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Epidemiology/Health Services/Psychosocial Research

Self-Management Education for Adults With Type 2 Diabetes

A meta-analysis of the effect on glycemic control

  1. Susan L. Norris, MD, MPH1,
  2. Joseph Lau, MD2,
  3. S. Jay Smith, MIS, MSC3,
  4. Christopher H. Schmid, PHD4 and
  5. Michael M. Engelgau, MD, MSC1
  1. 1Division of Diabetes Translation, National Center for Chronic Disease Prevention and Health Promotion, Centers for Disease Control and Prevention, Atlanta, Georgia
  2. 2Center for Clinical Evidence Synthesis, Division of Clinical Care Research, New England Medical Center, Boston, Massachusetts
  3. 3Epidemiology Program Office, Centers for Disease Control and Prevention, Atlanta, Georgia
  4. 4Biostatistics Research Center, Division of Clinical Care Research, New England Medical Center, Boston, Massachusetts
    Diabetes Care 2002 Jul; 25(7): 1159-1171. https://doi.org/10.2337/diacare.25.7.1159
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    • Figure 1—
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      Figure 1—

      Systematic review flow diagram. n = number of studies. Cinahl is the Nursing and Allied Health database; ERIC, Educational Resources Information Center database; RCT, randomized controlled trial.

    • Figure 2—
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      Figure 2—

      GHb, stratified by follow-up interval. Net change in GHb is shown for each individual study, with lines extending from the symbols representing 95% CIs. Pooled results are for each follow-up interval, with r = 0.5.

    Tables

    • Figures
    • Table 1—

      Characteristics of eligible clinical trials

      StudyNo. of patientsDuration of intervention (months)Total contact time (h)Follow-up intervals (months)*Care delivered to the intervention group
      Agurs-Collins, 1997 (78)646280, 3Additional care†
      Bloomgarden, 1987 (79)34519NR0UC
      Brown, 1999 (49)24712NR0UC
      Campbell, 1996 (38)23812NR−1‡, −1Additional care
      de Bont, 1981 (29)1486NR0Additional care
      de Weerdt, 1989 (39)5581126UC
      d’Eramo-Melkus, 1992 (45)823140, 3UC
      Estey, 1990 (80)602.510Additional care
      Falkenberg, 1986 (28)463166Additional care
      Franz, 1995 (57)2471.51.51.5, 4.5Additional care
      Glasgow, 1995 (50)206913UC
      Glasgow, 1992 (53)1022.5NR3UC
      Hawthorne, 1997 (73)201NRNR6UC
      Heller, 1988 (81)8767.5−1, 0, 6Additional care
      Kaplan, 1985 (27)762.52015.5Additional care
      Korhonen, 1987 (30)8012NR−1, −1, 0UC
      Mazzucca, 1986 (31)53263.612UC
      McCulloch, 1983 (41)446NR−1, 0Additional care
      Mulrow, 1987 (42)12010NR1Additional care
      Perry, 1997 (54)706NR0UC
      Raz, 1988 (47)5112NR0UC
      Ridgeway, 1999 (40)58690, 6UC
      Scott, 1984 (55)601NR0UC
      Trento, 1998 (82)1201240UC
      Tu, 1993 (75)311NR1.5UC
      Turnin, 1992 (56)105690UC
      Uusitupa, 1993 (51)8627NR−1, 0UC
      White, 1986 (48)416100Additional care
      Wing, 1986 (32)5010NR−1, 3Additional care
      Wing, 1988 (68)2010NR−1, 2Additional care
      Wise, 1986 (43)88626UC
      Total N4,263
      • *

        ↵* Follow-up is from the last educator-patient contact;

      • †

        ↵† additional = control group received an intervention in addition to usual care;

      • ‡

        ↵‡ follow-up of (−1) indicates that the measurement occurred during the course of the intervention. NR, not reported; UC, usual care.

    • Table 2—

      Summary of demographic, setting, intervention, and design characteristics of included studies

      VariableMean
      Demographics
       Age (years)55 (35–67)
       Using insulin (%)16 (0–100)
       Baseline GHb9.4 (6.1–12.9)
       Race/ethnicity (% NR)77
      Setting (%)
       United States45
       Clinic88
       Home9
       Senior center3
      Intervention
       Focus (%)
        Lifestyle44
        Knowledge23
        Skills (SMBG and foot care)3
        Coping skills0
        Mixed30
       Provider (%)
        Nurse13
        Dietitian13
        Physician with team25
        Team (nurse, dietitian, etc.)20
        Lay health care worker3
        Self (e.g. computer-assisted instruction)7
        NR20
       Duration (median) (months)6 (1.0–27)
       Number of contacts (median)6 (1–36)
       Total contact time (hours)9.2 (1–28)
       Individual (%)32
       Collaborative (%)87
       Theory-based (%)39
       Computer-assisted instruction (%)6
       Interface with primary care (%)13 (65% NR)
      Design and quality
       Recruitment (%)
        Random3
        Volunteers58
        Entire eligible population19
        Unclear19
       Comparison group: % Patients receiving usual care58
       Completion rate ≥80%65
      • Data are means (range) or %, unless otherwise indicated. NR, not reported; SMBG, self-monitoring of blood glucose.

    • Table 3—

      Change in glycated hemoglobin after self-management training in type 2 diabetes

      StudyBaseline GHbFirst follow-up interval*
      Second follow-up interval*
      Third follow-up interval*
      MonthsNet change GHbMonthsNet change GHbMonthsNet change GHb
      Agurs-Collins, 1997 (78)10.00−.803−2.60——
      Bloomgarden, 1987 (79)6.60−0.40————
      Brown, 1999 (49)12.40−2.00————
      Campbell, 1996 (38)11.9−1−0.50−1−2.30——
      de Bont, 1981 (29)9.20−0.04————
      de Weerdt, 1989 (39)9.26−0.24————
      d’Eramo-Melkus, 1992 (45)10.90−1.873−1.59——
      Estey, 1990 (80)6.10−0.40————
      Falkenberg, 1986 (28)7.360.00————
      Franz, 1995 (57)8.31.5−0.304.5−0.20——
      Glasgow, 1995 (50)7.93−0.10—0.00——
      Glasgow, 1992 (53)7.43−0.10————
      Hawthorne, 1997 (73)NR6−0.34————
      Heller, 1988 (81)12.7−1−0.700−1.606−0.50
      Kaplan, 1985 (27)7.515.5−0.24————
      Korhonen, 1987 (30)9.2−1−0.13−1−0.400−0.04
      Mazzucca, 1986 (31)9.412−0.78————
      McCulloch, 1983 (41)12.9−1−0.800−1.40——
      Mulrow, 1987 (42)9.510.00————
      Perry, 1997 (54)8.70−0.40————
      Raz, 1988 (47)9.60−2.20————
      Ridgeway, 1999 (40)12.30−0.996−0.14——
      Scott, 1984 (55)8.70−0.50————
      Trento, 1998 (82)7.30−0.21————
      Tu, 1993 (75)NR1.5−0.46————
      Tumin, 1992 (56)10.80−0.80————
      Uusitupa, 1993 (51)7.8−1−0.300−0.20——
      White, 1986 (48)11.300.40————
      Wing, 1986 (32)10.5−10.6830.51——
      Wing, 1988 (68)10.5−10.4921.06——
      Wise, 1986 (43)8.76−0.80————
      • *

        ↵* Follow-up is from the last educator-patient contact, in months.

    • Table 4—

      Meta-analysis results

      Study group and follow-up intervalNumber of studiesQ significance levelPoint estimate (net change in GHb [%])95% CI
      All studies
       During or immediately after the intervention20<0.05−0.76−1.18 to −0.34
       1–3 months9>0.10−0.26−0.73 to 0.21
       ≥4 months8>0.10−0.26−0.48 to −0.05
      All studies where the comparison group receives usual care
       During or immediately after the intervention12<0.05−0.91−1.40 to −0.42
       1–3 months4>0.10−0.11−0.57 to 0.36
      ≥4 months5>0.10−0.28−0.52 to −0.05
    • Appendix—Additional characteristics of eligible clinical trials of the effectiveness of self-management education in type 2 diabetes

      StudyAge (years)Baseline Control GHbPatients on insulin (%)In U.S. (yes/no)InterventionCare delivered to the control groupInterventionNo. of contactsTotal contact time (hours)Individual or groupDidactic or collaborativeTheory-based (Y,N)SamplingCompletion rate >80% (Y,N)
      Agurs-Collins, 1997 (78)6210.050YDidactic + participatory sessions: diet and activityOne class + mailed informationL1828GCYVY
      Bloomgarden, 1987 (79)586.6100YClasses on general diabetes issuesUCM9NRGCNEN
      Brown, 1999 (49)5412.425YWeekly sessions + group supportUCM26NRGUnclearNVNR
      Campbell, 1996 (38)5611.90NIndividual sessionsTwo group sessionsK10NRGCNVN
      de Bont, 1981 (29)559.21.5NIndividual sesions + home visits: low-fat dietSame intervention, with low-carbohydrate dietL4NRICNUnclearY
      de Weerdt, 1989 (39)449.2100NCollaborative education by health worker or patientUCK412GCYVY
      d’Eramo-Melkus, 1992 (45)5610.90YDidactic course + individual sessionsUCM1214GCYVN
      Estey, 1990 (80)556.10NGroup education + follow-up at home3-day course, no follow-upM41ICNUnclearY
      Falkenberg, 1986 (28)667.30NSmall group sessions: problem solving1-day didactic teachingK816GCYRN
      Franz, 1995 (57)578.316YIndividual visits with dieticianBasic nutrition careL31.5ICNVN
      Glasgow, 1995 (50)627.967YSingle visit: diet, goal-settingUCL81ICYVY
      Glasgow, 1992 (53)677.427YWeekly sessions: problem-solving and self-efficacyUCL10NRGCYVY
      Hawthome, 1997 (73)53NRNRNCulturally appropriate flashcards, by lay health care workerUCM1NRIDYVY
      Heller, 1988 (81)5612.70NGroup sessions on weight lossIndividual sessions with dieticianL57.5GCNEY
      Kaplan, 1985 (27)547.526YCollaborative sessions on diet and activitySame intervention, discuss general diabetes issuesL1020GCYVY
      Korhonen, 1987 (30)569.20NIndividual sessions on dietUCL5NRICNEY
      Mazzucca, 1986 (31)589.470YHome visitsUCK2.43.6GCNEN
      McCulloch, 1983 (41)3512.9100NMeal demonstrationsConventional diet teachingL3NRGCNVY
      Mulrow, 1987 (42)549.50NMonthly small group meetings in diet and activityUnclearL6NRGCYEN
      Perry, 1997 (54)428.7100NMonthly meetings, feedbackUCL6NRUnclearCNVY
      Raz, 1988 (47)539.60NDidactic + small group sessionsUCM15NRGDNUnclearY
      Ridgeway, 1999 (40)6412.316YMonthly group sessions on behavioral modificationUCK69GCYEN
      Scott, 1984 (55)NR8.70NGroup + individual sessionsUCK4NRGDNVN
      Trento, 1998 (82)617.30NGroup sessions on diet, activity and blood sugarUCM44GCNUnclearY
      Tu, 1993 (75)65NR89YWeekly telephone calls after hospital dischargeUCM4NRICNVY
      Tumin, 1992 (56)4510.880NInteractive computer program on dietUCL369ICNNRY
      Uusitupa, 1993 (51)537.80NIndividual sessions on diet, activityUCL10NRICNVY
      White, 1986 (48)6111.371YPsychologist-led group sessions on diet and activityDidactic teachingL1010GCYUnclearN
      Wing, 1986 (32)549.950YWeight loss program with focus on blood sugarBehavioral weight control interventionM18NRGCNVY
      Wing, 1988 (68)5310.50YSessions on diet, activity and blood sugarSame intervention, but no problem-solvingS22NRGCYVY
      Wise, 1986 (43)568.70NComputerized knowledge assessment programUCK22ICNVY
      • C, collaborative; D, didactic; E, entire accessible population recruited into the study; G, group; I, individual; K, knowledge; L, lifestyle; M, mixed; N, no; NR, not reported; R, recruitment of the study population by random sampling of the accessible population; S, skills teaching such as self-monitoring of blood glucose and foot care; UC, usual care; V, volunteers recruited into the study; Y, yes.

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    Self-Management Education for Adults With Type 2 Diabetes
    Susan L. Norris, Joseph Lau, S. Jay Smith, Christopher H. Schmid, Michael M. Engelgau
    Diabetes Care Jul 2002, 25 (7) 1159-1171; DOI: 10.2337/diacare.25.7.1159

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    Self-Management Education for Adults With Type 2 Diabetes
    Susan L. Norris, Joseph Lau, S. Jay Smith, Christopher H. Schmid, Michael M. Engelgau
    Diabetes Care Jul 2002, 25 (7) 1159-1171; DOI: 10.2337/diacare.25.7.1159
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