Effect of a community-based diabetes self-management empowerment program on mental health-related quality of life: a causal mediation analysis from a randomized controlled trial Design of a randomized, controlled, comparative-effectiveness trial testing a Family Model of Diabetes Self-Management Education (DSME) vs. Standard DSME for Marshallese in the United States Who Can Provide Diabetes Self-Management Support in Primary Care? Diabetes Self-Management Education: Miles to Go A culturally targeted self-management program for African Americans with type 2 diabetes mellitus. Do pre-existing diabetes social support or depressive symptoms influence the effectiveness of a diabetes management intervention? The diabetes nutrition education study randomized controlled trial: A comparative effectiveness study of approaches to nutrition in diabetes self-management education. Psychosocial Outcomes of Telemedicine Case Management for Elderly Patients With Diabetes Behavioural interventions for type 2 diabetes: an evidence-based analysis. Motivational interviewing delivered by diabetes educators: does it improve blood glucose control among poorly controlled type 2 diabetes patients? Comparative effectiveness of a mindful eating intervention to a diabetes self-management intervention among adults with type 2 diabetes: a pilot study. Social Support Groups in the Maintenance of Glycemic Control after Community-Based Intervention TeleHealth Improves Diabetes Self-Management in an Underserved Community Culturally Tailored Intervention for Rural African Americans With Type 2 Diabetes Comparative Effectiveness of Dipeptidylpeptidase-4 Inhibitors in Type 2 Diabetes: A Systematic Review and Mixed Treatment Comparison Peer-Led, Empowerment-Based Approach to Self-Management Efforts in Diabetes (PLEASED): A Randomized Controlled Trial in an African American Community Community-based care for the management of type 2 diabetes: an evidence-based analysis. A randomized comparison of a commercially available portion-controlled weight-loss intervention with a diabetes self-management education program A Home-Based Type 2 Diabetes Self-Management Intervention in Rural Guatemala
Background There is a paucity of evidence supporting the effectiveness of diabetes self-management education ( DSME ) in improving mental health-related quality of life ( HRQoL ) for African American and Latinos . Also , among studies supporting the favorable effects of DSME on mental HRQoL , the direct effect of DSME that is independent of improved glycemic control has never been investigated . The objectives of this study were to investigate the effect of community-based DSME intervention targeting empowerment on mental HRQoL and to determine whether the effect is direct or mediated by glycemic control . Methods We conducted secondary analyses of data from the Diabetes Self-Care Study , a r and omized controlled trial of a community-based DSME intervention . Study participants ( n = 516 ) were African Americans and Latinos 55 years or older with poorly controlled diabetes ( HbA1c ≥ 8.0 % ) recruited from senior centers and churches in Los Angeles . The intervention group received six weekly small-group self-care sessions based on the empowerment model . The control group received six lectures on unrelated geriatrics topics . The primary outcome variable in this secondary analysis was the change in Mental Component Summary score ( MCS-12 ) from the SF-12 Health Survey between baseline and six-month follow-up . We used the change in HbA1c during the study period as the main mediator of interest in our causal mediation analysis . Additionally , possible mediations via social support and perceived empowerment attributable to the program were examined . Results MCS-12 increased by 1.4 points on average in the intervention group and decreased by 0.2 points in the control group ( difference-in-change : 1.6 points , 95 % CI : 0.1 to 3.2 ) . In the causal mediation analysis , the intervention had a direct effect on MCS-12 improvement ( 1.7 points , 95 % CI : 0.2 to 3.2 ) with no indirect effects mediated via HbA1c change ( −0.1 points , 95 % CI : −0.4 to 0.1 ) , social support ( 0.1 points ) , and perception of empowerment ( 0.1 points ) . Conclusions This Diabetes Self-Care Study empowerment intervention had a modest positive impact on mental HRQoL not mediated by the improvement in glycemic control , as well as social support and perception of empowerment . This favorable effect on mental HRQoL may be a separate clinical advantage of this DSME intervention . Trial Registration Clinical Trial.gov NCT00263835 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 comparative effectiveness study is to compare diabetes self-management support ( DSMS ) approaches and determine who can be most effective in helping patients maintain/improve clinical  outcomes  ,  self-care behaviors , distress , and satisfaction following  diabetes self-management education ( DSME )  delivered in primary care . Methods After receiving DSME , 141 participants were r and omized to receive DSMS delivered by a trained supporter :  educator , peer , practice staff , or usual education during a 6-month follow-up period . DSMS groups were compared to determine which supporter helped participants to maintain/improve A1C , blood pressure , lipids , weight , self-care , and distress . DSMS satisfaction was also examined . Results There was a significant improvement in A1C , empowerment , aspects of self-care , and distress following DSME at 6 weeks . Those in the educator DSMS group best sustained improved A1C while those in the other DSMS groups maintained glycemic improvements but began to show trends toward worsening . No significant differences or clear trends were seen in other clinical , behavioral , or psychosocial outcomes . The Program Reinforcement Impacts Self-Management ( PRISM ) study demonstrates that following DSME , participants maintained improved glycemia , lipid , weight , and self-care behaviors and reductions in distress throughout the delivery of DSMS interventions regardless of DSMS supporter . All of the participants reported satisfaction with DSMS . Conclusions These findings reaffirm the critical role of educators but suggest that others may serve as DSMS supporters . Results suggest that DSME delivered in primary care is effective and multiple DSMS agents are reasonable . As patient-centered self-management approaches are being explored in primary care , delivery of DSME and DSMS becomes paramount This meta- analysis assessed how successfully Diabetes Self-Management Education ( DSME ) interventions help people with type 2 diabetes achieve and maintain healthy blood glucose levels . We included 52 DSME programs with 9,631 participants that reported post-intervention A1c levels in r and omized controlled trials . The training conditions result ed in significant reductions in A1c levels compared to control conditions . However , the impact of intervention was modest shifting of only 7.23 % more participants from diabetic to pre-diabetic or normal status , relative to the control condition . Most intervention participants did not achieve healthy A1c levels . Further , few DSME studies assessed long-term maintenance of A1c gains . Past trends suggest that gains are difficult to sustain over time . Our results suggested that interventions delivered by nurses were more successful than those delivered by non-nursing personnel . We suggest that DSME programs might do better by going beyond procedural interventions . Most DSME programs relied heavily on rules and procedures to guide decisions about diet , exercise , and weight loss . Future DSME may need to include cognitive self-monitoring , diagnosis , and planning skills to help patients detect anomalies , identify possible causes , generate corrective action , and avoid future barriers to maintaining healthy A1c levels . Finally , comprehensive descriptions of DSME programs would advance future efforts Inadequate knowledge of the influence of lifestyle on clinical outcomes contributes to the difficulties many African Americans experience with type 2 diabetes mellitus ( T2DM ) . This pilot study examined a 12-week church-based culturally targeted diabetes self-management education ( DSME ) intervention for middle-aged and older African Americans with T2DM . Quantitative data were collected at baseline and at 12 weeks and included question naires and anthropometric measures . There were significant increases in medication adherence ( p = .006 ) , healthy eating ( p = .009 ) , and foot care adherence ( p = .003 ) . The intervention had a clinical ly significant effect on systolic blood pressure , blood lipids , physical activity , and waist circumference . Church-based culturally targeted DSME interventions may result in improved outcomes for African-American adults with T2DM . The authors discuss the value of community-based interventions that target behavioural changes in population s of chronically ill patients , particularly those who historically have been disenfranchised and /or underserved 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 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 Diabetes case management ( DCM ) may improve medical outcomes ( 1,2 ) . Case managers coordinate care and often provide a mix of interventions , e.g. , telephone outreach , education , reminders . However , the efficacy of DCM is unclear . Three systematic review s lend only limited support for the efficacy of DCM for improving glycemic control but none for lipid , weight , or blood pressure benefits ( 3–5 ) . DCM studies typically target biomedical outcomes and ignore potential psychosocial effects . Yet , psychosocial variables ( e.g. , depression , anxiety , social support ) relate to hyperglycemia , complications , adherence , and quality of life ( 6–11 ) . Thus , a positive impact of DCM on these factors is important . Two studies did assess psychosocial outcomes of DCM and found improved self-efficacy and satisfaction ( cluster visit ) ( 12 ) and quality of life ( dietitian-led DCM group ) ( 13 ) . Because barriers ( e.g. , distance , weather ) limit DCM access , telemedicine can be used . A review of telemedicine versus face-to-face trials concluded that , while feasible and acceptable , there is little evidence that telemedicine has clinical benefits ( 14 ) . Our team published results of a trial of telemedicine DCM versus usual care for elderly diabetic patients ( 15 ) . The intervention result ed in significant improvements in glycemic control , blood pressure , and total and LDL cholesterol ( 16 ) . The purpose of the Informatics for Diabetes Education and Telemedicine ( IDEATel ) project , funded by the Centers for Medicare and Medicaid Services , is to evaluate the feasibility and effectiveness of telemedicine with a diverse , medically underserved , elderly diabetic sample . The purpose of this study is to assess the impact of the IDEATel intervention on secondary psychosocial outcomes . A detailed description of the IDEATel study design has been previously reported ( 15,16 ) . Medicare recipients were recruited if they were aged ≥55 years , diagnosed with diabetes , and without moderate/severe impairments or comorbidities . Research nurses blinded to the groups 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 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 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 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 OBJECTIVE To conduct a 1-year r and omized clinical trial to evaluate a remote comprehensive diabetes self-management education ( DSME ) intervention , Diabetes TeleCare , administered by a dietitian and nurse/certified diabetes educator ( CDE ) in the setting of a federally qualified health center ( FQHC ) in rural South Carolina . RESEARCH DESIGN AND METHODS Participants were recruited from three member health centers of an FQHC and were r and omized to either Diabetes TeleCare , a 12-month , 13-session curriculum delivered using telehealth strategies , or usual care .  RESULTS Mixed linear regression model results for repeated measures showed a significant reduction in glycated hemoglobin ( GHb ) in the Diabetes TeleCare group from baseline to 6 and 12 months ( 9.4 ± 0.3 , 8.3 ± 0.3 , and 8.2 ± 0.4 , respectively ) compared with usual care ( 8.8 ± 0.3 , 8.6 ± 0.3 , and 8.6 ± 0.3 , respectively ) . LDL cholesterol was reduced at 12 months in the Diabetes TeleCare group compared with usual care . Although not part of the original study design , GHb was reduced from baseline to 12 and 24 months in the Diabetes TeleCare group ( 9.2 ± 0.4 , 7.4 ± 0.5 , and 7.6 ± 0.5 , respectively ) compared with usual care ( 8.7 ± 0.4 , 8.1 ± 0.4 , and 8.1 ± 0.5 , respectively ) in a post hoc analysis of a subset of the r and omized sample who completed a 24-month follow-up visit . CONCLUSIONS Telehealth effectively created access to successfully conduct a 1-year remote DSME by a nurse CDE and dietitian that improved metabolic control and reduced cardiovascular risk in an ethnically diverse and rural population Purpose The purpose of this pilot study was to evaluate a culturally tailored intervention for rural African Americans . Social Cognitive Theory provided the framework for the study . Methods Twenty-two participants were recruited and r and omly assigned to either Group or Individual diabetes self-management ( DSME ) . Group DSME included story-telling , h and s-on activities , and problem-solving exercises . Individual DSME sessions focused on goal - setting and problem-solving strategies . Sessions were offered in an accessible community center over a 10-week period . Results Outcomes included glycosylated hemoglobin ( A1C ) , self-care actions , self-efficacy level , goal attainment , and satisfaction with DSME . Participants in both Group and Individual DSME improved slightly over the 3-month period in self-care activities , A1C level , and goal attainment . Although differences were not statistically significant , trends indicate improved scores on dietary actions , foot care , goal attainment , and empowerment for those experiencing Group DSME . Conclusions The culturally tailored approach was well received by all participants . Improvements among those receiving Individual DSME may indicate that brief sessions using a culturally tailored approach could enhance self-care and glycemic control . Additional testing among more participants over a longer time period is recommended Objective To compare the safety and efficacy of the dipeptidylpeptidase-4 ( DPP-4 ) inhibitors in patients with type 2 diabetes and inadequate glycemic control . Design Systematic review of r and omized controlled trials ( RCTs ) , health economic evaluation studies , systematic review s , and meta-analyses , followed by primary Bayesian mixed treatment comparison meta-analyses ( MTCs ) , and secondary frequentist direct-comparison meta-analyses using a r and om-effects model . Outcomes were reported as weighted mean change from baseline , or odds ratio ( OR ) with 95 % credible interval . Data sources MEDLINE , MEDLINE In-Process , EMBASE , and BIOSIS via Dialog ProQuest ; Cochrane Central Register of Controlled Trials and Cochrane Data base of Systematic Review s via EBSCO ; four diabetes and two technical congress abstract s ; and health technology assessment organization websites . Eligibility criteria Patients with type 2 diabetes and inadequate glycemic control receiving any pharmacological anti-diabetic treatment . Data extraction and analysis Title/ abstract s were review ed for eligibility , followed by full-text review of publications remaining after first pass . A three-person team filtered articles and an independent review er checked a r and om selection ( 10 % ) of filtered articles . Data extraction and quality assessment of studies were also independently review ed . Five DPP-4 inhibitors ( alogliptin , linagliptin , saxagliptin , sitagliptin , and vildagliptin ) were compared via meta- analysis ( where data were available ) as monotherapy , dual therapy ( plus metformin , sulfonylurea , pioglitazone , or insulin ) , and triple therapy ( plus metformin/sulfonylurea ) . Results The review identified 6,601 articles ; 163 met inclusion criteria and 85 publications from 83 RCTs contained sufficient or appropriate data for analysis . MTCs demonstrated no differences between DPP-4 inhibitors in mean change from baseline in glycosylated hemoglobin ( HbA1c ) or body weight , or the proportions of patients achieving HbA1c < 7 % or experiencing a hypoglycemic event , apart from in patients on alogliptin plus metformin , who achieved HbA1c < 7 % more frequently than those treated with saxagliptin plus metformin [ OR 6.41 ( 95 % CI 3.15–11.98 ) versus 2.17 ( 95 % CI 1.56–2.95 ) ] . Conclusions This systematic review and MTC showed similar efficacy and safety for DPP-4 inhibitors as treatment for type 2 diabetes , either as monotherapy or combination therapy 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 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 the efficacy of specialized multidisciplinary community care for the management of type 2 diabetes compared to usual care . CLINICAL NEED TARGET POPULATION AND CONDITION Diabetes ( i.e. diabetes mellitus ) is a highly prevalent chronic metabolic disorder that interferes with the body 's ability to produce or effectively use insulin . The majority ( 90 % ) of diabetes patients have type 2 diabetes . ( 1 ) Based on the United Kingdom Prospect i ve Diabetes Study ( UKPDS ) , intensive blood glucose and blood pressure control significantly reduce the risk of microvascular and macrovascular complications in type 2 diabetics . While many studies have documented that patients often do not meet the glycemic control targets specified by national and international guidelines , factors associated with glycemic control are less well studied , one of which is the provider(s ) of care . Multidisciplinary approaches to care may be particularly important for diabetes management . According guidelines from the Canadian Diabetes Association ( CDA ) , the diabetes health care team should be multi- and interdisciplinary . Presently in Ontario , the core diabetes health care team consists of at least a family physician and /or diabetes specialist , and diabetes educators ( registered nurse and registered dietician ) . Increasing the role played by allied health care professionals in diabetes care and their collaboration with physicians may represent a more cost-effective option for diabetes management . Several systematic review s and meta-analyses have examined multidisciplinary care programs , but these have either been limited to a specific component of multidisciplinary care ( e.g. intensified education programs ) , or were conducted as part of a broader disease management program , of which not all were multidisciplinary in nature . Most review s also do not clearly define the intervention(s ) of interest , making the evaluation of such multidisciplinary community programs challenging . EVIDENCE -BASED ANALYSIS METHODS RESEARCH QUESTIONS What is the evidence of efficacy of specialized multidisciplinary community care provided by at least a registered nurse , registered dietician and physician ( primary care and /or specialist ) for the management of type 2 diabetes compared to usual care ? [ Henceforth referred to as Model 1]What is the evidence of efficacy of specialized multidisciplinary community care provided by at least a pharmacist and a primary care physician for the management of type 2 diabetes compared to usual care ? [ Henceforth referred to as Model 2 ] INCLUSION CRITERIA English language full-reportsPublished between January 1 , 2000 and September 28 , 2008R and omized controlled trials ( RCTs ) , systematic review s and meta-analysesType 2 diabetic adult population ( ≥18 years of age)Total sample size ≥30Describe specialized multidisciplinary community care defined as ambulatory-based care provided by at least two health care disciplines ( of which at least one must be a specialist in diabetes ) with integrated communication between the care providers . Compared to usual care ( defined as health care provision by non-specialist(s ) in diabetes , such as primary care providers ; may include referral to other health care professionals/services as necessary)≥6 months follow-up EXCLUSION CRITERIA Studies where discrete results on diabetes can not be abstract edPredominantly home-based interventions Inpatient-based interventions OUTCOMES OF INTEREST The primary outcomes for this review were glycosylated hemoglobin ( rHbA1c ) levels and systolic blood pressure ( SBP ) . SEARCH STRATEGY A literature search was performed on September 28 , 2008 using 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 1 , 2000 and September 28 , 2008 . Abstract s were review ed by a single review er and , for those studies meeting the eligibility criteria , full-text articles were obtained . Reference lists were also examined for any additional relevant studies not identified through the search . Articles with unknown eligibility were review ed with a second clinical epidemiologist , then a group of epidemiologists until consensus was established . The quality of evidence was assessed as high , moderate , low or very low according to GRADE methodology . Given the high clinical heterogeneity of the articles that met the inclusion criteria , specific models of specialized multidisciplinary community care were examined based on models of care that are currently being supported in Ontario , models of care that were commonly reported in the literature , as well as suggestions from an Expert Advisory Panel Meeting held on January 21 , 2009 . SUMMARY OF FINDINGS The initial search yielded 2,116 unique citations , from which 22 RCTs trials and nine systematic review s published were identified as meeting the eligibility criteria . Of these , five studies focused on care provided by at least a nurse , dietician , and physician ( primary care and /or specialist ) model of care ( Model 1 ; see Table ES 1 ) , while three studies focused on care provided by at least a pharmacist and primary care physician ( Model 2 ; see Table ES 2 ) . Based on moderate quality evidence , specialized multidisciplinary community care Model 2 has demonstrated a statistically and clinical ly significant reduction in HbA1c of 1.0 % compared with usual care . The effects of this model on SBP , however , are uncertain compared with usual care , based on very-low quality evidence . Specialized multidisciplinary community care Model 2 has demonstrated a statistically and clinical ly significant reduction in both HbA1c of 1.05 % ( based on high quality evidence ) and SBP of 7.13 mm Hg ( based on moderate quality evidence ) compared to usual care . For both models , the evidence does not suggest a preferred setting of care delivery ( i.e. , primary care vs. hospital outpatient clinic vs. community clinic ) . Table ES1 : Summary of Results of Meta-Analyses of the Effects of Multidisciplinary Care Model 1 Outcome Estimate of effect(95 % CI)Heterogeneity I(2)(p-value ) GRADE Glycosylated Hemoglobin ( HbA1c [%])-1.00 [ -1.27 , -0.73]4 % (p=0.37)Moderate- quality Subgroup : Moderate-to-High Quality -0.91 [ -1.19 , -0.62]0 % (p=0.74)Systolic Blood Pressure ( mm Hg)-2.04 [ -13.80 , 9.72]89 % (p=0.002)Very-low quality * Mean change from baseline to follow-up between intervention and control groupsTable ES2 : Summary of Results of Meta-Analyses of the Effects of Multidisciplinary Care Model 2 Outcome Estimate of effect(95 % CI)Heterogeneity I(2)(p-value ) GRADE Glycosylated Hemoglobin ( HbA1c [%])-1.05 [ -1.57 , -0.52]0 % (p=0.75)High- quality Systolic Blood Pressure ( mm Hg)-7.13 [ -11.78 , -2.48]46 % (p=0.17)Moderate quality * Mean change from baseline to follow-up between intervention and control groups Objective : This study examined the efficacy of a commercially available , portion-controlled diet ( PCD ) on body weight and HbA1c over 6 months in obese patients with type 2 diabetes . Research Design and Methods : One-hundred participants with a mean±s.d . age of 55.6±10.6 year , body weight of 102.9±18.4 kg and HbA1c of 7.7±1.3 % were r and omly assigned to a 9-session group lifestyle intervention that included a PCD or to a 9-session group program of diabetes self-management education ( DSME ) . Participants in the two groups were prescribed the same goals for energy intake ( 1250–1550 kcal per day ) and physical activity ( 200 min per week ) . Results : While both groups produced significant improvements in weight and HbA1c after 6 months of treatment , PCD participants lost 7.3 kg [ 95 % confidence interval ( CI ) : −5.8 to −8.8 kg ] , compared with 2.2 kg ( 95 % CI : −0.7 to −3.7 kg ) in the DSME group ( P<0.0001 ) . Significantly more PCD than DSME participants lost ⩾5 % of initial weight ( 54.0 % vs 14.0 % , P<0.0001 ) and ⩾10 % ( 26.0 % vs 6.0 % , P<0.0001 ) . HbA1c declined by 0.7 % ( 95 % CI : −0.4 to −1.0 % ) in the PCD group , compared with 0.4 % ( 95 % CI : −0.1 to −0.7 % ) in DSME ( P<0.026 ) . Across both groups , larger weight losses were associated with greater reductions in HbA1c ( r=0.52 , P<0.0001 ) . Conclusions : These findings demonstrate that a commercially available portion-controlled meal plan can induce clinical ly meaningful improvements in weight and glycemic control in obese individuals with type 2 diabetes . These data have implication s for the management of obesity in primary care , as now provided by the Centers for Medicare and Medicaid Services Introduction Diabetes self-management education ( DSME ) is a fundamental element of type 2 diabetes care . Although 75 % of adults with diabetes worldwide live in low-income and middle-income countries ( LMICs ) , limited DSME research has been conducted in LMICs . The objective of this study was to evaluate a home-based DSME intervention in rural Guatemala . Methods We conducted a prospect i ve study of a DSME intervention using a quasi-experimental , single-group pretest – posttest design . We enrolled 90 participants in the intervention , which consisted of 6 home visits ( May 2014–July 2016 ) conducted by a diabetes educator using a curriculum culturally and linguistically tailored to rural Mayan population s. Primary outcomes were changes in mean hemoglobin A1c ( HbA1c ) and mean systolic and diastolic blood pressure at baseline and at 12 months . Secondary outcomes were diabetes knowledge and self-care activities at baseline and intervention completion . Results HbA1c decreased significantly from baseline to 12 months ( absolute mean change , −1.5 % ; 95 % confidence interval [ CI ] , −1.9 % to −1.0 % ; P < .001 ) . Systolic blood pressure also improved significantly at 12 months ( −6.2 mm Hg ; 95 % CI , −10.1 to −2.2 mm Hg ; P = .002 ) ; changes in diastolic blood pressure were not significant ( −1.6 mm Hg ; 95 % CI , −3.9 to −0.7 mm Hg ; P = .17 ) . We also found significant improvements in diabetes knowledge and self-care activities from baseline to intervention completion . Conclusion DSME interventions can be successfully delivered in a setting with an underre source d health system , high poverty rate , and unique cultural characteristics like Mayan Guatemala . Our findings point to the need for more DSME research in re source -limited setting s globally
Discussion Findings suggest that medically underserved patients with diabetes achieve glycemic benefit following HIT DSME interventions , with dissipating but significant effects at 12 months .
Telemedicine/telehealth interventions were the most successful HIT type because they incorporated interaction with educators similar to in-person DSME .
Conclusion These results are similar to in-person DSME in medically underserved patients , showing that well- design ed HIT DSME has the potential to increase access and improve outcomes for this vulnerable group
Objective The purpose of this systematic review and meta- analysis was to examine the effect of health information technology ( HIT ) diabetes self-management education ( DSME ) interventions on glycemic control in medically underserved patients .