Diabetes Metab J.  2012 Jun;36(3):222-229. 10.4093/dmj.2012.36.3.222.

Influence of the Duration of Diabetes on the Outcome of a Diabetes Self-Management Education Program

• Ko SH
• Park SA
• Cho JH
• Ko SH
• Shin KM
• Lee SH
• Song KH
• Park YM
• Ahn YB

• KMID: 2281403
• DOI: http://doi.org/10.4093/dmj.2012.36.3.222

Abstract

BACKGROUND
Diabetes education and lifestyle modification are critical components in controlling blood glucose levels of people with type 2 diabetes. Until now, available data on the effectiveness of education with respect to the duration of diabetes are limited. We investigated whether adherence to lifestyle behavior modification prompted by diabetes education was influenced by the duration of diabetes.
METHODS
Two hundred and twenty-five people with type 2 diabetes were recruited for an intensive, collaborative, group-based diabetes education program with annual reinforcement. We divided the patients into two groups based on the duration of their diabetes prior to the education program (< or =1 year [< or =1Y] vs. > or =3 years [> or =3Y]). Dietary habits, physical activity, and the frequency of blood glucose self-monitoring were evaluated with a questionnaire prior to education and at the follow-up endpoint.
RESULTS
The mean follow-up period was 32.2 months. The mean hemoglobin A1c (A1C) value was significantly lower in the < or =1Y group. Self-care behaviors, measured by scores for dietary habits (P=0.004) and physical activity (P<0.001), were higher at the endpoint in the < or =1Y group than in the > or =3Y group. Logistic regression analysis revealed that a longer diabetes duration before education was significantly associated with mean A1C levels greater than or equal to 7.0% (53 mmol/mol).
CONCLUSION
Diabetes duration influenced the effectiveness of diabetes education on lifestyle behavior modification and glycemic control. More-intense, regular, and sustained reinforcement with encouragement may be required for individuals with longstanding type 2 diabetes.

Keyword

Blood glucose; Diabetes mellitus, type 2; Education; Lifestyle modification

MeSH Terms

Behavior Therapy
Blood Glucose
Blood Glucose Self-Monitoring
Diabetes Mellitus, Type 2
Follow-Up Studies
Food Habits
Hemoglobins
Humans
Life Style
Logistic Models
Motor Activity
Reinforcement (Psychology)
Self Care
Surveys and Questionnaires
Blood Glucose
Hemoglobins

Figure

• 

  Fig. 1 Enrollment of patients with type 2 diabetes mellitus and the study design. Data represent the number (%) of patients.

• 

  Fig. 2 Changes in the scores of lifestyle behaviors during the study period with respect to the duration of diabetes before education. (A) Before education. (B) After education. Diet habit: Score 1, irregular diet with unlimited snacks; 2, irregular with intermittent snacks; 3, appropriate meal calories, regular diet with some snacks (>2 times/day or >300 kcal/day of excess intake; 4, appropriate meal calories, but a few snacks (≤1 time/day, or 100 to 300 kcal/day of excess calorie); 5, tightly controlled, with no intermittent snacks. Self-monitoring of blood glucose (SMBG): Score 1, never; 2, monthly; 3, weekly; 4, 3 to 4 times/wk; 5, ≥ daily. Physical activity: 1, never; 2, <30 min/wk (weekly); 3, <60 min/wk (1 to 2 times per week); 4, <120 min/wk (3 to 4 times per week); 5, daily, >150 min/wk. The P values denote the differences between the groups (≤1Y vs. ≥3Y) at the given time point.

• 

  Fig. 3 Mean hemoglobin A1c (A1C) levels in both groups. (A) Mean values during the study period. (B) Changes in A1C levels in both groups. Data are presented as the mean±standard deviation. ≤1Y, diabetes duration of less than 1 year before diabetes education or in recently diagnosed patients; ≥3Y, diabetes duration of more than 3 years before education. aP<0.05 vs. ≤1Y group.

Reference

1. American Diabetes Association. Standards of medical care in diabetes: 2011. Diabetes Care. 2011. 34:Suppl 1. S11–S61.

2. Assal JP, Muhlhauser I, Pernet A, Gfeller R, Jorgens V, Berger M. Patient education as the basis for diabetes care in clinical practice and research. Diabetologia. 1985. 28:602–613.

3. Norris SL, Lau J, Smith SJ, Schmid CH, Engelgau MM. Self-management education for adults with type 2 diabetes: a meta-analysis of the effect on glycemic control. Diabetes Care. 2002. 25:1159–1171.

4. Polonsky WH, Earles J, Smith S, Pease DJ, Macmillan M, Christensen R, Taylor T, Dickert J, Jackson RA. Integrating medical management with diabetes self-management training: a randomized control trial of the Diabetes Outpatient Intensive Treatment program. Diabetes Care. 2003. 26:3048–3053.

5. Gillett M, Dallosso HM, Dixon S, Brennan A, Carey ME, Campbell MJ, Heller S, Khunti K, Skinner TC, Davies MJ. Delivering the diabetes education and self management for ongoing and newly diagnosed (DESMOND) programme for people with newly diagnosed type 2 diabetes: cost effectiveness analysis. BMJ. 2010. 341:c4093.

6. Rubin RR, Peyrot M, Saudek CD. Effect of diabetes education on self-care, metabolic control, and emotional well-being. Diabetes Care. 1989. 12:673–679.

7. Tankova T, Dakovska G, Koev D. Education and quality of life in diabetic patients. Patient Educ Couns. 2004. 53:285–290.

8. Ko GT, Li JK, Kan EC, Lo MK. Effects of a structured health education programme by a diabetic education nurse on cardiovascular risk factors in Chinese type 2 diabetic patients: a 1-year prospective randomized study. Diabet Med. 2004. 21:1274–1279.

9. Clark CM Jr, Fradkin JE, Hiss RG, Lorenz RA, Vinicor F, Warren-Boulton E. The National Diabetes Education Program, changing the way diabetes is treated: comprehensive diabetes care. Diabetes Care. 2001. 24:617–618.

10. Norris SL, Engelgau MM, Narayan KM. Effectiveness of self-management training in type 2 diabetes: a systematic review of randomized controlled trials. Diabetes Care. 2001. 24:561–587.

11. Look AHEAD Research Group. Wing RR. Long-term effects of a lifestyle intervention on weight and cardiovascular risk factors in individuals with type 2 diabetes mellitus: four-year results of the Look AHEAD trial. Arch Intern Med. 2010. 170:1566–1575.

12. Ko SH, Song KH, Kim SR, Lee JM, Kim JS, Shin JH, Cho YK, Park YM, Jeong JH, Yoon KH, Cha BY, Son HY, Ahn YB. Long-term effects of a structured intensive diabetes education programme (SIDEP) in patients with type 2 diabetes mellitus: a 4-year follow-up study. Diabet Med. 2007. 24:55–62.

13. Charman D. Burnout and diabetes: reflections from working with educators and patients. J Clin Psychol. 2000. 56:607–617.

14. Muhlhauser I, Bruckner I, Berger M, Cheta D, Jorgens V, Ionescu-Tirgoviste C, Scholz V, Mincu I. Evaluation of an intensified insulin treatment and teaching programme as routine management of type 1 (insulin-dependent) diabetes. The Bucharest-Dusseldorf Study. Diabetologia. 1987. 30:681–690.

15. The Diabetes Prevention Program Research Group. The Diabetes Prevention Program. Design and methods for a clinical trial in the prevention of type 2 diabetes. Diabetes Care. 1999. 22:623–634.

16. Cronin FJ, Shaw AM, Krebs-Smith SM, Marsland PM, Light L. Developing a food guidance system to implement the dietary guidelines. J Nutr Educ. 1987. 19:281–302.

17. Mensing C, Boucher J, Cypress M, Weinger K, Mulcahy K, Barta P, Hosey G, Kopher W, Lasichak A, Lamb B, Mangan M, Norman J, Tanja J, Yauk L, Wisdom K, Adams C. National standards for diabetes self-management education. Task force to review and revise the national standards for diabetes self-management education programs. Diabetes Care. 2000. 23:682–689.

18. Franciosi M, Pellegrini F, De Berardis G, Belfiglio M, Cavaliere D, Di Nardo B, Greenfield S, Kaplan SH, Sacco M, Tognoni G, Valentini M, Nicolucci A. QuED Study Group. The impact of blood glucose self-monitoring on metabolic control and quality of life in type 2 diabetic patients: an urgent need for better educational strategies. Diabetes Care. 2001. 24:1870–1877.

19. Funnell MM, Brown TL, Childs BP, Haas LB, Hosey GM, Jensen B, Maryniuk M, Peyrot M, Piette JD, Reader D, Siminerio LM, Weinger K, Weiss MA. National standards for diabetes self-management education. Diabetes Care. 2010. 33:Suppl 1. S89–S96.

20. Peterson U, Demerouti E, Bergstrom G, Samuelsson M, Asberg M, Nygren A. Burnout and physical and mental health among Swedish healthcare workers. J Adv Nurs. 2008. 62:84–95.

21. Asberg M, Nygren A, Leopardi R, Rylander G, Peterson U, Wilczek L, Kallmen H, Ekstedt M, Akerstedt T, Lekander M, Ekman R. Novel biochemical markers of psychosocial stress in women. PLoS One. 2009. 4:e3590.

22. Lindstrom C, Aman J, Norberg AL. Increased prevalence of burnout symptoms in parents of chronically ill children. Acta Paediatr. 2010. 99:427–432.

23. Eom YS, Park HS, Kim SH, Yang SM, Nam MS, Lee HW, Lee KY, Lee S, Kim YS, Park IB. Evaluation of stress in Korean patients with diabetes mellitus using the Problem Areas in Diabetes-Korea questionnaire. Diabetes Metab J. 2011. 35:182–187.

24. Weinger K, Beverly EA, Lee Y, Sitnokov L, Ganda OP, Caballero AE. The effect of a structured behavioral intervention on poorly controlled diabetes: a randomized controlled trial. Arch Intern Med. 2011. 171:1990–1999.

25. Song MS, Song KH, Ko SH, Ahn YB, Kim JS, Shin JH, Cho YK, Yoon KH, Cha BY, Son HY, Lee DH. The long-term effect of a structured diabetes education program for uncontrolled type 2 diabetes mellitus patients: a 4-year follow-up. J Korean Diabetes Assoc. 2005. 29:140–150.