unclear . METHODS To test the efficacy of a behavioral diabetes intervention in improving glycemia in long- duration , poorly controlled diabetes , we r and omized 222 adults with diabetes ( 49 % type 1 ) ( mean [ SD ] age , 53 [ 12 ] years ; mean [ SD ] disease duration 18 [ 12 ] years ; mean [ SD ] hemoglobin A(1c ) [ HbA(1c ) ] concentration , 9.0 % [ 1.1 % ] ) to attend ( 1 ) a 5-session manual-based , educator-led structured group intervention with cognitive behavioral strategies ( structured behavioral arm ) ; ( 2 ) an educator-led attention control group education program ( group attention control ) ; or ( 3 ) unlimited individual nurse and dietitian education sessions for 6 months ( individual control ) . Outcomes were baseline and 3- , 6- , and 12-month postintervention HbA(1c ) levels ( primary ) and frequency of diabetes self-care , 3-day pedometer readings , 24-hour diet recalls , average number of glucose checks , physical fitness , depression , coping style , self-efficacy , and quality of life ( secondary ) . RESULTS Linear mixed modeling found that all groups showed improved HbA(1c ) levels ( P < .001 ) . However , the structured behavioral arm showed greater improvements than the group and individual control arms ( 3-month HbA(1c ) concentration changes : -0.8 % vs -0.4 % and -0.4 % , respectively ( P = .04 for group × time interaction ) . Furthermore , participants with type 2 disease showed greater improvement than those with type 1 ( P = .04 for type of diabetes × time interaction ) . Quality of life , glucose monitoring , and frequency of diabetes self-care did not differ by intervention over time . CONCLUSIONS A structured , cognitive behavioral program is more effective than 2 control interventions in improving glycemia in adults with long- duration diabetes . Educators can successfully use modified psychological and behavioral strategies . TRIAL REGISTRATION clinical trials.gov Identifier : NCT000142922 OBJECTIVE To assess whether knowledge or psychosocial and glycemic benefits of a diabetes education program are enhanced by a support group for older patients . DESIGN A partially r and omized controlled trial involving two groups of patients : Group A , subjects who received an education program followed by 18 months of support group sessions ; Group B , only the diabetes education program . A third convenience sample , Group C , received neither intervention . Groups A and B were assessed before and immediately after the education program , and all groups were assessed 2 years after the education program . SETTING Diabetes clinic at a Veterans Affairs Medical Center . PATIENTS All subjects were male ( mean age = 68 + /- 1.3 years , range = 57 - 82 years ; duration of diabetes = 10 + /- 2 years , range 3 - 16 ) . Sample sizes were 11 in Group A , 13 in Group B , and 8 in Group C. INTERVENTION The education program consisted of six weekly sessions covering aspects of diabetes self-care . The support group consisted of 18 monthly sessions for continuing education , discussion , and structured social activities . OUTCOME MEASURES Diabetes knowledge , psychosocial factors ( self-care-related quality of life , stress , family involvement in care , and social involvement ) , depression , and glycemic control . RESULTS Group A scored better ( at least P less than 0.05 ) on knowledge , quality of life , and depression than the other groups . Groups A and B showed less stress , greater family involvement , better glycemic control , but less involvement in social activities than Group C. CONCLUSION Diabetes education programs can have long term benefits on knowledge , psychosocial functioning , and glycemic control for older diabetic patients . The addition of support groups enhances diabetes knowledge and psychosocial functioning In recent years , great emphasis has been placed on the role of nonpharmacological self-management in the care of patients with diabetes . Studies have reported that nurses , compared to other healthcare professionals , are more likely to promote preventive healthcare seeking behaviors . The aim of this study was to investigate the effectiveness of a nurse-led diabetes self-management education on glycosylated hemoglobin . A two-arm parallel-group r and omized controlled trial with the blinded outcome assessors was design ed . One hundred forty-two adults with type 2 diabetes were r and omized to receive either usual diabetes care ( control group ) or usual care plus a nurse-led diabetes self-management education ( intervention group ) . Duration of the intervention was 12 weeks . The primary outcome was glycosylated hemoglobin ( HbA1c values ) . Secondary outcomes were changes in blood pressure , body weight , lipid profiles , self-efficacy ( efficacy expectation and outcome expectation ) , self-management behaviors , quality of life , social support , and depression . Outcome measures were assessed at baseline and at 12-week and 24-week postr and omizations . Patients in the intervention group showed significant improvement in HbA1c , blood pressure , body weight , efficacy expectation , outcome expectation , and diabetes self-management behaviors . The beneficial effect of a nurse-led intervention continued to accrue beyond the end of the trial result ing in sustained improvements in clinical , lifestyle , and psychosocial outcomes . This trial is registered with I RCT 2016062528627N1 OBJECTIVE To compare the effectiveness of different approaches to nutrition education in diabetes self-management education and support ( DSME/S ) . METHODS We r and omized 150 adults with type 2 diabetes to either certified diabetes educator (CDE)-delivered DSME/S with carbohydrate gram counting or the modified plate method versus general health education . The primary outcome was change in HbA1C over 6 months . RESULTS At 6 months , HbA1C improved within the plate method [ -0.83 % ( -1.29 , -0.33 ) , P<0.001 ] and carbohydrate counting [ -0.63 % ( -1.03 , -0.18 ) , P=0.04 ] groups but not the control group [ P=0.34 ] . Change in HbA1C from baseline between the control and intervention groups was not significant at 6 months ( carbohydrate counting , P=0.36 ; modified plate method , P=0.08 ) . In a pre-specified subgroup analysis of patients with a baseline HbA1C 7 - 10 % , change in HbA1C from baseline improved in the carbohydrate counting [ -0.86 % ( -1.47 , -0.26 ) , P=0.006 ] and plate method groups [ -0.76 % ( -1.33 , -0.19 ) , P=0.01 ] compared to controls . CONCLUSION CDE-delivered DSME/S focused on carbohydrate counting or the modified plate method improved glycemic control in patients with an initial HbA1C between 7 and 10 % . PRACTICE IMPLICATION S Both carbohydrate counting and the modified plate method improve glycemic control as part of OBJECTIVE —To test Web-based care management of glycemic control using a shared electronic medical record with patients who have type 2 diabetes . RESEARCH DESIGN AND METHODS —We conducted a trial of 83 adults with type 2 diabetes r and omized to receive usual care plus Web-based care management or usual care alone between August 2002 and May 2004 . All patients had GHb ≥7.0 % , had Web access from home , and could use a computer with English language –based programs . Intervention patients received 12 months of Web-based care management . The Web-based program included patient access to electronic medical records , secure e-mail with providers , feedback on blood glucose readings , an educational Web site , and an interactive online diary for entering information about exercise , diet , and medication . The primary outcome was change in GHb . RESULTS —GHb levels declined by 0.7 % ( 95 % CI 0.2−1.3 ) on average among intervention patients compared with usual-care patients . Systolic blood pressure , diastolic blood pressure , total cholesterol levels , and use of in-person health care services did not differ between the two groups . CONCLUSIONS —Care management delivered through secure patient Web communications improved glycemic control in type 2 diabetes Background Most studies of diabetes self-management that show improved clinical outcome performance involve multiple , time-intensive educational sessions in a group format . Most provider performance feedback interventions do not improve intermediate outcomes , yet lack targeted , patient-level feedback . Methods 5,457 low-income adults with diabetes at eight federally-qualified community health centers participated in this nested r and omized trial . Half of the patients received report card mailings quarterly ; patients at 4 of 8 clinics received report cards at every clinic visit ; and providers at 4 of 8 clinics received quarterly performance feedback with targeted patient-level data . Expert-recommended glycemic , lipid , and blood pressure outcomes were assessed . Assessment of report card utility and patient and provider satisfaction was conducted through mailed patient surveys and mid- and post-intervention provider interviews . Results Many providers and the majority of patients perceived the patient report card as being an effective tool . However , patient report card mailings did not improve process outcomes , nor did point-of-care distribution improve intermediate outcomes . Clinics with patient-level provider performance feedback achieved a greater absolute increase in the percentage of patients at target for glycemic control compared to control clinics ( 6.4 % vs 3.8 % respectively , Generalized estimating equations St and ard Error 0.014 , p < 0.001 , CI -0.131 - -0.077 ) . Provider reaction to performance feedback was mixed , with some citing frustration with the lack of both time and ancillary re sources . Conclusions Patient performance report cards were generally well received by patients and providers , but were not associated with improved outcomes . Targeted , patient-level feedback to providers improved glycemic performance . Provider frustration highlights the need to supplement provider outreach efforts . Trial Registration Clinical Trials.gov : Background : Diabetes mellitus ( DM ) requires continuous medical care , patients ’ self-management , education , and adherence to prescribed medication to reduce the risk of long-term complications . The aim of this study was to assess the benefits of an education program on diabetes , patient self-management , adherence to medication , anxiety , depression and glycemic control in type 2 diabetics in Saudi Arabia . Material s and Methods : This was a prospect i ve study , conducted among 104 diabetic patients at a major tertiary hospital in Riyadh , Saudi Arabia , between May 2011 and October 2012 .  Education material s given to diabetic patients included pamphlets/h and outs written in Arabic , the national language . Special videotapes about DM were made and distributed to all participants . In addition , specific educational programs through the diabetes educators and one-on-one counseling sessions with the doctor were also arranged . Patients were interviewed using a structured interview schedule both during the baseline , and after 6 months of the program . The interview schedule included , socio-demographics , clinical characteristics , diabetes self-management , adherence to medication , anxiety , and depression . Glycemic control was considered poor , if hemoglobin A1c ( HbA1c ) was ≥ 7 % . Results : The mean age of the study population was 57.3 ± 14.4 years . Seventy one were males ( 68.3 % ) and 33 ( 31.7 % ) were females . After six months of the diabetes education program , there were significant improvements in patients ’ dietary plan ( P = 0.0001 ) , physical exercise ( P = 0.0001 ) , self-monitoring of blood glucose ( SMBG ) ( P = 0.0001 ) , HbA1c ( P = 0.04 ) , adherence to medication ( P = 0.007 ) , and depression ( P = 0.03 ) . Conclusions : Implementation of education programs on diabetes among type 2 diabetic patients is associated with better outcomes such as their dietary plan , physical exercise , SMBG , adherence to medication , HbA1c and depression Objective . To examine the impact of two culturally competent diabetes education methods , individual counselling and individual counselling in conjunction with group education , on nutrition adherence and glycemic control in Portuguese Canadian adults with type 2 diabetes over a three-month period . Design . The Diabetes Education Centre is located in the urban multicultural city of Toronto , Ontario , Canada . We used a three-month r and omized controlled trial design . Eligible Portuguese-speaking adults with type 2 diabetes were r and omly assigned to receive either diabetes education counselling only ( control group ) or counselling in conjunction with group education ( intervention group ) . Of the 61 patients who completed the study , 36 were in the counselling only and 25 in the  counselling with group education intervention . We used a per- protocol analysis to examine the efficacy of the two educational approaches on nutrition adherence and glycemic control ; paired t-tests to compare results within groups and analysis of covariance ( ACOVA ) to compare outcomes between groups adjusting for baseline measures . The Theory of Planned Behaviour was used to describe the behavioural mechanisms that influenced nutrition adherence . Results . Attitudes , subjective norms , perceived behaviour control , and intentions towards nutrition adherence , self-reported nutrition adherence and glycemic control significantly improved in both groups , over the three-month study period . Yet , those receiving individual counselling with group education showed greater improvement in all measures with the exception of glycemic control , where no significant difference was found between the two groups at three months . Conclusions . Our study findings provide preliminary evidence that culturally competent group education in conjunction with individual counselling may be more efficacious in shaping eating behaviours than individual counselling alone for Canadian Portuguese adults with type 2 diabetes . However , larger longitudinal studies are needed to determine the most efficacious education method to sustain long-term nutrition adherence and glycemic control Introduction Community health workers ( CHWs ) can improve diabetes outcomes ; however , questions remain about translating research findings into practical low-intensity models for safety-net providers . We tested the effectiveness of a home-based low-intensity CHW intervention for improving health outcomes among low-income adults with diabetes . Methods Low-income patients with glycated hemoglobin A1c ( HbA1c ) of 8.0 % or higher in the 12 months before enrollment from 3 safety-net providers were r and omized to a 12-month CHW-delivered diabetes self-management intervention or usual care . CHWs were based at a local health department . The primary outcome was change in HbA1c from baseline enrollment to 12 months ; secondary outcomes included blood pressure and lipid levels , quality of life , and health care use . Results The change in HbA1c in the intervention group ( n = 145 ) ( unadjusted mean of 9.09 % to 8.58 % , change of −0.51 ) compared with the control group ( n = 142 ) ( 9.04 % to 8.71 % , change of −0.33 ) was not significant ( P = .54 ) . In an analysis of participants with poor glycemic control ( HbA1c > 10 % ) , the intervention group had a 1.23-point greater decrease in HbA1c compared with controls ( P = .046 ) . For the entire study population , we found a decrease in reported physician visits ( P < .001 ) and no improvement in health-related quality of life ( P = .07 ) in the intervention group compared with the control group . Conclusion A low-intensity CHW-delivered intervention to support diabetes self-management did not significantly improve HbA1c relative to usual care . Among the subgroup of participants with poor glycemic control ( HbA1c > 10 % at baseline ) , the intervention was effective Mindful eating offers promise as an effective approach for weight management and glycemic control in people with diabetes .  Diabetes self-management education ( DSME ) is an essential component of effective self-care . Yet , little research has compared the effect of mindful eating to DSME-based treatment . This study compared the impact of these two interventions in adults with type 2 diabetes mellitus . A prospect i ve r and omized controlled trial with two parallel interventions was used . Participants included adults age 35 to 65 years with type 2 diabetes mellitus for 1 year or more , body mass index ( BMI ) of 27 or more , and hemoglobin A1c ( HbA1c ) of 7 % or more who were r and omly assigned to a 3-month mindful eating ( MB-EAT-D ; n=27 ) or Smart Choices ( SC ) DSME-based ( n=25 ) intervention . Follow-up occurred 3 months after intervention completion . Dietary intake , physical activity , weight , HbA1c and fasting plasma glucose , and fasting insulin were assessed using repeated measures analysis of variance with contrast analysis . There was no significant difference between groups in the change in weight or glycemia at study end . Significant difference occurred between groups in the change in dietary intake/1,000 kcal of trans fats , total fiber , and sugars ( all P<0.05 ) . Mean ( ± st and ard error ) reduction in weight ( -2.92 ± 0.54 kg for SC vs -1.53 ± 0.54 kg for MB-EAT-D ) and HbA1c ( -0.67 ± 0.24 % for SC and -0.83 ± 0.24 % for MB-EAT-D ) were significant ( P<0.01 ) . Significant reduction in energy intake and glycemic load occurred ( all P<0.0001 ) for both groups . Training in mindful eating and diabetes self-management  facilitate improvement in dietary intake , modest weight loss , and glycemic control . The availability of effective treatments gives patients with diabetes choices in meeting their self-care needs Objective . Patients with type 2 diabetes often fail to achieve self-management goals . This study tested the impact on glycemic control of a two-way text messaging program that provided behavioral coaching , education , and testing reminders to enrolled individuals with type 2 diabetes in the context of a clinic-based quality improvement initiative . The secondary aim examined patient interaction and satisfaction with the program . Methods . Ninety-three adult patients with poorly controlled type 2 diabetes ( A1C > 8 % ) were recruited from 18 primary care clinics in three counties for a 6-month study . Patients were r and omized by a computer to one of two arms . Patients in both groups continued with their usual care ; patients assigned to the intervention arm also received from one to seven diabetes-related text messages per day depending on the choices they made at enrollment . At 90 and 180 days , A1C data were obtained from the electronic health record and analyzed to determine changes from baseline for both groups . An exit survey was used to assess satisfaction . Enrollment behavior and interaction data were pulled from a Web-based administrative portal maintained by the technology vendor . Results . Patients used the program in a variety of ways . Twenty-nine percent of program users demonstrated frequent engagement ( texting responses at least three times per week ) for a period of ≥90 days . Survey results indicate very high satisfaction with the program . Both groups ’ average A1C decreased from baseline , possibly reflecting a broader quality improvement effort underway in participating clinics . At 90 and 180 days , there was no statistically significant difference between the intervention and control groups in terms of change in A1C ( P > 0.05 ) . Conclusions . This study demonstrated a practical approach to implementing and monitoring a mobile health intervention for self-management support across a wide range of independent clinic practice UNLABELLED Long term diabetes self-management behaviors , and strict glycemic control are difficult to achieve in clinical practice . OBJECTIVE Asesss two different reinforcement strategies for diabetes selfcare management , psychological distress and glycemic control in a one year follow up study . METHODS 70 consecutive type 2 diabetic patients , were recruited and r and omly assigned to three study groups . Subjects in the control group ( CG ) continued with their normal treatment schedule . The second group received a reinforcement course at 6 months ( RCG ) and in the third group , patients were contacted monthly by phone ( PHCG ) to promote self-management attitudes and address problems as they arose . A battery of questions and laboratory work-up were obtained at baseline and at one year follow-up . RESULTS At one year follow-up , the three groups significantly increased their diabetes-related knowledge . Both experimental groups displayed improved treatment compliance and had better adherence to the recommended meal plan ( p=0.06 and 0.003 ) . In addition , the PHCG significantly increased ( p<0.0001 ) their adherence to pharmacological treatment . No significant differences were observed in glycemic control , prevalence of depression or diabetes related distress . CONCLUSIONS Follow-up patient reinforcement strategies improve strategic diabetes self-care management behaviors . Further studies are needed to demonstrate the positive impact of these benefits on diabetes related outcomes Background Providing care for adolescents with type 1 diabetes is complex , dem and ing , and often unsuccessful . Guided self-determination ( GSD ) is a life skills approach that has been proven effective in caring for adults with type 1 diabetes . To improve care , GSD was revised for adolescents , their parents , and interdisciplinary healthcare providers ( HCP ) to create GSD-Youth ( GSD-Y ) . We evaluated the impact of GSD-Y after it was integrated into pediatric outpatient visits versus treatment-as-usual , focusing on glycemic control and the development of life skills in adolescents with type 1 diabetes . Methods Seventy-one adolescents ( mean age : 15 years , mean duration of diabetes : 5.7 years , mean HbA1c : 77 mmol/mol ( 9.1 % ) , upon entering the study ) from two pediatric departments were r and omized into a GSD-Y group  ( n = 37 , GSD-Y was provided during individual outpatient sessions ) versus a treatment-as-usual group ( n = 34 ) . The primary outcome was the HbA1c measurement . The secondary outcomes were life skills development ( assessed by self-reported psychometric scales ) , self-monitored blood glucose levels , and hypo- and hyperglycemic episodes . The analysis followed an intention-to-treat basis . Results Fifty-seven adolescents ( 80 % ) completed the trial , and 53 ( 75 % ) completed a six-month post-treatment follow-up . No significant effect of GSD-Y on the HbA1c could be detected in a mixed-model analysis after adjusting for the baseline HbA1c levels and the identity of the HCP ( P = 0.85 ) . GSD-Y significantly reduced the amotivation for diabetes self-management after adjusting for the baseline value ( P = 0.001 ) . Compared with the control group , the trial completion was prolonged in the GSD-Y group ( P < 0.001 ) , requiring more visits ( P = 0.05 ) with a higher rate of non-attendance ( P = 0.01 ) . GSD-Y parents participated in fewer of the adolescents ’ visits ( P = 0.05 ) compared with control parents . Conclusions Compared with treatment-as-usual , GSD-Y did not improve HbA1c levels , but it did decrease adolescents ’ amotivation for diabetes self-management . Trial registration http://www.controlled-trials.com/is rct n/ search .html?srch=54243636%26sort=3%26dir = desc%26max=10%26Su bmi t = SU BMI T , registered on 10 January 2010 . Life skills for adolescents with type 1 diabetes and their parents Among patients with various levels of health literacy , the effects of collaborative , patient-provider , medication-planning tools on outcomes relevant to self-management are uncertain . Objective . Among adult patients with type II diabetes mellitus , we tested the effectiveness of a medication-planning tool ( Medtable ™ ) implemented via an electronic medical record to improve patients ' medication knowledge , adherence , and glycemic control compared to usual care . Design . A multicenter , r and omized controlled trial in outpatient primary care clinics . 674 patients received either the Medtable tool or usual care and were followed up for up to 12 months . Results . Patients who received Medtable had greater knowledge about indications for medications in their regimens and were more satisfied with the information about their medications . Patients ' knowledge of drug indication improved with Medtable regardless of their literacy status . However , Medtable did not improve patients ' demonstrated medication use , regimen adherence , or glycemic control ( HbA1c ) . Conclusion . The Medtable tool supported provider/patient collaboration related to medication use , as reflected in patient satisfaction with communication , but had limited impact on patient medication knowledge , adherence , and HbA1c outcomes . This trial is registered with Clinical Trials.gov NCT01296633 Background Type 2 diabetes ( T2D ) is a significant public health problem , with U.S. Pacific Isl and er communities — such as the Marshallese — bearing a disproportionate burden . Using a community-based participatory approach ( CBPR ) that engages the strong family-based social infrastructure characteristic of Marshallese communities is a promising way to manage T2D . Objectives Led by a collaborative community-academic partnership , the Family Model of Diabetes Self-Management Education ( DSME ) aim ed to change diabetes management behaviors to improve glycemic control in Marshallese adults with T2D by engaging the entire family . Design To test the Family Model of DSME , a r and omized , controlled , comparative effectiveness trial with 240 primary participants was implemented . Half of the primary participants were r and omly assigned to the St and ard DSME and half were r and omly assigned to the Family Model DSME . Both arms received ten hours of content comprised of 6–8 sessions delivered over a 6–8 week period . Methods The Family Model DSME was a cultural adaptation of DSME , whereby the intervention focused on engaging family support for the primary participant with T2D . The St and ard DSME was delivered to the primary participant in a community-based group format . Primary participants and participating family members were assessed at baseline and immediate post-intervention , and will also be assessed at 6 and 12 months . Summary The Family Model of DSME aim ed to improve glycemic control in Marshallese with T2D . The utilization of a CBPR approach that involves the local stakeholders and the engagement of the family-based social infrastructure of Marshallese communities increase potential for the intervention 's success and sustainability Purpose The purpose of this study was to evaluate the effectiveness of integrative health ( IH ) coaching on psychosocial factors , behavior change , and glycemic control in patients with type 2 diabetes . Methods Fifty-six patients with type 2 diabetes were r and omized to either 6 months of IH coaching or usual care ( control group ) . Coaching was conducted by telephone for fourteen 30-minute sessions . Patients were guided in creating an individualized vision of health , and goals were self-chosen to align with personal values . The coaching agenda , discussion topics , and goals were those of the patient , not the provider . Preintervention and postintervention assessment s measured medication adherence , exercise frequency , patient engagement , psychosocial variables , and A1C . Results Perceived barriers to medication adherence decreased , while patient activation , perceived social support , and benefit finding all increased in the IH coaching group compared with those in the control group . Improvements in the coaching group alone were also observed for self-reported adherence , exercise frequency , stress , and perceived health status . Coaching participants with elevated baseline A1C ( ≥7 % ) significantly reduced their A1C . Conclusions A coaching intervention focused on patients ’ values and sense of purpose may provide added benefit to traditional diabetes education programs . Fundamentals of IH coaching may be applied by diabetes educators to improve patient self-efficacy , accountability , and clinical outcomes Purpose The purpose of the study was to assess the value of reinforcing diabetes self-management for improving glycemia and self-care among adults with type 2 diabetes who had at least 3 hours of prior diabetes education . Methods In this r and omized controlled trial , 134 participants ( 75 % white , 51 % female , 59 ± 9 years old , 13 ± 8 years with diabetes , A1C = 8.4 % ± 1.2 % ) were r and omized  to either a group map-based program ( intervention ) or group education on cholesterol and blood pressure ( control ) . Participants were assessed for A1C levels , diabetes self-care behaviors ( 3-day pedometer readings , 6-minute walk test , blood glucose checks , frequency of self-care ) , and psychosocial factors ( distress , frustration , quality of life ) at baseline , 3 , 6 , and 12 months post intervention and health literacy at baseline . Results Groups did not differ on baseline characteristics including A1C levels , health literacy , or self-care ; however , the intervention group had more years of education than controls . Intervention arm participants modestly improved A1C levels at 3 months post intervention but did not maintain that improvement at 6 and 12 months while control patients did not improve A1C levels at any time during follow-up . Importantly , frequency of self-reported self-care , diabetes quality of life , diabetes-related distress , and frustration with diabetes self-care improved in both groups over time . Conclusions Reinforcing self-care with diabetes education for patients who have not met glycemic targets helps improve A1C and could be considered a necessary component of ongoing diabetes care . The best method to accomplish reinforcement needs to be established 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 It is well known that social family factors are of importance in diabetes care , but it is not clear whether the initial management regimen can buffer these factors . In a prospect i ve , r and omized intervention study , 36 children with diabetes mellitus ( type I ) were followed , the aim being to study if a family psychosocial intervention at diagnosis could improve glycemic control and minimize hospital admissions . The control group was treated initially in a hospital ward , while the study group received problem‐based learning and family‐therapeutic and social support in an out‐hospital training apartment . A number of family social variables were evaluated at the time of diagnosis and 6 , 12 and 24 mo later . Family function was assessed using the self‐estimated Family Climate Test at these same time‐points . HbA1c values and information concerning in‐ and out‐hospital visits to the pediatric clinic were collected for the 5‐y period following diagnosis . We found no association between the offered management regimen and glycemic control or rate of readmission . In the study group only , both parents reported a significant improvement of the family climate . An increased risk for poor glycemic control was recorded in children living in one‐parent families ( p= 0.03 ) or in families where the father had a low level of education ( p= 0.04 ) . Younger age ( p= 0.05 ) , a single‐parent family ( p= 0.05 ) and poor glycemic control ( p= 0.02 ) were associated with more days of rehospitalization . The rate of divorce in the whole group was at least as high as in the normal population but , surprisingly , maternal dysfunction was associated with lower HbA1c value Objectives : This study assessed the safety and clinical effectiveness of the training protocol for initiating insulin pump therapy with real-time continuous glucose monitoring ( MiniMed Paradigm REAL-Time System ) in a stepwise approach on pump naive subjects with type 1 diabetes compared to a control group who remained on multiple daily injection ( MDI ) therapy . Methods : This was a 15-week treat-to-target pilot study of 16 adult subjects ( n = 50 % male , age 45.9 ± 16 years ) with type 1 diabetes ( duration of diabetes 21.9 ± 11 years ) on MDI therapy with hemoglobin A1c levels at or above 7.5 % at baseline . Subjects were r and omized to either the study arm ( using a combined insulin pump and real-time continuous glucose monitoring system ) or the control arm [ which continued on MDI therapy with self-monitored blood glucose ( SMBG ) only ] . All subjects dosed insulin according to results of SMBG by finger stick and uploaded data into the CareLink data management software . Results : Significant improvements in glycemic control were observed from baseline in both study groups— study arm : pre-A1c 9.45 ± 0.55 and post-A1c 7.4 ± 0.66 ( p = 0.00037 ) ; control arm : pre-A1c 8.58 ± 1.30 and post-A1c 7.5 ±1.01 ( p = 0.04 ) . Both arms had no incidence of severe hypoglycemia . Conclusion : In this pilot study , the Paradigm REAL-Time System was initiated safely and effectively in type 1 diabetes patients who were pump naïve using a stepwise educational protocol AIM To determine whether glycemic control is improved when motivational interviewing ( MI ) , a patient-centered behavior change strategy , is used with diabetes self management education ( DSME ) as compared to DSME alone . METHODS poorly controlled type 2 diabetes ( T2DM ) patients ( n=234 ) were r and omized into 4 groups : MI+DSME or DSME alone , with or without use of a computerized summary of patient self management barriers . We compared HbA1c changes between groups at 6 months and investigated mediators of HbA1c change . RESULTS study patients attended the majority of the four intervention visits ( mean 3.4 ) , but drop-out rate was high at follow-up research visits ( 35 % ) . Multiple regression showed that groups receiving MI had a mean change in HbA1c that was significantly lower ( less improved ) than those not receiving MI ( t=2.10 ; p=0.037 ) . Mediators of HbA1c change for the total group were diabetes self-care behaviors and diabetes distress ; no between-group differences were found . CONCLUSIONS DSME improved blood glucose control , underlining its benefit for T2DM management . However , MI+DSME was less effective than DSME alone . Overall , weak support was found for the clinical utility of MI in the management of T2DM delivered by diabetes educators AIM The objective of the current study is to assess the effectiveness of Mobile Short Message Service ( SMS ) intervention on education of basic self-care skills in patients with type 2 diabetes . Moreover , we aim ed to determine whether delivering individually-tailored educational messages can be more effective than general educational messages . METHODS A total of 150 patients with diabetes type 2 were r and omized into three groups : tailored SMS group , non-tailored SMS group , and the control group .  Biochemical parameters including HbA1c , FBS , lipid profile were evaluated for the three groups at baseline and after 12 weeks . Moreover , self-care Inventory ( SCI ) , Diabetes Management Self-Efficacy Scale ( DMSES ) and Diabetes Self-Care Barriers assessment scale for Older Adults ( DSCB-OA ) were completed . In the tailored SMS group , each person received 75 % of their messages based on the top two barriers to adherence that they had experienced and reported in their scale . In the non-tailored SMS group , r and om messages were sent to every patient . RESULTS After 12 weeks , although HgA1c levels did not significantly change , significant decline was observed in FBS and mean BMI in both intervention groups . Mean SCI-R scores significantly increased and mean DSCB and DMSES scores significantly decreased in both tailored and non-tailored SMS groups . In the control group , mean SCI-R scores decreased and mean DSCB and DMSES scores significantly increased ( P<0.001 ) . CONCLUSION Sending short text messages as a method of education in conjunction with conventional diabetes treatment can improve glycemic control and positively influence other aspects of diabetes self-care . According to our findings , sending SMS regularly in particular times appears to be as effective as sending individually tailored messages BACKGROUND African American ( AA ) women with Type 2 diabetes mellitus ( T2DM ) in the rural south experience less weight loss and poorer glycemic control in traditional diabetes management programs compared to Caucasians . This paper describes the design , rationale , and baseline characteristics from an innovative community health worker ( CHW ) delivered intervention program in this population . METHODS / DESIGN This prospect i ve trial r and omized rural AA women with uncontrolled T2DM ( HbA1c ≥ 7.0 ) to receive a behaviorally-centered , culturally-tailored lifestyle intervention during 16 contacts  from a trained AA CHW or 16 approved diabetes educational mailings . Changes from baseline in glycosylated hemoglobin levels ( HbA1c ) , blood pressure ( BP ) , weight , body mass index ( BMI ) , self-reported dietary and physical activity patterns , and psychosocial measures including diabetes distress , empowerment , depression , self-care , medication adherence , and life satisfaction will be assessed at 6- and 12-months . BASELINE RESULTS Two hundred AA women ( mean age = 53.09 ± 10.89 years ) with T2DM from impoverished rural communities were enrolled . Baseline data demonstrated profoundly uncontrolled diabetes of long term duration ( mean HbA1c = 9.11 ± 1.82 ; mean BMI = 37.68 ± 8.20 ; mean BP = 134.51 ± 20.39/84.19 ± 11.68 ; 10.5 ± 0.7 years ) . Self-care behavior assessment revealed poor dietary and medication adherence and sedentary lifestyle . Most psychosocial measures ranged within normal limits . CONCLUSION The present sample of AA women from impoverished rural communities exhibited significantly uncontrolled T2DM of long duration with associated obesity and poor lifestyle behaviors . An innovative CHW led lifestyle intervention may lead to more effective strategies for T2DM management in this population OBJECTIVE The aim of this study was to determine the effect of regular st and ardized telephone contact by a diabetes nurse educator ( DNE ) on metabolic control , treatment compliance , and quality of life in adolescents with poorly controlled type 1 diabetes . METHODS A single-blinded 6-month r and omized controlled trial was used . Participants included 46 of 49 eligible adolescents ( 13 - 17 yr ) with type 1 diabetes > 1-yr duration and hemoglobin A1c ( HbA1c ) > 8.5 % for the previous 6 months . Subjects were r and omly assigned to 6 months of st and ard diabetes management or st and ard care plus weekly telephone contact by a DNE . Telephone conversations included review of events in the adolescents ' lives and diabetes education , but the primary focus was on blood glucose results and insulin-dose adjustments . HbA1c , compliance with glucose monitoring , quality of life [ Diabetes Quality of Life Scale for Youth ( DQOLY ) ] , and family functioning [ Family Environment Scale ( FES ) ] were assessed at baseline , and at 3 and 6 months . Posthoc , HbA1c levels were assessed 6 months following study completion . RESULTS Six months of regular telephone contact by a DNE had no immediate effect on any of the outcome measures . However , posthoc 6 months , HbA1c levels decreased ( 1 % change compared to baseline ) in 6/21 of the study group and 0/18 of the control group , while HbA1c increased in 4/21 of study subjects compared to 8/18 of control subjects ( p = 0.015 ) . CONCLUSIONS In contrast to adult studies , regular telephone contact did not lead to immediate improvements in metabolic control in adolescents with poorly controlled type 1 diabetes . However , knowledge and skills gained during the intervention may have had a delayed beneficial effect in these high-risk adolescents AIMS We evaluated a theoretically-derived family-oriented intervention aim ed to improve self-efficacy , self-management , glycemic control and quality of life in individuals living with Type 2 diabetes in Thail and . METHODS In a single-blinded r and omized controlled trial , 140 volunteer individuals with Type 2 diabetes , recruited from a diabetes clinic in rural Thail and , were r and omly allocated to intervention and control arms . Those in the intervention arm received routine care plus a family-oriented program that included education classes , group discussion s , a home visit , and a telephone follow-up while the control arm only received routine care . Improvement in outcomes over time ( baseline , Week 3 , and Week 13 following intervention ) was evaluated using Generalized Estimating Equations multivariable analyses . RESULTS Except for age , no between-group significant differences were observed in all other baseline characteristics . Diabetes self-efficacy , self-management , and quality of life improved in the intervention arm but no improvement was observed in the controls . In the risk-adjusted multivariable models , compared to the controls , the intervention arm had significantly better self-efficacy , self-management , outcome expectations , and diabetes knowledge ( p<0.001 , in each ) . Participation in the intervention increased the diabetes self-management score by 14.3 points ( β=14.3 , ( 95 % CI 10.7 - 17.9 ) , p<0.001 ) . Self-management was better in leaner patients and in females . No between-group differences were seen in quality of life or glycemic control , however , in the risk-adjusted multivariable models , higher self-management scores were associated with significantly decreased HbA1c levels ( p<0.001 ) and improved patient quality of life ( p<0.05 ) ( irrespective of group membership ) . CONCLUSIONS Our family-oriented program improved patients ' self-efficacy and self-management , which in turn could decrease HbA1c levels Background Inconsistent findings reported in the literature contribute to the lack of complete underst and ing of the association of literacy with health outcomes . We evaluated the association between literacy , physiologic control and diabetes complications among adults with diabetes . Methods A cross-sectional study of 1,002 English speaking adults with diabetes , r and omly selected from the Vermont Diabetes Information System , a cluster-r and omized trial of a diabetes decision support system in a region-wide sample of primary care practice s was conducted between July 2003 and March 2005 . Literacy was assessed by the Short-Test of Functional Health Literacy in Adults . Outcome measures included glycated hemoglobin , low density lipoprotein , blood pressure and self-reported complications . Results After adjusting for sociodemographic characteristics , duration of diabetes , diabetes education , depression , alcohol use , and medication use we did not find a significant association between literacy and glycemic control ( beta coefficent,+ 0.001 ; 95 % confidence interval [ CI ] , -0.01 to + 0.01 ; P = .88 ) , systolic blood pressure ( beta coefficent , + 0.08 ; 95 % CI , -0.10 to + 0.26 ; P = .39 ) , diastolic blood pressure ( beta coefficent , -0.03 ; 95 % CI , -0.12 to + 0.07 , P = .59 ) , or low density lipoprotein ( beta coefficent , + 0.04 ; 95 % CI , -0.27 to + 0.36 , P = .77 . We found no association between literacy and report of diabetes complications . Conclusion These findings suggest that literacy , as measured by the S-TOFHLA , is not associated with glycated hemoglobin , blood pressure , lipid levels or self-reported diabetes complications in a cross-sectional study of older adults with diabetes under relatively good glycemic control . Additional studies to examine the optimal measurement of health literacy and its relationship to health outcomes over time are needed BACKGROUND The aim of this study is to evaluate the effect of a web-based comprehensive information system , consisting of Internet and cellular phone use , on blood glucose control . METHODS We established eMOD ( electronic Management of Diabetes ) , a web-based ubiquitous information system , for cell phone users along with a website for Internet users to provide diabetes education . We examined whether this information system has the same impact on glycemic control as conventional education for the diabetes patient . Forty volunteers were enrolled and r and omly assigned to either the eMOD experimental group ( n = 20 ) or the control group ( n = 20 ) .  Blood glucose and glycated hemoglobin ( A1C ) levels were evaluated at baseline and after 6 months . RESULTS The two groups were homogeneous in terms of age , sex , and diabetes ' duration at baseline . A1C ( from 9.0 + /- 2.3 % to 7.5 + /- 1.4 % , P = 0.031 ) and postpr and ial glucose level ( 228.1 + /- 79.7 to 173.5 + /- 50.2 mg/dL , P = 0.030 ) were significantly decreased over time in the intervention group but not in the control group . There was a significant relationship between the change in A1C and the frequency of access to the eMOD system via cellular phone ( r = 0.766 , P = 0.03 ; coefficient -0.147 ) . CONCLUSIONS A1C was improved by a web-based intervention not only via computer but also via cellular phone at 6 months post-initiation in patients with type 2 diabetes . These results indicate that the use of a convenient web-based education system could be more effective for glycemic control than traditional education for diabetes patients OBJECTIVE The objective of this study was to compare two diabetes self-management interventions design ed for Mexican Americans : " extended "  ( 24 h of education , 28 h of support groups ) and " compressed " ( 16 h of education , 6 h of support groups ) . Both interventions were culturally competent regarding language , diet , social emphasis , family participation , and incorporating cultural beliefs . RESEARCH DESIGN AND METHODS We recruited 216 persons between 35 and 70 years of age diagnosed with type 2 diabetes > /=1 year . Intervention groups of eight participants and eight support persons were r and omly assigned to the compressed or extended conditions . The interventions differed in total number of contact hours over the year-long intervention period , with the major difference being the number of support group sessions held . The same information provided in the educational sessions of the extended intervention was compressed into fewer sessions , thus providing more information during each group meeting . RESULTS The interventions were not statistically different in reducing HbA(1c ) ; however , both were effective . A " dosage effect " of attendance was detected with the largest HbA(1c ) reductions achieved by those who attended more of the extended intervention . For individuals who attended > /=50 % of the intervention , baseline to 12-month HbA(1c ) change was -0.6 percentage points for the compressed group and -1.7 percentage points for the extended group . CONCLUSIONS Both culturally competent diabetes self-management education interventions were effective in promoting improved metabolic control and diabetes knowledge . A dosage effect was evident ; attending more sessions result ed in greater improvements in metabolic control OBJECTIVE In this r and omized controlled trial we evaluated the effect of registered dietitian – led management of diabetes on glycemic control and macronutrient intake in type 2 diabetic patients in primary care clinics in Taiwan and studied the association between changes in macronutrient intake and glycemic measures . RESEARCH DESIGN AND METHODS We recruited 154 adult patients with type 2 diabetes and r and omly assigned them to a routine care control group ( n = 79 ) or a registered dietitian – led intervention group ( n = 75 ) who received on-site diabetic self-management education every 3 months over 12 months . RESULTS Over the 1-year period , neither the intervention group ( n = 75 ) nor the control group ( n = 79 ) had significant changes in A1C , whereas the intervention patients with poorly controlled baseline A1C ( ≥7 % ) ( n = 56 ) had significantly greater improvements in A1C and fasting plasma glucose than the control subjects ( n = 60 ) ( −0.7 vs. −0.2 % , P = 0.034 ; −13.4 vs. 16.9 mg/dl , P = 0.007 ) during the same period . We also found significant net intervention-control group differences in overall energy intake ( −229.06 ± 309.16 vs. 56.10 ± 309.41 kcal/day ) and carbohydrate intake ( −31.24 ± 61.53 vs. 7.15 ± 54.09 g/day ) ( P < 0.001 ) in patients with poorly controlled A1C . Multivariable adjusted modeling revealed an independent association between changes in carbohydrate intake and A1C in the intervention group ( n = 56 ; β = 0.10 , SEM = 0.033 , P = 0.004 ) . CONCLUSIONS On-site registered dietitian – led management of diabetes can improve glycemic control in patients with poorly managed type 2 diabetes in primary care clinics in Taiwan . A reduction in carbohydrate intake may improve glycemic status OBJECTIVE To compare glycemic control and secondary outcomes of a 4-month telephonic couples behavioral intervention to individual intervention , and to education , for adults with type 2 diabetes . RESEARCH DESIGN AND METHODS A r and omized trial with the following three arms :  couples calls ( CC ) ( n = 104 ) ; individual calls ( IC ) ( n = 94 ) ; and diabetes education ( DE ) ( n = 82 ) . All arms had self-management education ( two calls ) . CC and IC had 10 additional behavior change calls . CC addressed collaboration and relationships/communication . Participants consisted of 280 couples , among whom one partner had type 2 diabetes and an A1C level ≥7.5 % . Blinded assessment s occurred at 4 , 8 , and 12 months . The primary outcome was change in A1C ; and secondary outcomes were BMI , waist circumference , blood pressure , depressive symptoms , diabetes self-efficacy , and diabetes distress . RESULTS Patients had a mean age of 56.8 years ; 61.6 % were male , and 30.4 % were minorities . The baseline mean A1C level was 9.1 % . Intention-to-treat analyses found significant A1C reductions for all ( 12 months : CC −0.47 % , IC −0.52 % , DE −0.57 % ) , with no differences between arms . Preplanned within-arm analyses were stratified by baseline A1C tertiles : lowest tertile ( 7.5–8.2 % ) , no change from baseline ; middle tertile ( 8.3–9.2 % ) , only CC led to significantly lower A1C level ; and highest tertile ( ≥9.3 % ) , significant improvement for all interventions . For BMI , CC showed significant improvement , and CC and DE led to decreased waist circumference . The IC group showed greater blood pressure improvement . Results for secondary psychosocial outcomes favored the CC group . CONCLUSIONS In adults with poorly controlled type 2 diabetes , a collaborative couples intervention result ed in significant , lasting improvement in A1C levels , obesity measures , and some psychosocial outcomes . For those with exceedingly high A1C levels , education alone was beneficial , but additional intervention is needed to achieve glycemic targets ABSTRACT Type 2 diabetes ( T2DM ) studies report that marital/family support relates to glycemic control , adherence , and quality of life . Yet , there are few reports on couples-focused interventions . This study aims to describe the challenges faced and lessons learned in the implementation of a theoretically based , couples intervention .  Three hundred fifty couples ( one partner has T2DM in poor glycemic control ) are r and omized to a couples intervention , individual intervention , or enhanced usual care .  All contacts are by telephone to increase reach . The medical ( e.g. , glycemic control ) , psychosocial ( e.g. , diabetes distress ) , and behavioral ( e.g. , regimen adherence ) outcomes were measured . Challenges in recruitment , assessment , and intervention with couples are described , with suggestions about how to address them . Findings concerning the efficacy and cost-effectiveness of the couples intervention , its effect on partners , and possible mechanisms of demonstrated changes , are anticipated in 2013 . Interventionists need specific skills to work with couples to promote communal coping and increase the likelihood of an efficacious couples intervention PURPOSE We compared a 3-month diabetes self-management education ( DSME ) program followed by a 12-month peer support intervention with a 3-month DSME program alone in terms of initial and sustained improvements in glycated hemoglobin ( HbA1c ) . Secondary outcomes were risk factors for cardiovascular disease ( CVD ) , diabetes distress , and social support . METHODS We r and omized 106 community-dwelling African American adults with type 2 diabetes to a 3-month DSME program followed by 12 months of weekly group sessions and supplementary telephone support delivered by peer leaders or to a 3-month DSME program with no follow-up peer support . Assessment s were conducted at baseline , 3 , 9 , and 15 months . RESULTS No changes in HbA1c were observed at 3 months or at 15 months for either group . The peer support group either sustained improvement in key CVD risk factors or stayed the same while the control group worsened at 15 months . At 15 months , the peer-support group had significantly lower low-density lipoprotein cholesterol levels ( −15 mg/dL , P = .03 ) , systolic blood pressure ( −10 mm Hg , P = .01 ) , diastolic blood pressure ( −8.3 mm Hg , P = .001 ) , and body mass index ( −0.8 kg/m2 , P = .032 ) than the DSME-alone group . CONCLUSIONS In this population of African American adults , an initial DSME program , whether or not followed by 12 months of peer support , had no effect on glycemic control . Participants in the peer-support arm of the trial did , however , experience significant improvements in some CVD risk factors or stay approximately the same while the control group declined OBJECTIVE To evaluate the effectiveness of a cluster visit model led by a diabetes nurse educator for delivering outpatient care management to adult patients with poorly controlled diabetes . RESEARCH DESIGN AND METHODS This study involved a r and omized controlled trial among patients of Kaiser Permanente 's Pleasanton , CA , center who were aged 16 - 75 years and had either poor glycemic control ( HbA1c > 8.5 % ) or no HbA1c test performed during the previous year . Intervention subjects received multidisciplinary outpatient diabetes care management delivered by a diabetes nurse educator , a psychologist , a nutritionist , and a pharmacist in cluster visit setting s of 10 - 18 patients /month for 6 months . Outcomes included change ( from baseline ) in HbA1c levels ; self-reported changes in self-care practice s , self-efficacy , and satisfaction ; and utilization of inpatient and outpatient health care . RESULTS After the intervention , HbA1c levels declined by 1.3 % in the intervention subjects versus 0.2 % in the control subjects ( P < 0.0001 ) . Several self-care practice s and several measures of self-efficacy improved significantly in the intervention group . Satisfaction with the program was high . Both hospital ( P = 0.04 ) and outpatient ( P < 0.01 ) utilization were significantly lower for intervention subjects after the program . CONCLUSIONS A 6-month cluster visit group model of care for adults with diabetes improved glycemic control , self-efficacy , and patient satisfaction and result ed in a reduction in health care utilization after the program 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 Objectives . Adherence to diabetes self care is poor for Hispanic American and African-American patients . This study examined the change in adherence over time and in response to a telemedicine intervention for elderly diabetes patients in these groups compared to white diabetes patients . We also examined whether adherence mediated the effect of the intervention on glycemic control ( A1c ) . Design . The Informatics for Diabetes Education and Telemedicine project r and omized medically underserved Medicare patients ( n=1665 ) to telemedicine case management ( televideo educator visits , individualized goal - setting /problem solving ) or usual care .  Hispanic and African-American educators delivered the intervention in Spanish if needed . Main outcome measures . Annual assessment included A1c and self-reported adherence ( Summary of Diabetes Self-Care Activities scale ) . A simple model ( only time and group terms ) and a model with covariates ( e.g. , age ) were examined for baseline and 5 years of follow-up . SAS PROC Mixed was used with non-linear terms to examine mediating effects of adherence on A1c , by performing tests of the mediating path coefficients . Results . Over time , self-reported adherence improved for the treatment group compared to usual care ( p<0.001 ) . There was no significant interaction with racial/ethnic group membership , i.e. , all groups improved . However , minority subjects were consistently less adherent than whites . Also , greater comorbidity and diabetes symptoms predicted poorer adherence , greater duration of diabetes and more years of education predicted better adherence . Adherence was a significant mediator of A1c ( p<0.001 ) . Conclusions . A unique , tailored telemedicine intervention was effective in achieving improved adherence to diabetes self care . However , African-American and Hispanic American participants were less adherent than white participants at all time points despite an individualized and accessible intervention . The finding that adherence did mediate glycemic control suggests that unique interventions for minority groups may be needed to overcome this disparity PURPOSE The purpose of this study was to compare 2 culturally competent diabetes self-management interventions design ed for Mexican Americans : an original extended program ( 24 hours of education , 28 hours of support groups ) versus a shorter , more re source -efficient compressed strategy ( 16 hours of education , 6 hours of support groups ) . The effects of the interventions on health beliefs are compared . METHODS The authors recruited 216 persons between 35 and 70 years of age diagnosed with type 2 diabetes for at least 1 year . Intervention groups of 8 participants and 8 support persons were r and omly assigned to 1 of the interventions . RESULTS Mean health belief scores on each subscale improved for both intervention groups . Both intervention groups reported significant improvements in perceptions of control of their diabetes . Improvements in health beliefs were more sustained at 12 months for individuals in the longer , extended program . The health belief subscale control was the most significant predictor of HbA1c levels at 12 months . CONCLUSIONS Both culturally competent diabetes self-management education interventions were effective in promoting more positive health beliefs . These findings on health beliefs indicate a dosage effect of the intervention and support the importance of ongoing contact through support groups to attain more sustainable improvements in health beliefs 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 Purpose The purpose of this study was to determine if improvements observed in clinical , behavioral , and psychosocial outcomes measured at 12 months following a multifaceted diabetes care intervention were sustained at 3-year follow-up . Methods This study was a multilevel , nonblinded , cluster design , r and omized controlled trial that took place in an under-served suburb of Pittsburgh , Pennsylvania , between 1999 and 2005 . Eleven primary care practice s , and their patients , were r and omly assigned to 3 groups :  chronic care model ( CCM ) intervention ( n = 30 ) , provider education only ( PROV ) ( n = 38 ) , and usual care ( UC ) ( n = 51 ) . Subjects were followed for 3 years . Results Improvements observed at 12-month follow-up in glycemic ( —0.5 % ) and blood pressure control ( —4.8 mm Hg ) , and the proportion of participants who self-monitor their blood glucose ( 86.7%-100 % ) , were sustained at 3-year follow-up in the CCM group . Additional improvements occurred in non-HDLc levels in all study groups and quality of well-being scores in the CCM intervention group . All associations remained after controlling for medication treatment intensification . Conclusions We have demonstrated that improvements in outcomes can be sustained over time following a multifaceted diabetes care intervention . Future research in this area is necessary to underst and if improvements in outcomes can be sustained following diabetes self-management education ( DSME ) and what type of patient fares the best from multifaceted diabetes care interventions PURPOSE This study was conducted to determine whether objective clinical , patient performance , quality -of-life , and subjective outcomes are significantly different among African American men with type 2 diabetes who received follow-up at either monthly or 3-month intervals after participating in a structured diabetes self-management education program . METHODS Prior to the diabetes self-management education program , 30 African American men with type 2 diabetes were r and omly assigned to 2 groups to receive telephone follow-up at either monthly or 3-month intervals over a 6-month period . Information obtained at follow-up contact included HbA1c level , perception of general health , and present diabetes knowledge . In addition , daily foot care , dietary , exercise , and medication compliance measures were assessed postprogram . RESULTS There were no significant differences between the participants who received follow-up at monthly and 3-month intervals on any measures of the selected clinical , patient performance , quality -of-life , and subjective outcomes . CONCLUSIONS This cross-sectional study showed that telephone follow-up at 3 month intervals following a structured program of diabetes self-management education may be just as effective in contributing to favorable diabetes health outcomes as monthly follow-up OBJECTIVE It is unknown whether computer-generated , patient-tailored feedback leads to improvements in glycemic control in people with type 2 diabetes . RESEARCH DESIGN AND METHODS We recruited people with type 2 diabetes aged ≥40 years with a glycated hemoglobin ( A1C ) ≥7 % , living in Hamilton , Canada , who were enrolled in a community-based program ( Diabetes Hamilton ) that provided regular evidence -based information and listings of community re sources design ed to facilitate diabetes self-management . After completing a question naire , participants were r and omly allocated to either receive or not receive periodic computer-generated , evidence -based feedback on the basis of their question naire responses and design ed to facilitate improved glycemic control and diabetes self-management . The primary outcome was a change in A1C after 1 year . RESULTS A total of 465 participants ( 50 % women , mean age 62 years , and mean A1C 7.83 % ) were r and omly assigned , and 12-month A1C values were available in 96 % of all participants , at which time the A1C level had decreased by an absolute amount of 0.24 and 0.15 % in the intervention and control groups , respectively . The difference in A1C reduction for the intervention versus control group was 0.09 % ( 95 % CI −0.08 to 0.26 ; P = 0.3 ) . No between-group differences in measures of quality of life , diabetes self-management behaviors , or clinical outcomes were observed . CONCLUSIONS Providing computer-generated tailored feedback to registrants of a generic , community-based program that supports diabetes self-management does not lead to lower A1C levels or a better quality of life than participation in the community-based program ( augmented by periodic A1C testing ) alone OBJECTIVE To determine whether a system of telemedicine support can improve glycemic control in type 1 diabetes . RESEARCH DESIGN AND METHODS A 9-month r and omized trial compared glucose self-monitoring real-time result transmission and feedback of results for the previous 24 h in the control group with real-time graphical phone-based feedback for the previous 2 weeks together with nurse-initiated support using a web-based graphical analysis of glucose self-monitoring results in the intervention group .  All patients aged 18 - 30 years with HbA(1c ) ( A1C ) levels of 8 - 11 % were eligible for inclusion . RESULTS A total of 93 patients ( 55 men ) with mean diabetes duration ( means + /- SD ) 12.1 + /- 6.7 years were recruited from a young adult clinic . In total , the intervention and control groups transmitted 29,765 and 21,400 results , respectively . The corresponding median blood glucose levels were 8.9 mmol/l ( interquartile range 5.4 - 13.5 ) and 10.3 mmol/l ( 6.5 - 14.4 ) ( P < 0.0001 ) . There was a reduction in A1C in the intervention group after 9 months from 9.2 + /- 1.1 to 8.6 + /- 1.4 % ( difference 0.6 % [ 95 % CI 0.3 - 1.0 ] ) and a reduction in A1C in the control group from 9.3 + /- 1.5 to 8.9 + /- 1.4 % ( difference 0.4 % [ 0.03 - 0.7 ] ) . This difference in change in A1C between groups was not statistically significant ( 0.2 % [ -0.2 to 0.7 , P = 0.3 ) . CONCLUSIONS Real-time telemedicine transmission and feedback of information about blood glucose results with nurse support is feasible and acceptable to patients , but to significantly improve glycemic control , access to real-time decision support for medication dosing and changes in diet and exercise may be required Diabetes is the leading cause of major complications , such as end-stage renal disease and lower extremity amputations , and is a significant contributor to ischemic heart disease , stroke , peripheral vascular disease , and vision loss ( 1 ) . There has been increasing acceptance of the importance of individualizing glycemic management and assessment of risk for adverse events , especially hypoglycemia ( 26 ) . This is of great importance for all patients , especially older adults ( aged 65 years ) with comorbid conditions . In 2013 , 12.0 million older adults in the United States had diabetes , comprising 40 % of the 30.2 million persons with the disease ( 7 ) . Older adults account for an estimated 60 % to 70 % of the U.S. Department of Veterans Affairs ( VA ) and U.S. Department of Defense ( DoD ) diabetic population ( largely retirees ) ( VA/DoD. Unpublished data ) . These considerations make safe and effective diabetes management a policy priority for health care providers ( physicians , nurses , dietitians , and pharmacists ) and policymakers in both the VA and the DoD. The 2017 VA/DoD Clinical Practice Guideline ( CPG ) for the Management of Type 2 Diabetes Mellitus in Primary Care offers health care providers an evidence -based framework to evaluate , treat , and manage persons with type 2 diabetes  mellitus in the context of their individual needs and preferences ( 8) . The current article is a summary of key CPG recommendations , which was developed with multiple stakeholders to ensure representation by a broad spectrum of clinicians . It provides practice recommendations for the care of patients with diabetes , with an emphasis on shared decision making . Guideline Development and Review Process These recommendations were developed using methods established by the VA/DoD Evidence -Based Practice Work Group ( EBPWG ) ( 9 ) , which are aligned with st and ards for trustworthy guidelines ( 10 ) . The EBPWG and the U.S. Army Medical Comm and selected guideline panel cochairs ( 1 each from the VA and the DoD ) . The cochairs then selected a multidisciplinary panel of practicing clinician stakeholders , including primary care physicians ( family and internal medicine ) , endocrinologists , medical nutritionists , pharmacists , diabetes educators , and nurse practitioners . At the start of the CPG development process and at other key points throughout , all members were required to su bmi t disclosure statements for potential conflicts of interest in the previous 24 months . Verbal affirmations of no conflicts were used during meetings throughout the development process . The project team was also subject to r and om Web-based surveillance ( for example , ProPublica ) . The VA/DoD contracted with The Lewin Group , a third party with expertise in clinical practice guideline development , to facilitate meetings . The guideline panel , in collaboration with the ECRI Institute , developed 9 key questions using the PICOTS ( population , intervention , comparator , outcomes , timing of outcomes measurement , and setting ) format . A systematic search of the peer- review ed literature from January 2009 through March 2016 was conducted to find evidence relevant to the key questions that focused on r and omized trials , systematic review s , and meta-analyses of fair or better quality . One key question was up date d through 14 June 2016 . The search methods and results are detailed in the full guideline ( 8) . The guideline panel rated recommendations by using the GRADE ( Grading of Recommendations Assessment , Development and Evaluation ) method ( 11 ) . The guideline panel focused on developing new and up date d recommendations using the evidence review for the key questions . The panel also considered , without a complete review of the relevant evidence , the current applicability of recommendations that were included in the 2010 CPG . As part of the development process , a patient focus group was also convened to better underst and the perspectives of patients receiving diabetes treatment in the VA and the DoD. Five patients were included , consistent with the requirements of the federal Paperwork Reduction Act . All patients had type 2 diabetes and were veterans receiving care in the VA . The focus group explored knowledge of treatment options , views on the delivery of care , patients ' needs and preferences , and the effect of diabetes on their lives . Important concepts that emerged from the focus group were shared with the panel and informed guideline development . It was acknowledged that this convenience sample may not be representative of all VA and DoD patients receiving treatment for type 2 diabetes . The draft guideline was sent to more than 15 expert review ers inside and outside the federal sector . Comments were review ed and , where appropriate , were incorporated into the final guideline based on panel consensus . The VA/DoD EBPWG approved the final document on 3 April 2017 and released it on 17 April 2017 . Recommendations are presented in the Table , and an algorithm for establishing a personalized glycemic goal and treatment plan is presented in the Figure . Key recommendations are review ed in this article . Table . Summary of Recommendations From the 2017 VA/DoD CPG on the Management of Type 2 Diabetes Mellitus Figure . Algorithmic approach to evaluating glycemic control risk factors , setting a personalized glycemic control target range , providing self-management ( including lifestyle and nutrition ) education , and initiating or reevaluating medication therapy . Recommendations Provide Patient-Centered Care and Incorporate Shared Decision Making The CPG strongly encourages clinicians to incorporate shared decision making and partner with their patients . Shared decision making is the process by which the patient and family , in conjunction with the care provider , reach an agreement about a plan of care and treatment . Key principles include readiness of the patient and family , tools with underst and able information about the benefits and harms of all options , and strategies to identify and incorporate patient preferences . Patients can not effectively participate in care and shared decision making unless they underst and diabetes and how they can be involved in planning and carrying out the jointly developed care plan . Shared decision making reinforces a trusted therapeutic relationship and increases patient satisfaction and treatment buy-in with regard to the methods used to reach a particular goal or treatment plan ( 1214 ) . It should be used not only for patients with stable glycemic control but also to assist those who are not able or willing to make lifestyle changes and decisions that affect their diabetes at any time during the course of treatment . At a minimum , shared decision making should be included at the time of diagnosis , during difficulties with management , and at times of transition or development of complications ( 14 ) . Benefits include greater knowledge of medications ( 13 ) and underst and ing of risks ( 14 ) . In addition , patient-centered care and shared decision making together may decrease patient anxiety , increase trust in clinicians ( 15 ) , and improve treatment adherence ( 16 ) . Family involvement should be considered if appropriate , especially in older adults ( 17 ) . Patient information should be culturally appropriate ; underst and able and actionable by people with limited literacy skills ; and accessible to those with physical , sensory , or learning needs ( 18 ) . As part of the patient-centered care approach to diabetes management , clinicians should explore with the patient the outcomes of previous opportunities for shared decision making , their ability to self-manage , prior efforts to change health behaviors , past treatment experiences ( including reasons for discontinuing treatment ) , and relevant clinical outcomes . In actively sharing decisions , they should involve the patient in prioritizing problems to be addressed and setting specific goals regardless of the setting or level of care . Assess Patient Characteristics and Nonglycemic Factors When Interpreting Results of Hemoglobin A1c , Fructosamine , and Other Glycemic Biomarker Testing Many factors affect measurement of hemoglobin A1c ( HbA1c ) besides the level of glycemia ( 19 ) . Because HbA1c level depends on the duration of erythrocyte exposure to glucose , conditions that alter erythrocyte life span affect the measured level of HbA1c ( 20 , 21 ) . Iron deficiency anemia , which prolongs erythrocyte life span and exposes the cell to glucose for a longer period , is associated with falsely elevated HbA1c levels ( 22 ) . In contrast , conditions that shorten erythrocyte life span ( such as hemolytic anemia ) may result in falsely low HbA1c levels . Various other conditions , such as chronic kidney disease , may alter HbA1c measurement . Hemoglobin variants can result in falsely elevated or falsely lowered HbA1c levels , depending on the assay used ( 2325 ) . In addition , oral hypoglycemic agents ( metformin or sulfonylureas ) may alter the relationship between blood glucose and HbA1c levels , although the clinical significance is unclear ( 26 ) . There are also racial/ethnic differences in HbA1c levels for a given level of glycemia . A previous study found that African Americans with prediabetes ( 27 ) had HbA1c values that were 0.4 % higher than among white persons ; those who were within 3 years of diagnosis ( 28 ) also had higher HbA1c values than white persons for any measure of glycemia . This difference can not be explained by measured differences in glycemia , clinical factors known to affect HbA1c measurement , or sociodemographic factors ( 27 , 28 ) . Therefore , it is recommended that a new diagnosis of diabetes be based on a confirmatory fasting blood glucose level of at least 7.0 mmol/L ( 126 mg/dL ) if the initial HbA1c value is 6.5 % to 6.9 % . How and where the HbA1c level is measured can also affect results because of intralaboratory variation ( variation in test accuracy and precision ) and interlaboratory variation ( variation related to use of different test methods ) . A single HbA1c measurement , even from a 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 Introduction This study evaluated the impact of a waiting room-administered , low-literacy , computer multimedia diabetes education program on patient self-management and provider intensification of therapy . Methods In this r and omized , controlled trial , 129 participants either viewed a computer multimedia education program ( intervention group ) or read an educational brochure ( control group ) while in the waiting room . Participants were uninsured , primarily ethnic minority adults with type 2 diabetes receiving care from a county clinic in Chicago , Illinois . Wilcoxon test , t-test , and linear mixed model analyses evaluated changes in diabetes knowledge , self-efficacy , behaviors , medications prescribed , hemoglobin A1c ( HbA1c ) , and blood pressure levels over 3 months . Results During the study period , there was an increase in the number of oral diabetes medications prescribed over three months to multimedia users compared with those in the control group ( P=0.017 ) . HbA1c declined by 1.5 in the multimedia group versus 0.8 in the control group ( P=0.06 ) . There were no differences between groups in changes in blood pressure levels , self-efficacy , and most diabetes-related behaviors . Self-reported exercise increased in the control group compared with the multimedia group ( 0.9 days/week vs. 0.1 days/week , P=0.016 ) . Conclusion Multimedia users received a greater intensification of diabetes therapy , but demonstrated no difference in self-management in comparison with those receiving educational brochures . The availability of a computer multimedia program in the waiting room appears to be a novel and acceptable approach in providing diabetes education for underserved population BACKGROUND Type 2 diabetes is a serious and growing problem in Taiwan where it is the fifth leading cause of death , and health care costs are 4.3 times higher than for people without diabetes . OBJECTIVES The purpose of this study was to determine whether participation in a motivational interview for  people with type 2 diabetes would improve their self-management , psychological and glycemic outcomes . DESIGN A r and omized controlled trial to assess the effects of the motivational interviewing intervention . SETTING S Participants were drawn from the diabetes outpatient clinic of a large teaching hospital in South Taiwan . PARTICIPANTS A sample of 250 type 2 diabetes people . METHODS Type 2 diabetes people were r and omly allocated into either the motivational interview group or the usual care group from baseline to 3 months follow-up . The intervention was based on motivational interviewing which encompassed a variety of interviewing techniques , and reflected each person 's readiness stage to change . The control group was provided with usual care by nursing staff . RESULTS A total of 250 type 2 diabetic participants were r and omized . The retention rate in the intervention group was 83 % ( n=104 ) . The motivational interview did improve participants significantly in self-management , self-efficacy , quality of life , and HbA1c among diabetes people with appropriate baseline value ( < 121.24 , < 174.57 , < 107.18 , and > 7.62 , respectively ) but not in depression , anxiety and stress ( F=0.13 , p=0.72 ) compared to the control group at 3 months follow-up . CONCLUSION The findings provided important evidence concerning the positive effect of motivational interventions in self-management , psychological and glycemic outcomes . This research provided evidence for future clinical practice s in diabetes care OBJECTIVE To evaluate the psychosocial barriers to insulin use in low-income , type 2 diabetic patients ; the clinical characteristics of these patients ; and the possible causes of nonadherence to insulin regimens months after prescription . METHODS We studied a prospect i ve cohort of low-income patients with type 2 diabetes mellitus , aged 45 to 75 years , attending a tertiary health care center in Mexico City , Mexico . Patients were eligible if their diabetes was not controlled with oral agents , and they were excluded if they had type 1 diabetes mellitus , a secondary cause of diabetes , had been admitted to the hospital within the month before study commencement , had been previously treated with insulin , had severe diabetic complications , or had a chronic or disabling medical illness . All patients were prescribed 6 to 10 units of neutral protamine Hagedorn insulin before bedtime and received a referral to visit with a diabetes nurse educator . The main outcome was adherence or nonadherence to insulin therapy  , and it was correlated with several variables including attitudes toward insulin , diabetes self-management , diabetes-related knowledge , depression , and diabetes-related distress . Brief medical history , complete battery of question naires , and laboratory workup were obtained at baseline and 1 to 3 months after insulin prescription . RESULTS Twenty-nine consecutive patients were included . Mean age ( + /- st and ard deviation ) was 59 + /- 8 years , 18 ( 62 % ) were women , mean diabetes duration was 14 + /- 9 years , and mean hemoglobin A1c level was 10.8 + /- 1.4 % .  Negative attitudes toward insulin  were very common , particularly in patients with less education and poorer diabetes-related knowledge ( odds ratio , 6.2 ; 95 % confidence interval , 1.04 - 47.3 ; P = .02 ) . Even when they received precise recommendations , 12 patients ( 41 % ) did not adhere to insulin treatment . Patients who did not adhere to therapy were most commonly women and were depressed ( P = .05 ) . Improved adherence was significantly associated with the additional support of a diabetes nurse educator ( odds ratio , 6.6 ; 95 % confidence interval , 1.0 - 55.7 ; P = .02 ) . CONCLUSIONS Improving patient perception and acceptance of insulin with the help of diabetes educators can facilitate earlier and more aggressive intervention and thus optimize glycemic control OBJECTIVE Management of diabetes is frequently suboptimal in primary care setting s , where providers often fail to intensify therapy when glucose levels are high , a problem known as clinical inertia . We asked whether interventions targeting clinical inertia can improve outcomes . RESEARCH DESIGN AND METHODS A controlled trial over a 3-year period was conducted in a municipal hospital primary care clinic in a large academic medical center . We studied all patients ( 4,138 ) with type 2 diabetes who were seen in continuity clinics by 345 internal medicine residents and were r and omized to be control subjects or to receive one of three interventions . Instead of consultative advice , the interventions were hard copy computerized reminders that provided patient-specific recommendations for management at the time of each patient 's visit , individual face-to-face feedback on performance for 5 min every 2 weeks , or both . RESULTS Over an average patient follow-up of 15 months within the intervention site , improvements in and final HbA1c ( A1C ) with feedback + reminders ( deltaA1C 0.6 % , final A1C 7.46 % ) were significantly better than control ( deltaA1C 0.2 % , final A1C 7.84 % , P < 0.02 ) ; changes were smaller with feedback only and reminders only ( P = NS vs. control ) . Trends were similar but not significant with systolic blood pressure ( sBP ) and LDL cholesterol . Multivariable analysis showed that the feedback intervention independently facilitated attainment of American Diabetes Association goals for both A1C and sBP . Over a 2-year period , overall glycemic control improved in the intervention site but did not change in other primary care sites ( final A1C 7.5 vs. 8.2 % , P < 0.001 ) . CONCLUSIONS Feedback on performance aim ed at overcoming clinical inertia and given to internal medicine resident primary care providers improves glycemic control . Partnering generalists with diabetes specialists may be important to enhance diabetes management in other primary care setting 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 : OBJECTIVE To determine the effects of a culturally competent diabetes self-management intervention in Mexican Americans with type 2 diabetes . RESEARCH DESIGN AND METHODS A prospect i ve , r and omized , repeated measures study was conducted on the Texas-Mexico border in Starr County . A total of 256 r and omly selected individuals with type 2 diabetes between 35 and 70 years of age , diagnosed with type 2 diabetes after 35 years of age , and accompanied by a family member or friend were included . The intervention consisted of 52 contact hours over 12 months and was provided by bilingual Mexican American nurses , dietitians , and community workers . The intervention involved 3 months of weekly instructional sessions on nutrition , self-monitoring of blood glucose , exercise , and other self-care topics and 6 months of biweekly support group sessions to promote behavior changes . The approach was culturally competent in terms of language , diet , social emphasis , family participation , and incorporation of cultural health beliefs . Outcomes included indicators of metabolic control ( HbA(1c ) and fasting blood glucose ) , diabetes knowledge , and diabetes-related health beliefs . RESULTS Experimental groups showed significantly lower levels of HbA(1c ) and fasting blood glucose at 6 and 12 months and higher diabetes knowledge scores . At 6 months , the mean HbA(1c ) of the experimental subjects was 1.4 % below the mean of the control group ; however , the mean level of the experimental subjects was still high ( > 10 % ) . CONCLUSIONS This study confirms the effectiveness of culturally competent diabetes self-management education on improving health outcomes of Mexican Americans , particularly for those individuals with HbA(1c ) levels > 10 % 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 Uncontrolled diabetes is a major health problem in Thail and . The objective of this study was to determine the effects of a diabetes self-management program on glycemic control , coronary heart disease ( CHD ) risk , and quality of life in 147 diabetic patients ( aged 56.8 + /- 10.2 years ) . Type 2 diabetic patients who met the research criteria were r and omized into two groups for a period of 6 months : the experimental group received the diabetes self-management program and the control group received the usual nursing care . The findings indicated that the experimental group demonstrated a significant decrease in the hemoglobin A(1c ) level and CHD risk , with an increase in quality of life ( QOL ) compared to the control group . The diabetes self-management program was effective for improving metabolic control and the QOL for individuals with diabetes . Further studies should be replicated using larger groups over a longer time frame Background African Americans with Type 2 diabetes ( T2DM ) have higher prevalence of diabetes , poorer metabolic control , and greater risk for complications and death compared to American Whites . Poor outcomes in African Americans with T2DM can be attributed to patient , provider , and health systems level factors . Provider and health system factors account for < 10 % of variance in major diabetes outcomes including hemoglobin A1c ( HbA1c ) , lipid control , and re source use . Key differences appear to be at the patient level . Of the patient level factors , consistent differences between African Americans and American Whites with T2DM have been found in diabetes knowledge , self-management skills , empowerment , and perceived control . A variety of interventions to improve diabetes self-management have been tested including : 1 ) knowledge interventions ; 2 ) lifestyle interventions ; 3 ) skills training interventions ; and 4 ) patient activation and empowerment interventions . Most of these interventions have been tested individually , but rarely have they been tested in combination , especially among African Americans who have the greatest burden of diabetes related complications . This study provides a unique opportunity to address this gap in the literature . Methods / Design We describe an ongoing four-year r and omized clinical trial , using a 2 × 2 factorial design , which will test the efficacy of separate and combined telephone-delivered , diabetes knowledge/information and motivation/behavioral skills training interventions in high risk African Americans with poorly controlled T2DM ( HbA1c ≥ 9 % ) . Two-hundred thirty-two ( 232 ) male and female African-American participants , 18 years of age or older and with an HbA1c ≥ 9 % , will be r and omized into one of four groups for 12-weeks of phone interventions : ( 1 ) an education group , ( 2 ) a motivation/skills group , ( 3 ) a combined group or ( 4 ) a usual care/general health education group . Participants will be followed for 12-months to ascertain the effect of the interventions on glycemic control . Our primary hypothesis is that among African Americans with poorly controlled T2DM , patients r and omized to the combined diabetes knowledge/information and motivation/behavioral skills training intervention will have significantly greater reduction in HbA1c at 12 months of follow-up compared to the usual care/general health education group . Discussion Results from this study will provide important insight into how best to deliver diabetes education and skills training in ethnic minorities and whether combined knowledge/information and motivation/behavioral skills training is superior to the usual method of delivering diabetes education for African Americans with poorly controlled T2DM.Trial registration National Institutes of Health Clinical Trials Registry ( Clinical Trials.gov identifier # NCT00929838 ) 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 Introduction The objective of this pilot 6-month r and omized controlled trial was to determine the effectiveness of an intensive , community-based , group intervention that focused on diet , physical activity , and peer support for reducing weight among urban-dwelling African Americans with comorbid type 2 diabetes and hypertension . Methods Sixty-one participants were r and omized into an intervention or control group . The 6-month intervention consisted of 18 group sessions led by a dietitian in a community setting and weekly telephone calls from a peer supporter . The intervention featured culturally tailored nutrition education , behavioral skills training , and social support focused on changes to diet and physical activity . The control group consisted of two 3-hour group sessions of diabetes self-management education taught by a community health worker . Outcome measures were assessed at baseline and 6 months . The primary outcome was achievement of a 5 % weight reduction at 6 months . A secondary outcome was achievement of a 0.5 percentage-point reduction in hemoglobin A1c ( HbA1c ) . Results Groups did not differ in achievement of the weight-loss goal . Intervention participants  lost a mean of 2.8 kg ( P = .01 ) ; control participants did not lose a significant amount of weight . A greater proportion of intervention ( 50.0 % ) than control ( 21.4 % ) participants reduced HbA1c by 0.5 percentage points or more at 6 months ( P = .03 ) . Conclusion The intervention was more effective than usual care ( short-term diabetes education ) at improving glycemic control , but not weight , in low-income African Americans with comorbid diabetes and hypertension . A community-based 6-month group class with culturally tailored education , behavioral skills training , and peer support can lead to a clinical ly significant reduction in HbA1c 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 In recent years , patient-centered chronic care models ( CCMs ) have been widely recognized as the most effective approach for the management of chronic diseases including type 2 diabetes ( T2DM ) [ 1 ] ; however , their implementation in the real world is a dem and ing challenge [ 2 , 3 ] . In Italy , the SINERGIA CCM was developed in the diabetes outpatient clinic of Cusano Milanino [ 4 ] . In this model , self-monitoring blood glucose ( SMBG ) represents the key tool for patient engagement ; within the empowerment philosophy , patients undergo an educational process , which incorporates interactive teaching strategies design ed to involve patients in problem-solving and address their clinical , cultural and psychosocial needs [ 5 ] . Patients are actively involved in the discussion of their goals and instructed about the importance of glycemic control , lifestyle modifications , reduction in body weight and regular monitoring of diabetes complications and their risk factors . Organizational aspects , i.e. , training , skills and roles of each member of diabetes team , electronic data collection , and continuity of communication with the patients are also addressed by the model [ 4 ] . Following a preliminary evaluation of the SINERGIA impact in an observational cohort of over 1000 patients with T2DM cared for by the Cusano Milanino center [ 4 ] , the Self-Care Study was design ed as a multicenter , national , r and omized ( 1:1 ) , open-label , parallel group , controlled clinical trial of a duration of 12 months to compare SINERGIA models versus usual care . The primary end point was the change after 12 months from r and omization in HbA1c levels . Secondary end points were changes in body weight , waist circumference , blood pressure , lipid profile , specific quality -of-life scores , incidence of hypoglycemia and adverse events , and contacts between patient and center . After 24 months from r and omization , an additional analysis ( post-trial observational phase of the study ) assessed the long-term impact of SINERGIA versus  usual care . Inclusion criteria were : men or women aged ≥ 45 years with diagnosis of T2DM , at their first access at the diabetes clinic , with any diabetes duration , HbA1c > 7.0 and ≤ 9.0 % , treated or requiring the initiation of therapy with any oral oral hypoglycemic agent ( OHA ) , not using SMBG ( i.e. , frequency ≤ 1 test/week ) and signature of informed consent . Exclusion criteria were : treated or requiring the initiation of therapy with insulin , any condition that could render the subject unlikely or unable to comply with the protocol requirements ( full list of eligibility criteria available in https:// clinical trials.gov/ct2/show/NCT02082028?term= SINERGIA&cond = Diabetes+Mellitus%2C+Type+2&cntr y1=EU%3AIT&rank=1 ) . Patients were r and omized to two study arms :  patients allocated to the  experimental group received the SINERGIA diabetes educational model [ 4 ] and patients allocated to the control group received the st and ard diabetes education provided by the center , and SMBG ( any glucose meter ) was prescribed only if deemed appropriate based on physician ’s judgment . Patients in both groups were seen six times during the study period : 2 weeks before r and omization , at r and omization visit , 3 , 6 and 12 months after r and omization and 24 months after r and omization ( post-trial ) . Considering as clinical ly relevant a minimum betweengroup difference in HbA1c levels of 0.4 % after 12 months and assuming a st and ard deviation of HbA1c of 0.9 % and a Managed by Antonio Secchi OBJECTIVE —We sought to determine whether self-monitoring of blood glucose ( SMBG ) is associated with better glycemic control in type 2 diabetes . RESEARCH DESIGN AND METHODS —We used cross-sectional and longitudinal data from type 2 diabetic participants in the observational , community-based Fremantle Diabetes Study ( FDS ) who reported SMBG status at study entry ( n = 1,286 ) and annual review s over 5 years ( n = 531 ) . RESULTS —At study entry , 70 % of patients performed SMBG , with a median of four tests per week ( interquartile range two to seven ) . Patients with shorter diabetes duration ; who were attending diabetes education , diabetes-related clinics , or medical specialists ; who were taking insulin with or without oral hypoglycemic agents ( OHAs ) ; and who were self-reporting hypoglycemic events were more likely to use SMBG . Both cross-sectional and longitudinal FDS data showed that HbA1c ( A1C ) was not significantly different between SMBG users and nonusers , either overall or within diabetes treatment groups ( diet , OHAs , and insulin with or without OHAs ) . There was also no independent cross-sectional relationship between A1C and SMBG frequency . The average annual societal cost of using SMBG ( in year 2000 Australian dollars [ A$ ] , excluding glucometers ) was A$ 162 per type 2 diabetic patient or A$ 51 million when projected to the Australian diagnosed type 2 diabetic population . CONCLUSIONS —Neither SMBG testing nor its frequency was associated with glycemic benefit in type 2 diabetic patients regardless of treatment . Our data did not include methods of SMBG delivery and application , factors that require further assessment in the evaluation of SMBG utility in non – insulin-treated type 2 diabetes . SMBG may be still of value in the identification and prevention of hypoglycemia and in dose adjustment in insulin-treated patients PURPOSE To assess the efficacy of a pharmacist-led , primary care-based , disease management program to improve cardiovascular risk factors and glycated hemoglobin ( A(1C ) ) levels in vulnerable patients with poorly controlled diabetes . METHODS A r and omized controlled trial of 217 patients with type 2 diabetes and poor glycemic control ( A(1C ) level > or=8.0 % ) was conducted at an academic general medicine practice from February 2001 to April 2003 . Intervention patients received intensive management from clinical pharmacists , as well as from a diabetes care coordinator who provided diabetes education , applied algorithms for managing glucose control and decreasing cardiovascular risk factors , and addressed barriers to care . Control patients received a one-time management session from a pharmacist followed by usual care from their primary care provider . Outcomes were recorded at baseline and at 6 and 12 months . Primary outcomes included blood pressure , A(1C ) level , cholesterol level , and aspirin use . Secondary outcomes included diabetes knowledge , satisfaction , use of clinical services , and adverse events . RESULTS For the 194 patients ( 89 % ) with 12-month data , the intervention group had significantly greater improvement than did the control group for systolic blood pressure ( -9 mm Hg ; 95 % confidence interval [ CI ] : -16 to -3 mm Hg ) and A(1C ) level ( -0.8 % ; 95 % CI : -1.7 % to 0 % ) . Change in total cholesterol level was not significant . At 12 months , aspirin use was 91 % in the intervention group versus 58 % among controls ( P < 0.0001 ) . Intervention patients had greater improvements in diabetes knowledge and satisfaction than did control patients . There were no significant differences in use of clinical services or adverse events . CONCLUSION Our comprehensive disease management program reduced cardiovascular risk factors and A(1C ) levels among vulnerable patients with type 2 diabetes and poor glycemic control BACKGROUND The Diabetes Education and Self-Management for Ongoing and Newly Diagnosed ( DESMOND ) Self-monitoring Trial reported that people with newly diagnosed type 2 diabetes attending community-based structured education and r and omized to self-monitoring of blood glucose ( SMBG ) or urine monitoring  had comparable improvements in biomedical outcomes , but differences in satisfaction with , and continued use of monitoring method , well-being and perceived threat from diabetes . OBJECTIVES To explore experiences of SMBG and urine monitoring following structured education . We specifically addressed the perceived usefulness of each monitoring method and the associated well-being . METHODS Qualitative semi-structured interviews with 18 adults with newly diagnosed type 2 diabetes participating in the DESMOND Self-monitoring Trial ( SMBG , N=10 ; urine monitoring , N=8)~12 months into the trial . Analysis was informed by the constant comparative approach . RESULTS Interviewees reported SMBG as accurate , convenient and useful . Declining use was explained by having established a pattern of managing blood glucose with less frequent monitoring or lack of feedback or encouragement from health care professionals . Many initially positive views of urine monitoring progressively changed due to perceived inaccuracy , leading some to switch to SMBG . Perceiving diabetes as less serious was attributable to lack of symptoms , treatment with diet alone and -in the urine-monitoring group-consistently negative readings . Urine monitoring also provided less visible evidence of diabetes and of the effect of behaviour on glucose . CONCLUSIONS The findings highlight the importance for professionals of considering patients ' preferences when using self-monitoring technologies , including how these change over time , when supporting the self-care behaviours of people with type 2 diabetes PURPOSE We sought to evaluate the effect of automated telephone assessment and self-care education calls with nurse follow-up on the management of diabetes . SUBJECTS AND METHODS We enrolled 280 English- or Spanish-speaking adults with diabetes who were using hypoglycemic medications and who were treated in a county health care system . Patients were r and omly assigned to usual care or to receive an intervention that consisted of usual care plus bi-weekly automated assessment and self-care education calls with telephone follow-up by a nurse educator . Outcomes measured at 12 months included survey-reported self-care , perceived glycemic control , and symptoms , as well as glycosylated hemoglobin ( Hb A1c ) and serum glucose levels . RESULTS We collected follow-up data for 89 % of enrollees ( 248 patients ) . Compared with usual care patients , intervention patients reported more frequent glucose monitoring , foot inspection , and weight monitoring , and fewer problems with medication adherence ( all P -0.03 ) . Follow-up Hb A , , levels were 0.3 % lower in the intervention group ( P = 0.1 ) , and about twice as many intervention patients had Hb A1c levels within the normal range ( P = 0.04 ) . Serum glucose levels were 41 mg/dL lower among intervention patients than usual care patients ( P = 0.002 ) . Intervention patients also reported better glycemic control ( P = 0.005 ) and fewer diabetic symptoms ( P < 0.0001 ) , including fewer symptoms of hyperglycemia and hypoglycemia . CONCLUSIONS Automated calls with telephone nurse follow-up may be an effective strategy for improving self-care behavior and glycemic control , and for decreasing symptoms among vulnerable patients with diabetes OBJECTIVE To determine if scheduled telephone calls from a pediatric diabetes educator to children who have type 1 diabetes improve hemoglobin A1c ( HbA1c ) level , hospital admissions , diabetes knowledge , compliance , and psychological well-being . RESEARCH DESIGN AND METHODS A r and omized controlled trial of 123 young subjects ( mean age 11.9 yr , 69 male ) with type 1 diabetes ( mean duration 3.65 yr ) . For 7 months , the intervention group held bimonthly 15 - 30 min scheduled supportive telephone discussion s. The primary outcome was change in the HbA1c level . Admission rates and changes in diabetes knowledge , psychological parameters , compliance , and patient perception were measured . RESULTS There was no significant difference between the treatment and control groups either before or after the intervention . The mean HbA1c level in the control group increased from 8.32 to 8.82 % and in the intervention group from 8.15 to 8.85 % ( p = 0.24 ) . Both groups showed an increase in admissions of 0.2 per yr ( p = 0.57 ) . There was no improvement in diabetes knowledge ( p = 0.34 ) , compliance , or psychological function . The intervention group viewed their contact with the clinic as more helpful ( p = 0.003 ) . Analysis of family function did not reveal subgroups with statistically significant differences . A mean of 13 calls was made to each subject at a cost of 36 Australian dollars per child per month . CONCLUSIONS Scheduled bimonthly phone support does not improve the HbA1c level , admission rates , diabetes knowledge , psychological function , or self-management but is perceived by patients as helpful . Further study into the effects of more frequent but shorter periods of support for patients experiencing specific difficulties is needed OBJECTIVE Evaluate a 16-week decision support and goal - setting intervention to compare diet quality , decision , and diabetes-related outcomes to a control group . METHODS Adults with type 2 diabetes ( n=54 ) were r and omly assigned to an intervention or control group . Intervention group participants completed one in-person motivational interviewing and decision support session followed by seven biweekly telephone coaching calls . Participants reported previous goal attempts and set diet- and /or physical activity-related goals during coaching calls . Control group participants received information about local health care re sources on the same contact schedule . RESULTS There was a significant difference between groups for diabetes empowerment ( p=0.045 ) . A significant increase in diet quality , diabetes self-efficacy , and diabetes empowerment , and a significant decrease in diabetes distress and depressive symptoms ( all p≤0.05 ) occurred in the intervention group . Decision confidence to achieve diet-related goals significantly improved from baseline to week 8 but then declined at study end ( both p≤0.05 ) . CONCLUSIONS Setting specific diet-related goals may promote dietary change , and telephone coaching can improve psychosocial outcomes related to diabetes self-management . PRACTICE IMPLICATION S Informed shared decision making can facilitate progressively challenging yet attainable goals tailored to individuals ' lifestyle . Decision coaching may empower patients to improve self-management practice s and reduce distress Background Individuals with a learning disability ( LD ) are at higher risk of developing type 2 diabetes , but LD is not straightforward to define or identify , especially at the milder end of the spectrum , which makes case finding difficult . While supported self-management of health problems is now established , current material is largely educational and didactic with little that facilitates behavioural change . The interaction between the person with diabetes and others supporting their care is also largely unknown . For these reasons , there is considerable work needed to prepare for a definitive trial . The aim of this paper is to publish the abridged protocol of this preparatory work . Methods / Design Phase I is a prospect i ve case-finding study ( target n = 120 to 350 ) to identify and characterise potential participants , while developing a st and ardised supported self-management intervention . Phase II is a r and omised feasibility trial ( target n = 80 ) with blinded outcome assessment . Patients identified in Phase I will be interviewed and consented prior to being r and omised to ( 1 ) st and ard treatment , or ( 2 ) supported self-management . Both arms will also be provided with an ‘ easy read ’ accessible information re source on managing type 2 diabetes . The intervention will be st and ardised but delivered flexibly depending on patient need , including components for the participant , a supporter , and shared activities . Outcomes will be ( i ) robust estimates of eligibility , consent and recruitment rates with refined recruitment procedures ; ( ii ) characterisation of the eligible population ; ( iii ) a st and ardised intervention with associated written material s , ( iv ) adherence and negative outcomes measures ; ( v ) preliminary estimates of adherence , acceptability , follow-up and missing data rates , along with refined procedures ; and ( vi ) description of st and ard treatment . Discussion Our study will provide important information on the nature of type 2 diabetes in adults with LD living in the community , on the challenges of identifying those with milder LD , and on the possibilities of evaluating a st and ardised intervention to improve self-management in this population .Trial registration Current Controlled Trials IS RCT N41897033 ( registered 21 January 2013 ) Purpose The purpose of this study was to evaluate an interdisciplinary approach and test the efficacy of diabetes group visits tailored to low-income patients in a community-based medical practice . Methods A r and omized repeated measures design was used with 40 patients in the experimental group and 40 patients in the control group . The diabetes group visit consisted of individualized sessions with a physician or nurse practitioner to review medications and conduct a medical examination and group sessions to deliver diabetes self-management education . Data collected included clinical data and question naires . A control group shared comparable demographic characteristics , medication regimens , and baseline A1C levels . Results The patients in the experimental group decreased their A1C , triglycerides , and heart rate from time 1 to time 5 and maintained their high-density lipoprotein significantly more than the control group . In exit interviews , the patients said that the group diabetes visits helped them be more accountable about their diabetes self-management goals . Conclusions Diabetes group visits that combined diabetes self-management education and a medical visit with a health care provider improved A1C and were well received by the patients . The study provided patients with a quality program in an environment in which they felt safe to learn and that met them where they were in their diabetes self-management behaviors . This approach could be widely disseminated into other clinic setting s that serve patients with type 2 diabetes Background The prevalence of type 2 diabetes is rising with the majority of patients practicing inadequate disease self-management . Depression , anxiety , and diabetes-specific distress present motivational challenges to adequate self-care . Health systems globally struggle to deliver routine services that are accessible to the entire population , in particular in rural areas .  Web-based diabetes self-management interventions can provide frequent , accessible support regardless of time and location Objective This paper describes the protocol of an Australian national r and omized controlled trial ( RCT ) of the OnTrack Diabetes program , an automated , interactive , self-guided Web program aim ed to improve glycemic control , diabetes self-care , and dysphoria symptoms in type 2 diabetes patients . Methods A small pilot trial is conducted that primarily tests program functionality , efficacy , and user acceptability and satisfaction . This is followed by the main RCT , which compares 3 treatments : ( 1 ) delayed program access : usual diabetes care for 3 months postbaseline followed by access to the full OnTrack Diabetes program ; ( 2 ) immediate program : full access to the self-guided program from baseline onward ; and ( 3 ) immediate program plus therapist support via Functional Imagery Training ( FIT ) . Measures are administered at baseline and at 3 , 6 , and 12 months postbaseline . Primary outcomes are diabetes self-care behaviors ( physical activity participation , diet , medication adherence , and blood glucose monitoring ) , glycated hemoglobin A1c ( HbA1c ) level , and diabetes-specific distress . Secondary outcomes are depression , anxiety , self-efficacy and adherence , and quality of life . Exposure data in terms of program uptake , use , time on each page , and program completion , as well as implementation feasibility will be conducted . Results This trial is currently underway with funding support from the Wesley Research Institute in Brisbane , Australia . Conclusions This is the first known trial of an automated , self-guided , Web-based support program that uses a holistic approach in targeting both type 2 diabetes self-management and dysphoria . Findings will inform the feasibility of implementing such a program on an ongoing basis , including in rural and regional locations . Trial Registration Australian and New Zeal and Clinical Trials Registration number : ACTRN12612000620820 ; https://anzctr.org.au/Trial/ Registration /Trial Review .aspx?ACTRN=12612000620820 ( Archived by WebCite at http://www.webcitation.org/6a3BeXC5 m ) OBJECTIVE To report results from YourWay , an Internet-based self-management intervention for adolescents with type 1 diabetes . RESEARCH DESIGN AND METHODS A total of 72 adolescents with type 1 diabetes , ages 13–17 years , were r and omized to a  usual-care-plus-Internet support or a usual-care group . The intervention was design ed to enhance problem-solving barriers to self-management . A1C was obtained from medical records , and problem-solving and self-management were obtained via adolescent report . RESULTS Group differences were not statistically significant using intent-to-treat analyses . Using as-treated analyses , adolescents in the treatment condition showed statistically significant improvement in self-management ( d = 0.64 ; P = 0.02 ) and important improvements in problem-solving ( d = 0.30 ; P = 0.23 ) and A1C ( d = −0.28 ; P = 0.27 ) . Mean A1C for the intervention group remained constant ( −0.01 % ) , while the control group increased ( 0.33 % ) . CONCLUSIONS This brief trial suggests that self-management support delivered through a secure website may improve self-management and offset typical decreases in adolescent glycemic control Purpose The purpose of this study is to assess factors related to diabetes medication nonadherence in a sample of predominantly Spanish-speaking Mexican-origin adults residing along the US-Mexico border . Methods As part of a r and omized controlled trial , 302 patients r and omly sample d from a clinic roster completed a baseline interview .  Medication nonadherence was assessed with the  Morisky Medication Adherence Scale .  Consistent with the framework proposed by Venturini et al , four factors were examined : patient-related attributes , drug regimen characteristics and complexity , health status , and patient-provider interaction characteristics . Results Sixty percent of the patients were classified as nonadherent . Men , those who engaged in diabetes control behaviors less frequently , and individuals with depression were more likely to be classified as nonadherent . Among those who were Spanish-dominant , education and self-rated health also were significantly and negatively related to medication adherence ; patients with a high school education or greater and those who more positively rated their health were more likely to be classified as nonadherent compared to those with less than a high school education and those who rated their health as poor . Conclusions Results reflect potentially higher medication nonadherence rates for Latinos with type 2 diabetes living in rural communities along the US-Mexico border . Additionally , this study supports the need to address strategies to support medication adherence , including addressing depression , for diabetes control . Strategies to promote adherence among Latino men are sorely needed , as are strategies to address forgetfulness and carelessness regarding diabetes medicine taking Context Psychological issues can interfere with behavior modification that is necessary to manage type 1 diabetes , so psychological therapy might improve diabetes control . Contribution This r and omized , controlled trial compared motivational enhancement therapy with and without cognitive behavior therapy with usual care in 344 adults with type 1 diabetes ( average baseline hemoglobin A1c level , 9.4 % ) . Patients who received motivational enhancement therapy plus cognitive behavior therapy had a greater decrease in hemoglobin A1c over 12 months than patients who received usual care ( difference between groups , 0.46 % ) . No other improvements were observed . Implication Motivational enhancement therapy plus cognitive behavior therapy led to only small improvements in diabetes control , despite a total of 16 therapy sessions prescribed over 6 months . The Editors Suboptimal glycemic control in type 1 diabetes is common , despite the effectiveness of intensive insulin therapies , continuous subcutaneous insulin infusion pumps , and structured education programs ( 13 ) . Depression , anxiety , and disordered eating patterns are common in persons with diabetes and are associated with suboptimal glycemic control , complications , and death ( 412 ) . Diabetes-related anxieties related to hypoglycemia , complications , self-injections , and glucose self-testing are also well recognized ( 13 , 14 ) . The effectiveness of psychological treatments in improving glycemic control in adults with type 1 diabetes has not been established ( 15 ) . One reason may be that previous trials have not specifically targeted the broad range of diabetes-related problems ( 15 ) . Evidence in substance misuse setting s suggests that adding cognitive behavior therapy to motivational enhancement therapy may increase efficacy ( 16 ) . Motivational enhancement therapy is a brief ( usually 1 to 4 sessions ) counseling method for enhancing motivation to change problematic health behaviors by exploring and resolving the ambivalence about change ( 17 ) . Motivational enhancement therapy is effective in improving alcohol misuse and smoking , and preliminary evidence suggests that it may be effective in diabetes ( 18 , 19 ) . Cognitive behavior therapy is a longer therapy ( usually a minimum of 6 to 12 sessions ) that aims to enable the patient to identify , challenge , and substitute unhelpful cognitions and behaviors with more constructive ones ( 20 , 21 ) . In diabetes , several trials have predominantly used behavioral techniques ( 2225 ) and , more recently , cognitive techniques ( 2628 ) , but this novel method of integrating motivational enhancement therapy and cognitive behavior therapy has yet to be tested in diabetes setting s. One question we examined when we design ed the trial was whether diabetes nurses could be trained to deliver psychological treatments , because such a model of intervention could be used more widely than one that relied on psychologists . We added cognitive behavior therapy to motivational enhancement therapy as 1 of the interventions , rather than cognitive behavior therapy alone , because we aim ed to reach a group of patients who had persistent problems with diabetes control and were more likely to be ambivalent about change . Our objective of this r and omized , controlled trial ( RCT ) was to determine whether motivational enhancement therapy plus cognitive behavior therapy was more effective than usual care in improving glycemic control in adults with type 1 diabetes and persistent , suboptimal glycemic control and whether motivational enhancement therapy alone was more effective than usual care in improving glycemic control . The secondary objective was to assess whether either psychological intervention was more effective than usual care in improving depressive symptoms , fear of hypoglycemia , diabetes self-care behaviors , body mass index , and diabetes quality of life . Methods Design We followed the CONSORT ( Consoli date d St and ards of Reporting Trials ) guidelines ( 29 ) . The Clinical Trials Unit , Institute of Psychiatry , King 's College London , London , United Kingdom , sponsored the trial . The South West Multi-Centre Research Ethics Committee and the ethics committees of all participating hospitals approved the trial . A trial steering committee and data monitoring and ethics committee oversaw the conduct of the study . All participants provided signed informed consent . Setting Five hospitals in southeast London ( King 's College Hospital , Guy 's and St Thomas ' Hospitals , Lewisham Hospital , and Mayday University Hospital ) , and 3 hospitals in Greater Manchester ( Manchester Royal Infirmary , North Manchester General , and Stockport General Hospital/Stepping Hill Hospitals ) , United Kingdom , served as the recruiting centers . Participants Local clinicians screened their hospital data bases or lists to identify patients with type 1 diabetes . Adults ( age 18 to 65 years ) with type 1 diabetes for at least 2 years who had persistent , suboptimal glycemic control were c and i date s for inclusion into the study . Type 1 diabetes was defined as onset at age younger than 35 years and onset of insulin therapy within 6 months of diagnosis or ketones in the urine . Persistent , suboptimal glycemic control was defined as having at least 2 records of hemoglobin A1c levels between 8.2 % and 15 % : one measurement in the past 12 months and the second being the current ( in other words , at recruitment ) hemoglobin A1c level . We excluded participants if they did not speak English , were pregnant , had a short-term or serious medical illness defined by the treating physician , had advanced diabetes complications ( registered blind , serum creatinine levels # # gt##300 mol/L [ # # gt##3.39 mg/dL ] ) , had known hemaglobinopathy , had psychotic disorders , had alcohol dependence , were in psychotherapy , or had been in a structured diabetes education program less than 3 months previously . We did not exclude persons with major depression unless they were receiving antidepressant therapy initiated less than 2 months prior . Before patients were r and omly assigned , they had at least 1 session of nurse-delivered diabetes education and received a fact sheet containing the minimum accepted level of diabetes knowledge ( 30 ) . The hemoglobin A1c level was measured by ion-exchange , high-pressure liquid chromatography by using analyzers at each participating clinic : Menarini HA-8140 , HA-8121 , or HA-8160 ( Menarini Diagnostics , Florence , Italy ) ; Tosoh 2.2 Plus ( Tosoh Medics , Foster City , California ) ; or Variant II HPLC System ( Bio-Rad Laboratories , Hercules , California ) , by using methods aligned with the Diabetes Control and Complications Trial ( 1 , 31 ) . Baseline Measures We collected data on the following baseline characteristics : sociodemographic factors ( age , sex , employment status , educational level , ethnicity , marital status ) ; lifestyle factors ( current smoking status and units of alcohol intake per week ) ; physical health ( hemoglobin A1c level ) ; resting blood pressure ( mm Hg ) , body mass index ( kg/m2 ) ; total r and om cholesterol level ( moL/L [ mg/dL ] ) ; duration of diabetes ( years ) ; presence of diabetes complications ( early morning albumincreatinine ratio level ) ; peripheral neuropathy ( screened using the 10-g monofilament ) ; retinopathy status coded as none or any ( treated , nonsight-threatening , and sight-threatening ) from retinal color photographs or fundoscopy assessment s ; and depressive symptoms assessed on the well-vali date d and reliable self-reported Patient Health Question naire-9 ( score range , 0 to 27 ; scores 10 represent major depressive disorder ) ( 32 ) . We measured diabetes-related cognitions and behaviors on the revised Hypoglycaemia Fear Survey ( 33 , 34 ) , which consists of 10 behavior items ( score range , 0 to 40 ) and 13 worry items ( score range , 0 to 52 ) self-rated on 5-point Likert scales . The revised Summary of Diabetes Self-Care Activities asks how many days in the last 7 days the participant engaged in diet , exercise , and blood sugar testing ( score range , 0 to 7 days ) ( 35 ) . Higher scores denote a greater tendency to maintain high blood glucose levels and fear of hypoglycemia , respectively . Quality of life was measured by satisfaction and impact subscales of the Diabetes Quality of Life scale ( score range per subscale , 1 to 5 ) ( 36 ) . R and omization We prepared a computer-generated r and omization list , stratified by hospital site , which used blocks of r and om sizes ( 3 , 6 , 9 , and 12 ) in advance . The data base manager of the Clinical Trials Unit , who was independent of the study , held the list electronically in a password-protected data base . Allocation could only be revealed to the recruiting research er , who then assigned each participant after obtaining consent . We collected all baseline measures before r and omization . The laboratory technicians , who were blinded to the allocation throughout the study and the self-reported psychological measures , assessed hemoglobin A1c levels , which was the main outcome . The research ers , study participants , and nurse therapists were not blinded to allocation after r and omization because of the nature of delivering psychological treatments . Interventions Usual Care All 3 groups continued to receive usual diabetes care . The participating hospitals agreed to a protocol of minimum st and ards of diabetes care for persons with suboptimal glycemic control  on the basis of national guidelines aim ing toward hemoglobin A1c levels of 7 % or less with no problematic hypoglycemia ( 30 ) . The frequency of clinic attendance was expected to vary depending on patient and clinic factors , but all patients were offered a minimum of 2 to 4 clinic appointments per year . At the time of the study , 2 hospital centers offered basalbolus intensive insulin therapy in combination with structured education programs and continuous , subcutaneous insulin infusion pumps ( King 's College Hospital and Guy 's and St Thomas ' Hospitals ) ( 3 ) . Treatment protocol s did not substantially change during the study . Usual Care with Motivational Enhancement Therapy We developed a OBJECTIVE Self-management of type 2 diabetes including avoidance of hypoglycemia is complex , but the impact of cognition on safe self-management is not well understood . This study aim ed to assess the effect of baseline cognitive function and cognitive decline on subsequent risk of severe hypoglycemia and to assess the effect of different glycemic strategies on these relationships . RESEARCH DESIGN AND METHODS Prospect i ve cohort analysis of data from the ACCORD trial included 2,956 adults aged ≥55 years with type 2 diabetes and additional cardiovascular risk factors .  Cognitive tests ( Digit Symbol Substitution Test [ DSST ] , Rey Auditory Verbal Learning Test , Stroop Test , and Mini Mental Status Examination )  were conducted at baseline and 20 months . Study outcomes were incident confirmed severe hypoglycemia requiring medical assistance ( HMA ) and hypoglycemia requiring any assistance ( HAA ) . RESULTS After a median 3.25-year follow-up , a 5-point-poorer baseline score on the DSST was predictive of a first episode of HMA ( hazard ratio 1.13 [ 95 % CI 1.08–1.18 ] ) . Analyses of the other cognitive tests and of HAA were consistent with the DSST results . Cognitive decline over 20 months increased the risk of subsequent hypoglycemia to a greater extent in those with lower baseline cognitive function ( Pinteraction = 0.037 ) . R and omization to an intensive versus st and ard glycemic strategy had no impact on the relationship between cognitive function and the risk of severe hypoglycemia . CONCLUSIONS Poor cognitive function increases the risk of severe hypoglycemia in patients with type 2 diabetes . Clinicians should consider cognitive function in assessing and guiding their patients regarding safe diabetes self-management regardless of their glycemic targets BACKGROUND Cardiovascular disease ( CVD ) and diabetes account for one-third of the mortality difference between African American and white patients . We evaluated the effect of a CVD risk reduction intervention in African Americans with diabetes . METHODS We r and omized 359 African Americans with type 2 diabetes to receive usual care or a nurse telephone intervention .  The 12-month intervention provided monthly self-management support and quarterly medication management facilitation . Co primary outcomes were changes in systolic blood pressure ( SBP ) , hemoglobin A1c ( HbA1c ) , and low-density lipoprotein cholesterol ( LDL-C ) over 12 months . We estimated between-intervention group differences over time using linear mixed-effects models . The secondary outcome was self-reported medication adherence . RESULTS The sample was 72 % female ; 49 % had low health literacy , and 37 % had annual income < $ 10,000 . Model-based estimates for mean baseline SBP , HbA1c , and LDL-C were 136.8 mm Hg ( 95 % CI 135.0 - 138.6 ) , 8.0 % ( 95 % CI 7.8 - 8.2 ) , and 99.1 mg/dL ( 95 % CI 94.7 - 103.5 ) , respectively . Intervention patients received 9.9 ( SD 3.0 ) intervention calls on average . Primary providers replied to 76 % of nurse medication management facilitation contacts , 18 % of these result ed in medication changes . There were no between-group differences over time for SBP ( P = .11 ) , HbA1c ( P = .66 ) , or LDL-C ( P = .79 ) . Intervention patients were more likely than those receiving usual care to report improved medication adherence ( odds ratio 4.4 , 95 % CI 1.8 - 10.6 , P = .0008 ) , but adherent patients did not exhibit relative improvement in primary outcomes . CONCLUSIONS This intervention improved self-reported medication adherence but not CVD risk factor control among African Americans with diabetes . Further research is needed to determine how to maximally impact CVD risk factors in African American patients Purpose The purpose of this study was to examine the role of self , interpersonal ( ie , family/friend ) , and organizational ( ie , health care ) support in performing diabetes-related self-management behaviors and hemoglobin A1C ( A1C ) levels among rural Latinos with type 2 diabetes . Methods Cross-sectional data from baseline interviews and medical records were used from a r and omized controlled trial conducted in rural Southern California involving a clinic sample of Latinos with type 2 diabetes ( N = 317 ) .  Self-management behaviors included  fruit and vegetable intake , fat intake , physical activity , glucose monitoring , daily examination of feet , and medication adherence . Multivariate linear and logistic regression models were used to assess the relationships of sources of support with self-management behaviors and A1C . Results Higher levels of self-support were significantly associated with eating fruits and vegetables most days/week , eating high-fat foods few days/week , engaging in physical activity most days/week , daily feet examinations , and self-reported medication adherence . Self-support was also related to A1C . Family/friend support was significantly associated with eating fruits and vegetables and engaging in physical activity most days/week . Health care support was significantly associated with consuming fats most days/week . Conclusions Health care practitioners and future interventions should focus on improving individuals ’ diabetes management behaviors , with the ultimate goal of promoting glycemic control . Eliciting family/friend support should be encouraged to promote fruit and vegetable consumption and physical activity BACKGROUND Cardiovascular disease ( CVD ) and diabetes account for over one third of the mortality difference between African Americans and white patients . The increased CVD risk in African Americans is due in large part to the clustering of multiple CVD risk factors . OBJECTIVES The current study is aim ed at improving CVD outcomes in African-American adults with diabetes by addressing the modifiable risk factors of systolic blood pressure , glycosylated hemoglobin , and low-density lipoprotein cholesterol . METHODS A sample of African American patients with diabetes ( N = 400 ) will receive written education material at baseline and be r and omized to one of 2 arms : ( 1 ) usual primary care or ( 2 ) nurse-administered disease-management intervention combining patient self-management support and provider medication management . The nurse administered intervention is delivered monthly over the telephone . The nurses also interacts with the primary care providers at 3 , 6 , and 9 months to provide concise patient up date s and facilitate changes in medical management . All patients are followed for 12 months after enrollment . The primary outcomes are change in glycosylated hemoglobin , systolic blood pressure , and low-density lipoprotein cholesterol over 12-months . Secondary outcomes include change in overall cardiovascular risk , aspirin use , and health behaviors . CONCLUSION Given the continued racial disparities in CVD , the proposed study could result in significant contributions to cardiovascular risk reduction in African-American patients Abstract Background : Overseeing proper insulin initiation and titration remains a challenging task in diabetes care . Recent advances in mobile technology have enabled new models of collaborative care between patients and healthcare providers ( HCPs ) . We hypothesized that the adoption of such technology could help individuals starting basal insulin achieve better glycemic control compared with st and ard clinical practice . Material s and Methods : This was a 12 ± 2-week r and omized controlled study with 40 individuals with type 2 diabetes who were starting basal insulin due to poor glycemic control . The control group ( n = 20 ) received st and ard face-to-face care and phone follow-up as needed in a tertiary center , whereas the intervention group ( n = 20 ) received care through the cloud-based diabetes management program where regular communications about glycemic control and insulin doses were conducted via patient self-tracking tools , shared decision-making interfaces , secure text messages , and virtual visits ( audio , video , and shared screen control ) instead of office visits . Results : By intention-to-treat analysis , the intervention group achieved a greater hemoglobin A1c decline compared with the control group ( 3.2 ± 1.5 % vs. 2.0 % ± 2.0 % ; P = 0.048 ) . The Diabetes Treatment Satisfaction Question naire showed a significant improvement in the intervention group compared with the control group ( an increase of 10.1 ± 11.7 vs. 2.1 ± 6.5 points ; P = 0.01 ) . HCPs spent less time with patients in the intervention group compared with those in the control group ( 65.9 min per subject vs. 81.6 min per subject ) . However , the intervention group required additional training time to use the mobile device . Conclusions : Mobile health technology could be an effective tool in sharing data , enhancing communication , and improving glycemic control while enabling collaborative decision making in diabetes care OBJECTIVE To determine whether short-time , real-time continuous glucose monitoring ( RT-CGM ) has long-term salutary glycemic effects in patients with type 2 diabetes who are not on pr and ial insulin . RESEARCH DESIGN AND METHODS This was a r and omized controlled trial of 100 adults with type 2 diabetes who were not on pr and ial insulin . This study compared the effects of 12 weeks of intermittent RT-CGM with self-monitoring of blood glucose ( SMBG ) on glycemic control over a 40-week follow-up period . Subjects received diabetes care from their regular provider without therapeutic intervention from the study team . RESULTS There was a significant difference in A1C at the end of the 3-month active intervention that was sustained during the follow-up period . The mean , unadjusted A1C decreased by 1.0 , 1.2 , 0.8 , and 0.8 % in the RT-CGM group vs. 0.5 , 0.5 , 0.5 , and 0.2 % in the SMBG group at 12 , 24 , 38 , and 52 weeks , respectively ( P = 0.04 ) . There was a significantly greater decline in A1C over the course of the study for the RT-CGM group than for the SMBG group , after adjusting for covariates ( P < 0.0001 ) . The subjects who used RT-CGM per protocol ( ≥48 days ) improved the most ( P < 0.0001 ) . The improvement in the RT-CGM group occurred without a greater intensification of medication compared with those in the SMBG group . CONCLUSIONS Subjects with type 2 diabetes not on pr and ial insulin who used RT-CGM intermittently for 12 weeks significantly improved glycemic control at 12 weeks and sustained the improvement without RT-CGM during the 40-week follow-up period , compared with those who used only SMBG OBJECTIVE Continuous glucose monitoring ( CGM ) has been demonstrated to improve glycemic control in adults with type 1 diabetes but less so in children . We design ed a study to assess CGM benefit in young children aged 4 to 9 years with type 1 diabetes . RESEARCH DESIGN AND METHODS After a run-in phase , 146 children with type 1 diabetes ( mean age 7.5 ± 1.7 years , 64 % on pumps , median diabetes duration 3.5 years ) were r and omly assigned to CGM or to usual care . The primary outcome was reduction in HbA1c at 26 weeks by ≥0.5 % without the occurrence of severe hypoglycemia . RESULTS The primary outcome was achieved by 19 % in the CGM group and 28 % in the control group ( P = 0.17 ) . Mean change in HbA1c was −0.1 % in each group ( P = 0.79 ) . Severe hypoglycemia rates were similarly low in both groups . CGM wear decreased over time , with only 41 % averaging at least 6 days/week at 26 weeks . There was no correlation between CGM use and change in HbA1c ( rs = −0.09 , P = 0.44 ) . CGM  wear was well tolerated , and parental satisfaction with CGM was high . However , parental fear of hypoglycemia was not reduced . CONCLUSIONS CGM in 4- to 9-year-olds did not improve glycemic control despite a high degree of parental satisfaction with CGM . We postulate that this finding may be related in part to limited use of the CGM glucose data in day-to-day management and to an unremitting fear of hypoglycemia . Overcoming the barriers that prevent integration of these critical glucose data into day-to-day management remains a challenge 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 : Of adults with type 2 diabetes , 84 % take antihyperglycemic medication . Successful treatment requires active monitoring and medication dose adjustment by health providers . The objective of this study was to determine how a mobile-phone-based coaching system for diabetes management influences physician prescribing behavior . Method : This secondary data analysis is based on a cluster r and omized clinical trial that reported patients provided with mobile self-management had reduction in glycated hemoglobin ( HbA1c ) of 1.9 % over 1 year , compared to 0.7 % in control patients ( P < .001 ) . Participants were primary care patients with type 2 diabetes r and omized at physician practice level into a control group ( n = 55 ) and intervention group ( n = 62 ) . Main study measures were patients ’ medication records ( medication , dose , frequency , start and end date ) abstract ed at baseline and study end .  Antihyperglycemic medications  , including sulfonylureas or thiazolidinediones , and antihypertensive and antilipemic medications were analyzed . Results : A higher percentage of patients in the intervention group had modification and intensification of incretin mimetics during the 1-year study period ( 9.7 % vs 0.0 % and 8.1 % vs 0.0 % , both P = .008 ) . A higher percentage of patients in the intervention group had modification and intensification of metformin  ( 24.2 % vs 7.3 % , P = .033 ) . The overall difference in physician prescribing of oral antihyperglycemic medications was not statistically significant . Conclusions : Our results suggest mobile diabetes interventions can encourage physicians to modify and intensify antihyperglycemic medications in patients with type 2 diabetes . Differences in physician prescribing behavior were modest , and do not appear to be large enough to explain a 1.2 % decrease in HbA1c The glycemic index ( GI ) reflects the postpr and ial glucose response of carbohydrate-containing foods , and adoption of a lower-GI diet may be beneficial in diabetes management . The purpose of this study was to evaluate change in food-group intake by participants after completing an intervention that included instruction about carbohydrate and the GI using a quasi-experimental design . Recruitment occurred from February to August 2005 and September to December 2006 . Individuals 40 to 70 years old with type 2 diabetes for 1 year or longer were r and omly assigned to an immediate ( n=55 ) or delayed ( n=48 ) treatment group . A 9-week group-based intervention regarding the quantity and type of carbohydrate for diabetes management was provided . Three sets of 24-hour dietary recalls were used to assess food-group intake . Foods were divided into nine main food groups and 166 subgroups based on the Dietary Guidelines for Americans 2005 and the United States Department of Agriculture 's Food Guide Pyramid . Analysis of variance was used to examine between-group differences and paired t test compared maintenance of change for the immediate group . Change in dietary GI was significantly different between groups upon completion of the intervention by the immediate group ( P<0.05 ) . Participants consumed significantly more servings of whole fruit and nonfat dairy products following the intervention and fewer servings of vegetable fats ( all P<0.05 ) . Only whole-fruit consumption significantly declined in the immediate group during the maintenance period ( P<0.05 ) . Nutrition education can facilitate adoption of a lower-GI diet among free-living people with diabetes . Maintaining dietary change likely requires further intervention and support There is an independent progressive epidemiologic relation between glycemia and cardiovascular disease ( CVD ) events ; however , whether lowering glucose levels with currently available therapies can reduce CVD events remains unknown . The Action to Control Cardiovascular Risk in Diabetes ( ACCORD ) trial is design ed to answer this question in high-risk patients with type 2 diabetes mellitus . In ACCORD , 10,251 patients with type 2 diabetes and other CVD risk factors or CVD were r and omly allocated to intensive glycemic control , targeting a glycosylated hemoglobin ( HbA1c ) level < 6 % , or st and ard glycemic control , targeting an HbA1c level of 7.0%-7.9 % . All participants are provided with diabetes education , glucose-monitoring equipment , and antidiabetic medications . All participants in the intensive glycemic control group are started on > or = 2 classes of agents . Doses are intensified or a new medication class is added every month if HbA1c levels are > or = 6 % or if > 50 % of premeal or postmeal capillary glucose readings are > 5.6 mmol/L ( 100 mg/dL ) or > 7.8 mmol/L ( 140 mg/dL ) , respectively . All drug combinations are permitted , and drugs are reduced only because of side effects or contraindications . Annual training , menus of approaches for intensification , regular electronic messaging , audits of achieved glycemia , and central feedback to sites support glycemic intensification strategies in intensive participants . In participants in the st and ard glycemic control group , therapy is intensified whenever HbA1c is > or = 8 % , and  antihyperglycemic drugs  that promote hypoglycemia  ( ie , insulin or insulin secretagogues ) are reduced if HbA1c persistently decreases to < 7 % in the setting of hypoglycemia . ACCORD addresses the hypothesis that aggressive glucose lowering prevents CVD events in patients with type 2 diabetes . It is focused on the levels of glycemia achieved using a variety of strategies , not on the specific therapies used . It will also provide information on how to safely approach near-normal levels of glucose control in clinical practice and evidence to support future clinical guidelines for diabetes management in older adults OBJECTIVE The study objective was to evaluate how the use of a pervasive blood glucose monitoring ( BGM ) technology relates to glycemic control , report of self-care behavior , and emotional response to BGM of children with type 1 diabetes and their parents . RESEARCH DESIGN AND METHODS Forty-eight children aged less than 12 years ( mean 8.8 years ) with type 1 diabetes were r and omly assigned to one of two study groups , a control group ( conventional care without technology ) or an experimental group ( conventional care with technology ) , and followed for 12 months . Families in the experimental group were given the Automated Diabetes Management System ( ADMS ) , which automatically collects blood glucose ( BG ) values and sends to parent(s ) a 21-day BG trending report via e-mail each night . Measures of glycemic control ( HbA1c ) were collected at baseline and at quarterly diabetes clinic visits ; BGM effect and diabetes self-care behavior measures were obtained at the baseline , 6-month , and 12-month visits . RESULTS Children in the experimental group had significantly ( P = 0.01 ) lower HbA1c at 12 months ( 7.44 ± 0.94 , −0.35 from baseline ) than controls ( 8.31 ± 1.24 , + 0.15 from baseline ) . Improvement in HbA1c was more profound in families using the ADMS more frequently . In addition , in these families , parents showed a significant improvement in BGM effect ( P = 0.03 ) and children became more meticulous in diabetes self-care ( P = 0.04 ) . Children in both experimental and control groups experienced no change in their emotional response to BGM . CONCLUSIONS Using the ADMS 1–3 times/week may help children with type 1 diabetes  improve glycemic control and gain diabetes self-management skills , as well as improve the BGM effect of parents Purpose The purpose of this study was to determine the impact of diabetes self-management education ( DSME ) in improving processes and outcomes of diabetes care as measured by a five component diabetes bundle and HbA1c , in individuals with type 2 diabetes mellitus ( T2DM ) . Methods A retrospective analysis was performed for adult T2DM patients who received DSME training in 2011–2012 from an accredited American Diabetes Association center at Intermountain Healthcare ( IH ) and had an HbA1c measurement within the prior 3 months and 2–6 months after completing their first DSME visit . Control patients were selected from the same clinics as case- patients using r and om number generator to achieve a 1 to 4 ratio . Case and control patients were included if 1 ) pre-education HbA1c was between 6.0%–14.0 % ; 2 ) their main provider was a primary care physician ; 3 ) they met the national Healthcare Effectiveness Data and Information Set criteria for inclusion in the IH diabetes registry . The IH diabetes bundle includes retinal eye exam , nephropathy screening or prescription of angiotensin converting enzyme or angiotensin receptor blocker ; blood pressure < 140/90 mmHg , LDL < 100 mg/dL , HbA1c < 8.0 % . Results DSME patients had a significant difference in achievement of the five element IH diabetes bundle and in HbA1c % compared to those without DSME . After adjusting for possible confounders in a multivariate logistic regression model , DSME patients had a 1.5 fold difference in improvement in their diabetes bundle and almost a 3 fold decline in HbA1c compared to the control group . Conclusion St and ardized DSME taught within an IH American Diabetes Association center is strongly associated with a substantial improvement in patients meeting all five elements of a diabetes bundle and a decline in HbA1c beyond usual care . Given the low operating cost of the DSME program , these results strongly support the value adding benefit of this program in treating T2DM patients Purpose The purpose of this study is to evaluate the impact of a promotores-led diabetes self-management program by comparing the outcomes ( knowledge , beliefs , and HbA1c level ) of Mexican American patients with type 2 diabetes who received usual diabetic care in a wait-list control group  to those who received self-management education and follow-up by promotores in consultation with clinic providers and staff . Methods This r and omized control study compared the results of 63 patients who attended a promotores-led culturally sensitive diabetes self-management course at a commu- nity clinic with 68 patients in a wait-list , usual-care control group . Participants were Mexican Americans with type 2 diabetes who were patients at the clinic and at least 18 years of age . At baseline , 3 months , and 6 months , the Diabetes Knowledge Question naire ( DKQ ) , Health Beliefs Question naire ( HBQ ) , and HbA1c levels ( drawn by the clinic laboratory ) were collected . Results There was a significant improvement in the intervention group 's DKQ scores over time and in treatment by time . The baseline HbA1c level was 7.49 and did not change over time in either group . The DKQ , HBQ , and HbA1c results were significantly affected by age ; the DKQ and HbA1c were affected by years with diabetes . Conclusions The promotores-led diabetes self-management course improved the knowledge of patients with diabetes . Participant baseline HbA1c level was close to therapeutic level ( much lower than reported in previous studies ) , suggesting participants received good medical care within the community clinic Purpose The purpose of this study was to determine whether “ clinical inertia”—inadequate intensification of therapy by the provider — could contribute to high A1C levels in patients with type 2 diabetes managed in a primary care site . Methods In a prospect i ve observational study , management was compared in the Medical Clinic , a primary care site supervised by general internal medicine faculty , and the Diabetes Clinic , a specialty site supervised by endocrinologists . These municipal hospital clinics serve a common population that is largely African American , poor , and uninsured . Results Four hundred thirty-eight African American patients in the Medical Clinic and 2157 in the Diabetes Clinic were similar in average age , diabetes duration , body mass index , and gender , but A1C averaged 8.6 % in the Medical Clinic versus 7.7 % in the Diabetes Clinic ( P < .0001 ) . Use of pharmacotherapy  was less intensive in the Medical Clinic ( less use of insulin ) , and when patients had elevated glucose levels during clinic visits , therapy was less than half as likely to be advanced in the Medical Clinic compared to the Diabetes Clinic ( P < .0001 ) . Intensification rates were lower in the Medical Clinic regardless of type of therapy ( P < .0001 ) , and intensification of therapy was independently associated with improvement in A1C ( P < .001 ) . Conclusions Medical Clinic patients had worse glycemic control , were less likely to be treated with insulin , and were less likely to have their therapy intensified if glucose levels were elevated . To improve diabetes management and glycemic control nationwide , physicians in training and generalists must learn to overcome clinical inertia , to intensify therapy when appropriate , and to use insulin when clinical ly indicated OBJECTIVE Web-based diabetes management can be used to provide frequent interactions between patients and providers and thus result in improved glycemic control . METHODS In a single-center , prospect i ve feasibility study , 16 poorly controlled patients with either type 1 or 2 diabetes mellitus were enrolled to assess the impact of using MyCareTeam , a web-based diabetes management application , for diabetes management . Patients were asked to transfer their blood glucose data electronically , maintain exercise logs , and communicate with their provider via MyCareTeam . The provider gave clinical interventions to optimize blood glucose control and provided feedback via MyCareTeam . Diabetes , nutrition , and exercise information was also available via MyCareTeam . RESULTS A significant reduction of over 2.22 % points in hemoglobin A1C was seen for the total patient population . Differences between moderate/heavy users ( n = 8) versus light/never users ( n = 8) of MyCareTeam were evaluated for intergroup differences based upon utilization . Moderate/heavy users had a significant 6-month A1C reduction of 3.15 percentage points compared with a reduction of 1.28 percentage points in light/never users . Other secondary end points were improved as well , including systolic blood pressure , diastolic blood pressure , total cholesterol , high-density lipoprotein , low-density lipoprotein , and triglycerides . However , as expected , body mass index levels increased because of aggressive diabetes management with insulin therapy . CONCLUSIONS These results demonstrate a significant treatment effect from the MyCareTeam application . A larger r and omized control trial is under way at the Boston Veterans Administration Healthcare System . If these results are confirmed as expected , then web-based diabetes management may prove to be the link to achieving target American Diabetes Association glycemic goals in patients with poorly controlled diabetes OBJECTIVE To test cognitive behavioral therapy for  adherence and depression ( CBT-AD ) in type 2 diabetes . We hypothesized that CBT-AD would improve adherence ; depression ; and , secondarily , hemoglobin A1c ( A1C ) . RESEARCH DESIGN AND METHODS Eighty-seven adults with unipolar depression and uncontrolled type 2 diabetes received enhanced treatment as usual ( ETAU ) , including medication adherence , self-monitoring of blood glucose ( SMBG ) , and lifestyle counseling ; a provider letter documented psychiatric diagnoses . Those r and omized to the intervention arm also received 9–11 sessions of CBT-AD . RESULTS Immediately after acute treatment ( 4 months ) , adjusting for baseline , CBT-AD had 20.7 percentage points greater oral medication adherence on electronic pill cap ( 95 % CI −31.14 to −10.22 , P = 0.000 ) ; 30.2 percentage points greater SMBG adherence through glucometer downloads ( 95 % CI −42.95 to −17.37 , P = 0.000 ) ; 6.44 points lower depression scores on the Montgomery-Asberg Depression Rating Scale ( 95 % CI 2.33–10.56 , P = 0.002 ) ; 0.74 points lower on the Clinical Global Impression ( 95 % CI 0.16–1.32 , P = 0.01 ) ; and 0.72 units lower A1C ( 95 % CI 0.29–1.15 , P = 0.001 ) relative to ETAU . Analyses of 4- , 8- , and 12-month follow-up time points indicated that CBT-AD maintained 16.3 percentage points higher medication adherence ( 95 % CI −26.1 to −6.5 , P = 0.001 ) ; 22.3 percentage points greater SMBG adherence ( 95 % CI −36.1 to −8.6 , P = 0.002 ) ; and 0.63 units lower A1C ( 95 % CI 0.06–1.2 , P = 0.03 ) after acute treatment ended . For depression , there was some evidence of continued improvement posttreatment , but no between-group differences . CONCLUSIONS CBT-AD is an effective intervention for adherence , depression , and glycemic control , with enduring and clinical ly meaningful benefits for diabetes self-management and glycemic control in adults with type 2 diabetes and depression
This systematic review found robust data demonstrating that engagement in diabetes self-management education results in a statistically significant decrease in A1C levels .
PRACTICE IMPLICATION S The data suggest mode of delivery , hours of engagement , and baseline A1C can affect the likelihood of achieving statistically significant and clinical ly meaningful improvement in A1C
OBJECTIVE Assess effect of diabetes self-management education and support methods , providers , duration , and contact time on glycemic control in adults with type 2 diabetes .