tugas pak wid judul buku

MAPPING TEORY DAN REVIEW JURNAL

Di Ajukan Guna Memenuhi Tugas Mata Kuliah Logika Sains dan Berfikir Sistem

Oleh :

HARIYONONIM 101317087303

UNIVERSITAS AIRLANGGAFAKULTAS KESEHATAN MASYARAKATPROGRAM DOKTOR PRODI ILMU KESEHATANSURABAYA2014BUKU Judul BukuIsi UtamaInformasi ilmiah/alur informasiGrand teory

Substansi teoryConclusion/

kesimpulan

Judul Buku :

Quality of Life and DiabetesPenulis :

Richard R. Rubin1Mark PeyrotTahun :

1999

Jenis :

Tex Book

1. Issue penting kualitas hidup penderita Diabetes Melitus

2. Bagaimana kualitas hidup dikonseptualisasikan dan diukur?3. Kualitas hidup dan lama diabetes

4. Kualitas hidup dan adanya komplikasi yang berhubungan dengan diabetesPasien diabetes sering merasa tertantang oleh penyakit mereka dan tuntutan sehari- hariuntuk manajemen hari. Dan tuntutan ini substansial. pasien harus menangani diabetes mereka sepanjang hari, membuat keputusan yang tak terhitung jumlahnya yang sering upaya tersebut sia-sia untuk mendekati keadaan metabolik non-diabetes. Diabetes, terapi seperti insulin, secara substansial dapat mempengaruhi kualitas hidup yang baikGrand teoryDibandingkan dengan orang-orang tanpa diabetes, kebanyakan studi melaporkan kualitas hidup yang lebih buruk bagi orang-orang dengan diabetes, terutama mengenai fungsi fisik dan kesejahteraan. Mereka dengan diabetes melaporkan kualitas hidup yang lebih baik daripada orang yang memiliki berbagai kondisi kronis lainnya (seperti masalah jantung, epilepsi dengan kejang, arthritis, multiple sclerosis, stroke dan masalah paru-paru) di beberapa atau sebagian besar domain fungsi dan kesejahteraan.

Judul buku :

Decision Making in the Transtheoretical

Model of Behavior ChangePengarang :

James O. ProchaskaTahun : 2008 Pengambilan keputusan merupakan bagian integral dari model transtheoretical perubahan perilaku. Tahap perubahan merupakan dimensi temporal untuk perubahan perilaku dan telah menjadi dimensi utama untuk mengintegrasikan prinsip-prinsip dan proses perubahan dari seluruh teori psikoterapi dan perubahan perilaku.. Implikasi dari pola-pola hubungan dibahas dalam konteks untuk membantu pasien membuat keputusan yang lebih efektif untuk mengurangi perilaku berisiko kesehatan dan meningkatkan perilaku kesehatan-menggambarkan bagaimana penelitian tentang pengambilan keputusan didorong oleh teori perubahan perilaku , seperti model transtheoretical ( TM ) , dapat memajukan perawatan berbasis ilmu pengetahuan untuk populasi pasien yang secara historiskarena mereka tidak patuh , tidak termotivasi , atau tidak siap TTM ini dirancang untuk mengintegrasikan prinsip-prinsip dan proses perubahan dari seluruh teori terkemuka psikoterapi dan perubahan perilaku intinya mengintegrasikan dimensi

Grand te0ryHal yang paling penting dalam konsep ini adalah bahwa penelitian tentang pengambilan keputusan didorong oleh teori perubahan perilaku, seperti TTM, dapat memajukan ilmu pengetahuan-pengobatan berbasis populasi pasien yang secara historis understudied dan terlayani karena mereka patuh, tidak termotivasi, tahan, atau tidak siap untuk ilmu kami dan layanan kami

Judul Buku :

Quality of life and pharmaeconomic in clinical trialsPengarang :

Bert Spilker

Tahun : 1996Instrument pengkajian Kualitas hidup menurut WHO, instrument ini mengkaji secara holistik dan seimbang, dimana aspek positif dan negatif dapat terkaji yang meliputi 6 domain yaitu fisik, psikologis,tingkat ketergantungan,hubungan sosial, dan spiritual atau religiusKualitas hidup dapat didefinisakan sebagai persepsi individu dalam hidupnya yang meliputi budaya dan nilai hidup yang berhubungan dengan tujuan hidupGrand teoryWHO berkomitment untuk mengembangkan pengkajian kualitas hidup secara inernasional yang di gunakan untuk mengembangkan pengukuran status kesehatan individu akibat dampak dari penyakit kronis

JURNAL ILMIAHJudul artikel Tujuan PenelitianInformasi ilmiah/alur informasi

Dasar teori/konsep ilmiahMateri and methodeGrand teory

Substansi teoryConclusion/

kesimpulan

Perkembangan dan validasi DMOS (Diabetes Management orientation Scale) :Pengkajian Budaya berhubungan dengan pendekatan diabetes self management

Penulis

Aaron K.Y Wong Andrew G.O Stewart

John S. FurlerTahun

2009Jenis

Jurnal

Internasional

Meningkatkan sefl efficacy dengan perilaku managemen diriPerilaku manajemen diri diabetes tipe 2 yang ditingkatkan dengan self-efficacy sementaraperan budaya belum dipahami dengan baik. Penelitian ini dieksplorasi individualis budaya danaspek kolektivis manajemen diri dan hubungannya dengan kontrol diabetes.

Skala Manajemen Diabetes Orientasi dirancang untukmengukur orientasi individu dan kelompok diabetes

Analisis statistik dilakukan dengan menggunakan SPSS 15.0 forwindows [20]. Analisis faktor eksploratori dengan maksimalekstraksi kemungkinan dan rotasi miring dilakukan untukmemeriksa struktur faktor dari DMOS dan pilih item untukskala inklusi. Item yang dipertahankan untuk skala akhir jika merekamemiliki lebih dari 0,45 pemuatan, memastikan khas kontribusi masing-masing item ke faktor masing-masing [21]. paralelanalisis dan minimum rata-rata parsial (MAP) tes Velicer inidigunakan untuk menentukan jumlah faktor untuk ekstraksi.

Substansi teoryStudi ini menunjukkan bahwa intervensi ini memiliki potensi positif berdampak pada kesehatan masyarakat luas individu dengan diabetes, bukan hanya minoritas yang siap untuk perubahan.

Judul :Perubahan perilaku perawatan diri Membuat Perbedaan di Control GlikemikPenulis : HELEN JONES

LYNN EDWARDS, PDT, MHSA2

T. MICHAEL VALLIS

LAURIE RUGGIERO,

SUSAN R. ROSSITahun

2003

Jenis jurnal

IntenationalPenelitian ini bertujuan untuk membandingkan pengobatan diabetes Treatment As Usual (TAU) dengan (PTC), intervensi yang dikembangkan dari Transtheoretical Model of Change (TTM), untukmenentukan apakah intervensi PTC akan menghasilkan kesiapan yang lebih besar untuk berubah, lebih besarmeningkat dalam perawatan diri, dan meningkatkan kontrol diabetes.

Model TranstheoreticalPerubahan ( TTM ) telah diterapkan untuk kesehatanintervensi perubahan perilaku menggunakansistem komputerisasi , PersiapanPerubahan ( PTC ) , yang menyediakan perawatan diriPeserta dikelompokkan berdasarkan pengobatan diabetes dan diacak untuk pengobatan dengan PTC atau TAU serta menjadi acak mengenai penerimaan strip tes darah gratis. PTC terdiri dari laporan tahap-cocok pribadi assessment, self-help manual, newsletter, dan konseling telepon individu yang dirancang untuk meningkatkan kesiapan untuk diri-monitor glukosa darah (SMBG), makan sehat, dan / atau berhenti merokok.Sebanyak 1.029 orang dengan tipe 1 dan diabetes tipe 2 yang berada di salah satu dari tigatahap pra tindakan baik untuk SMBG, makan sehat, atau merokok direkrut.Substansi teoryStudi ini menunjukkan bahwa intervensi ini memiliki potensidari positif berdampak pada kesehatan yang luaspopulasi individu dengan diabetes, tidakhanya minoritas yang siap untuk perubahan

Judul : pengalaman management diri penderita diabetes : fokus grup studi pada penderita diabetes tipe 2 di taiwan

Penulis : Chiu-Chu Lin Robert M Anderson Bonnie M Hagerty Bih-O LeeTahun :

2006

Jenis jurnal :

Internasional

Tujuan dari penelitian ini adalah untuk memahami dan mendokumentasikanperspektif pasien Taiwan dengan diabetes tipe 2 mengenai proses danstrategi yang digunakan untuk mengelola sendiri kondisi kronis mereka

tujuan utama pengelolaan penderita diabetes adalah membantu penderita dan keluarga untuk berpartisipasi aktif dalam pengelolaan penyakit. Pada awal setiap kelompok fokus, moderator memperkenalkan dirinya dan lain anggota tim peneliti yang mengambil catatan lapangan dan menggambarkan sesi kelompok fokus yang direncanakan. Selain itu, untuk mendorong diskusi aktif dari semua anggota kelompok fokus, peserta diminta untuk secara terbuka mendiskusikan pengalaman mereka dan memberikan tanggapan jujur, bahkan jika mereka berbeda dari tanggapan peserta lain. Semua sesi, yang berlangsung 90-120 menit, direkam oleh dua microcassette tape recorder untuk memastikan kejelasan dan keakuratan transkripsi.

Grand teoryProses self-regulation Data dari lima kelompok fokus menunjukkan bahwa pasien mempelajari strategi untuk mengelola penyakit mereka dari serangkaian proses mengatur diri sendiri termasuk perilaku biologisdan penyesuaian psikologis. Misalnya, melalui 'mengidentifikasi respon tubuh,' peserta belajar hubungan antara kadar gula darah dan kontrol diet dan relaksasi emosional.

Judul :Faktor Risiko Perilaku yang Berhubungan dengan Kadar Gula Darah pada Penderita

Diabetes Melitus Tipe 2 di RSUD Kabupaten KaranganyarPenulis :

Rosita Purnama DewiTahun :

2013

Jenis Jurnal :

Nasional

Tujuan penelitian :Tujuan

penelitian ini adalah untuk mengetahui hubungan antara perilaku (pengetahuan, sikap dan

praktik) dalam hal diet, olahraga dan pengobatan dengan kadar gula darah

Diabetes Melitus (DM) merupakan penyakit kronik yang tidak dapat disembuhkan, tetapi

dapat dikendalikan melalui pengelolaan DM. Orang dengan DM memiliki

peningkatan risiko mengembangkan

sejumlah masalah kesehatan akibat

komplikasi akut maupun kronik.Penelitian ini merupakan penelitian

analitik dengan desain cross sectional.

Populasi penelitian ini adalah pasien DM

tipe 2 yang berobat di Poliklinik Penyakit

Dalam RSUD Kabupaten Karanganyar.

Sampel diambil sebanyak 72 orang,

menggunakan teknik purposive sampling.

Variabel terikat adalah kadar glukosa

darah puasa. Variabel bebas terdiri dari

pengetahuan diet, pengetahuan olahraga,

pengetahuan pengobatan, sikap diet,

sikap olahraga, sikap pengobatan, praktik

diet, praktik olahraga dan praktik

pengobatan. Pengambilan data dengan

wawancara menggunakan kuesioner.

Data dianalisis menggunakan uiji chi-

square.Substansi teoryDari penelitian ini dapat disimpulkan

bahwa sebagian besar pasien DM tipe 2

yang menjalani rawat jalan di Poliklinik

Penyakit Dalam RSUD Kabupaten

Karanganyar sudah memiliki pengetahuan

dan sikap yang baik terhadap pengelolaan

DM yang meliputi diet, olahraga dan

pengobatan. Akan tetapi dalam praktiknya

masih banyak yang tidak melaksanakan

pengelolaan DM dengan benar sehingga

kadar gula darah sebagian besar pasien

berada pada kategori tidak normal.

Judul penelitian :UPAYA PENANGANAN DAN PERILAKU PASIEN PENDERITA DIABETES

MELITUS TIPE 2 DI PUSKESMAS MARADEKAYA KOTA MAKASSAR

TAHUN 2013

Penulis :

1. Dian Lestari

2. Citrakesumasari3. Sriah Alharini

Mengetahui PENANGANAN DAN PERILAKU PASIEN PENDERITA DIABETES

MELITUS TIPE 2 DI PUSKESMAS MARADEKAYA KOTA MAKASSARPenyakit diabetes melitus telah menjadi masalah kesehatan dunia. Prevalensi dan insiden

penyakit ini terus meningkat di negara-negara industri maupun negara berkembang termasuk

Indonesia. Kurang terkontrolnya kadar glukosa darah sangat dipengaruhi oleh perilaku hidup pasien,

oleh karena itu pengetahuan yang dapat mengubah perilaku merupakan domain yang sangat penting

untuk terbentuknya perilaku.Penelitian ini telah dilaksanakan di Puskesmas Maradekaya Kota Makassar. Jenis

penelitian ini adalah penelitian survei observasional deskriptif yaitu untuk mengamati dan

mendeskripsikan upaya penanganan yang dilakukan oleh petugas kesehatan dan perilaku 4

pasien penderita DM tipe 2. Populasi dalam penelitian ini adalah semua pasien DM tipe 2

yang datang memeriksakan kesehatan ke Puskesmas Maradekaya pada 11 Maret sampai 13

April 2013. Sampel dalam penelitian ini diambil dari rata-rata kunjungan pasien DM perbulan

sebanyak 29 orang yang memenuhi kriteria penelitian. Dimana kriteria inklusi dari penelitian

ini yaitu pasien DM tipe 2 yang berkunjung ke puskesmas Maradekaya pada bulan Maret-

April 2013, tidak mengalami komplikasi yang mempengaruhi pola makan, dapat

berkomunikasi secara sadar dan bersedia menjadi responden. Dan kriteria eksklusi yaitu

dalam keadaan hamil atau menyusui, menderita penyakit neurogeneratif (pikun, stroke) dan

tidak mengikuti protokol penelitian. Data penelitian diperoleh dengan mengumpulkan data

primer dan data sekunder.

Grand teoryUpaya penanganan pasien penderita DM Tipe 2 di Puskesmas Maradekaya tidak

berjalan sesuai dengan pilar penanganan DM. Pengetahuan responden lebih banyak termasuk

kategori kurang dan hanya sebagian kecil yang memiliki pengetahuan cukup. Responden

dengan pengetahuan cukup lebih banyak memiliki kadar GDS tidak terkontrol.

Judul artikel :Efektivitas pendidikan diabetes dan manajemen diri untuk program yang sedang berlangsung dan baru didiagnosis (DESMOND) bagi orang-orang yang baru didiagnosis diabetes tipe 2: cluster percobaan terkontrol acakPenulis :

1. M J Davies2. SHeller

3. T C Skinner, Tahun:

2008

Jenis :

InternasionalUntuk mengevaluasi efektivitas program pendidikan kelompok terstruktur pada langkah-langkah biomedis, psikososial, dan gaya hidup pada orang yang baru didiagnosis diabetes tipe 2.diabetes di hubungkan dengan peningkatan morbiditas dan kematian dini akibat penyakit jantung, termasuk stroke dan infark miokard. Dalam praktek klinis dalam tim perawatan primer di Inggris kini imbalan finansial untuk mencapai target glikemik dan metabolik ketat pada pasien di bawah perawatan mereka dan ini telah menyebabkan tingkat peningkatan kontrol glikemik, terutama pada pasien dengan tipe 2 diabetes diabetes.meskipun layanan nasional kerangka telah membuat rekomendasi untuk penyediaan lebih luas kelompok terstruktur pendidikan, saat ini tidak ada bukti yang mendukung keyakinan bahwa pendidikan terstruktur memberikan manfaat tambahan bagi pasien dari pokok diagnosis.Klaster multisenter percobaan terkontrol acak dalam perawatan primer dengan pengacakan pada tingkat praktek.Grand teorySebuah program pendidikan kelompok terstruktur untuk pasien dengan diabetes tipe 2 yang baru didiagnosa menghasilkan peningkatan yang lebih besar dalam penurunan berat badan dan berhenti merokok dan perbaikan positif dalam keyakinan tentang penyakit tetapi tidak ada perbedaan dalam tingkat hemoglobin A1c sampai 12 bulan setelah diagnosis.

Judul artikel :Factors that Inuence Diabetes Self-Management in Hispanics

Living in Low Socioeconomic Neighborhoods in San Bernardino,

CaliforniaPenulis :

Delweiss Ramal

Anne Berit Petersen

Kathie Marlene Ingram Andrea Marie ChamplinTahun :

2012Jenis :

Internasional

untuk mengidentifikasi faktor yang mempengaruhi pengelolaan diri penderita diabetes pada orang Hispanik, data kualitatif yang dikumpulkan melalui lima kelompok fokus wawancara telah diteliti dengan menggunakan metode teori dasar

Program yang bertujuan untuk meningkatkan praktek manajemen diri harus memasukkan konteks sosial budaya dan sosial ekonomi di yang Hispanik dengan diabetes hidup.

Grounded theory, metode penelitian induktif digunakan untuk mempelajari fenomena tanpa sebelumnya dirumuskan dengan baik teori, digunakan untuk mengumpulkan, menganalisis, dan menginterpretasikan data kualitatif. Kami melakukan lima diskusi kelompok terfokus dengan 13, 2, 4, 3, dan 5 masing-masing peserta di empat lokasi yang berbeda di sebagian besar rendah sosial ekonomi, lingkungan Hispanik di Kota San Bernardino. Data dikumpulkan melalui interaksi kelompok fokus di mana sekelompok kecil individu dari populasi sasaran mengungkapkan pendapat mereka tentang suatu topik tertentu. Peserta sendiri dipilih dari Hispanik, yang telah mengikuti program pendidikan diabetes antara Juni 2008 dan Maret 2010 bertempat di salah satu dari empat komunitas-Grand teory

_1451663304.pdf

Effectiveness of Self-ManagementTraining in Type 2 DiabetesA systematic review of randomized controlled trials

SUSAN L. NORRIS, MD, MPHMICHAEL M. ENGELGAU, MD, MSCK.M. VENKAT NARAYAN, MD, MPH

OBJECTIVE To systematically review the effectiveness of self-management training in type2 diabetes.

RESEARCH DESIGN AND METHODS MEDLINE, Educational Resources Informa-tion Center (ERIC), and Nursing and Allied Health databases were searched for English-languagearticles published between 1980 and 1999. Studies were original articles reporting the results ofrandomized controlled trials of the effectiveness of self-management training in people with type2 diabetes. Relevant data on study design, population demographics, interventions, outcomes,methodological quality, and external validity were tabulated. Interventions were categorizedbased on educational focus (information, lifestyle behaviors, mechanical skills, and copingskills), and outcomes were classified as knowledge, attitudes, and self-care skills; lifestyle be-haviors, psychological outcomes, and quality of life; glycemic control; cardiovascular disease riskfactors; and economic measures and health service utilization.

RESULTS A total of 72 studies described in 84 articles were identified for this review.Positive effects of self-management training on knowledge, frequency and accuracy of self-monitoring of blood glucose, self-reported dietary habits, and glycemic control were demon-strated in studies with short follow-up (,6 months). Effects of interventions on lipids, physicalactivity, weight, and blood pressure were variable. With longer follow-up, interventions thatused regular reinforcement throughout follow-up were sometimes effective in improving glyce-mic control. Educational interventions that involved patient collaboration may be more effectivethan didactic interventions in improving glycemic control, weight, and lipid profiles. No studiesdemonstrated the effectiveness of self-management training on cardiovascular diseaserelatedevents or mortality; no economic analyses included indirect costs; few studies examined health-care utilization. Performance, selection, attrition, and detection bias were common in studiesreviewed, and external generalizability was often limited.

CONCLUSIONS Evidence supports the effectiveness of self-management training in type2 diabetes, particularly in the short term. Further research is needed to assess the effectiveness ofself-management interventions on sustained glycemic control, cardiovascular disease risk fac-tors, and ultimately, microvascular and cardiovascular disease and quality of life.

Diabetes Care 24:561587, 2001

D iabetes self-management training,the process of teaching individualsto manage their diabetes (1), hasbeen considered an important part of

clinical management since the 1930s (2).The goals of diabetes education are to op-timize metabolic control, prevent acuteand chronic complications, and optimize

quality of life while keeping costs accept-able (3). One of the goals of Healthy Peo-ple 2010 is to increase to 60% (from the1998 baseline of 40%) the proportion ofindividuals with diabetes who receive for-mal diabetes education (4). There are sig-nificant knowledge and skill deficits in5080% of individuals with diabetes (5),and ideal glycemic control (HbA1c ,7.0%) (6) is achieved in less than half ofpersons with type 2 diabetes (7). The di-rect and indirect costs of diabetes and itscomplications were estimated to be $98billion in 1997 (8), although the cost ofdiabetes education as a discrete compo-nent of care has not been defined.

A large body of literature exists on di-abetes education and its effectiveness, in-cluding several important quantitativereviews showing positive effects. How-ever, these reviews aggregated studies ofheterogeneous quality (911) and typesof interventions (9,10) and do not iden-tify the most effective form of diabetes ed-ucation for specific populations oroutcomes. Moreover, educational tech-niques have evolved since these reviews(911) and have shifted from didacticpresentations to interventions involvingpatient empowerment (12).

The objective of this study was to sys-tematically review reports of publishedrandomized controlled trials to ascertainthe effectiveness of self-managementtraining in type 2 diabetes, to providesummary information to guide diabetesself-management programs and futurequantitative analyses, and to identify fur-ther research needs.

RESEARCH DESIGN ANDMETHODS

Search methodsThe English-language medical literaturepublished between January 1980 and De-cember 1999 was searched using theMEDLINE database of the National Li-brary of Medicine, the Educational Re-sources Information Center (ERIC)database, and the Nursing and Allied

c c c c c c c c c c c c c c c c c c c c c c c c c c c c c c c c c c c c c c c c c c c c c c c c c

From the Division of Diabetes Translation, National Center for Chronic Disease Prevention and HealthPromotion, Centers for Disease Control and Prevention, Atlanta, Georgia.

Address correspondence and reprint requests to Susan L. Norris, MD, Centers for Disease Control andPrevention, MS K-10, 4770 Buford Highway NE, Atlanta, GA 30341. E-mail: [email protected].

Received for publication 11 April 2000 and accepted in final form 19 October 2000.Abbreviations: SMBG, self-monitoring of blood glucose.A table elsewhere in this issue shows conventional and Syste`me International (SI) units and conversion

factors for many substances.

R e v i e w s / C o m m e n t a r i e s / P o s i t i o n S t a t e m e n t sR E V I E W

DIABETES CARE, VOLUME 24, NUMBER 3, MARCH 2001 561

Health database (commenced in 1982).The medical subject headings (MeSH)searched were Health Education com-bined with Diabetes Mellitus, includingall subheadings. Abstracts were not in-cluded because they generally contain in-sufficient information to assess thevalidity of the study by the criteria de-scribed below. Dissertations were also ex-cluded because the available abstractscontained insufficient information forevaluation and the full text was frequentlyunavailable. Titles of articles extracted bythe search were reviewed for their rele-vance to the effectiveness of diabetes ed-ucation, and if potentially relevant, thefull-text article was retrieved. Because au-tomated databases are incomplete (1315), the following journals, believed tohave the highest relevance, were searchedmanually: Diabetes Care, Diabetes Educa-tor, Diabetes Research and Clinical Practice,Diabetologia, and Diabetic Medicine.

Study selectionOnly randomized, controlled trial reportswere selected because this type of studydesign generally supports maximum va-lidity and causal inference (16). We re-viewed only studies in which all or mostsubjects had type 2 diabetes. If the type ofdiabetes was unclear, then the study wasincluded when the mean age was .30years. It was believed that the educationaltechniques and social influences (espe-cially family and peers) relevant to chil-dren and adolescents with either type 1 ortype 2 diabetes were sufficiently differentto warrant a separate review. To examineas broadly as possible the effectiveness ofdiabetes education, we included studiesof subjects with type 2 diabetes .18 yearsof age, with any degree of disease severityand with any comorbidity. Interventionsin all settings were included. Educationcould be delivered by any provider type,could involve any medium (written, oral,video, computer), could be individual- orgroup-based, and could be of any dura-tion and intensity. Studies with multi-component interventions were includedonly if the effects of the educational com-ponent could be examined separately.

Self-management training interven-tions were classified into one of the fol-lowing categories by primary educationalfocus: knowledge or information; lifestylebehaviors, including diet and physical ac-tivity; skill development, including skillsto improve glycemic control such as self-

monitoring of blood glucose (SMBG), aswell as skills to prevent and identify com-plications (e.g., foot care); and copingskills (to improve psychosocial function),including interventions using empower-ment techniques or promoting relaxationor self-efficacy. Studies with a focus onknowledge or information were subclas-sified by primary type of educational ap-proach: didactic or collaborative. Didacticeducation occurred when the patient at-tended to the information but did not in-teract with the instructor or participateactively in teaching sessions. Collabora-tive education occurred when the patientparticipated actively in the learning pro-cess, including group discussions orhands-on practice, or when teachingtechniques included empowerment (17),individualized goal-setting, biofeedback,or modeling. The other three categories oflifestyle, skill development, and copingskills education were generally all collab-orative to some extent; therefore, thesetypes of interventions were not subclassi-fied.

Data extractionData extracted from eligible studies in-cluded descriptive information, analysismethods, and results. Extraction was notblinded, because there is no evidence thatblinding results in a decrease in bias in theconduct of systematic reviews and meta-analyses (18,19).

Validity assessmentQuality assessment was determined bywhat was reported in each article, and in-ternal validity was assessed using Co-chrane methodology (20) for four types ofbias (Table 1). These biases are believed tohave significant effects on measured out-comes in intervention studies (21), and ifpresent in an article, note was made in thetables.

These criteria for bias were modifiedfrom those used in Cochrane methodolo-gies, because not one study in the litera-ture reviewed fulfilled all definitions forthe absence of bias. To avoid selectionbias, ideally one requires concealment ofthe allocation schedule so that neither pa-tient nor researcher can influence assign-ment sequence (22). However, becausemost studies in this review did not com-ment on method of allocation, beyondstating that subjects were randomized, al-location concealment was not used as anecessary criteria for the absence of selec-tion bias. To avoid performance bias,blinding of patients to the intervention isrequired, which is impossible in diabeteseducation studies; therefore, patientblinding was not used as a validity crite-rion. Attrition was noted as a potentialbias when more than 20% of initially en-rolled subjects dropped out before datacollection, and dropouts were not com-pared or were not found equivalent tocompleters at baseline.

External validity was also assessed

Table 1Assessment of internal validity based on Cochrane Collaboration Criteria (20)

Type of bias Definition

Selection bias Systematic differences in control and intervention groups at baselineTo avoid requires randomization and no significant differences

between baseline variables in control and intervention groups,or adequate statistical consideration of potential confounders ifbaseline differences exist

Performance bias Systematic differences in care provided to control and interventiongroups, apart from the intervention being evaluated

To avoid requires no evidence of contamination or cointervention,including no additional contacts with researcher or providers forthe intervention group compared with the control group

Attrition bias Systematic differences between study groups in withdrawals from thestudy

To avoid requires attrition ,20% of total n, or dropouts mustresemble completers in baseline characteristics

Detection bias Systematic differences in outcomes assessment between study groupsTo avoid requires blinding for any outcome subject to assessor

interpretation

Self-management training in type 2 diabetes

562 DIABETES CARE, VOLUME 24, NUMBER 3, MARCH 2001

and was considered adequate if the acces-sible population reasonably representedthe target population and study subjectswere either a random sample of the acces-sible population or consecutively referredpatients, or if no significant differencesbetween participants and nonparticipantswere demonstrated at baseline. Studieswith populations that consisted of volun-teers, that were convenience samples, orwere otherwise selected by the research-ers may not be generalizable to targetpopulations; therefore, the nature of thesestudy populations is indicated in the ta-bles.

OutcomesOutcomes are summarized in a qualita-tive fashion to 1) aid in generating hy-potheses, 2) detail the categorization ofvariables for future quantitative syntheses(23), and 3) portray the heterogeneity ofthe populations, interventions, method-ology, study quality, and outcomes in thisliterature. It was believed that derivationof a single summary statistic would not bemeaningful in determining what inter-ventions are effective in what popula-tions. The power of statistical tests ofhomogeneity is low, and failure to reject ahypothesis of homogeneity does notprove that studies are sufficiently similarto be aggregated (24).

We classified outcomes as 1) processmeasures including knowledge, attitudes,and self-care skills; 2) lifestyle behaviors,psychological outcomes, and quality oflife; 3) glycemic control; 4) cardiovasculardisease risk factors; and 5) economicmeasures and health service utilization.Because a study can have multiple out-comes, each study can be listed one ormore times in the results tables, which areclassified by outcome. Glycated hemoglo-bin measures are presented as percentagechange in the text and the figure, due tothe measurement of different glycatedcomponents of hemoglobin in differentstudies as well as the variability of mea-surement between laboratories and overtime (25).

RESULTS A total of 72 discretestudies, published in 84 articles, wereidentified. These studies are heteroge-neous with respect to patient population,educational intervention, outcomes as-sessed, study quality, and generalizability(Tables 26). Review of this literature re-veals a number of important generaliza-

tions concerning the components anddeterminants of effective interventionsand the outcomes most conducive to im-provement.

Process measuresKnowledge. Most studies measuringchanges in diabetes knowledge demon-strate improvement with education (Ta-ble 2) (26 46), including those withfollow-up of 612 months after the lastintervention contact (2830,36,40,43).Seven studies demonstrated improvedknowledge for both the intervention andcontrol groups (4753), suggesting pos-sible contamination due to the infeasibil-ity of blinding participants. A number ofstudies demonstrated that regular rein-forcement or repetition of the interven-tion seemed to improve knowledge levelsat variable lengths of follow-up: Bloom-garden et al. (34) (nine visits in 18months), Korhonen et al. (35) (one visitevery 3 months for 12 months), Campbellet al. (29) (regular reinforcement with vis-its and telephone calls over 12 months),and Rettig et al. (46) (12 visits in 12months). Knowledge was measured usinga variety of instruments, often specificallydeveloped for the study and lacking indocumented reliability and validity(26,30,32,33,35,39,44,47,52,5456).Self-care. Several studies observed in-creased frequency of, or more accurateSMBG, demonstrated by a decreased dis-crepancy between measurement by thepatient and health-care personnel(40,45,5759) (Table 2). Several studiesexamined the relationship between skillsteaching and glycemic control. Althoughthree of these studies (40,57,60) noted anincrease in frequency of SMBG, no corre-sponding improvement in HbA1c wasfound. Wing et al. (61) taught adjustmentof diet and physical activity in conjunc-tion with SMBG, but the patients in thisstudy failed to show improved glycemiccontrol at 1 year.

Several studies examined interven-tions focusing on foot lesions with mixedresults. Litzelman et al. (62) noted a de-crease in serious foot lesions at 1 year af-ter an intervention consisting of groupeducation, with three follow-up visits, pro-vider guidelines, and chart remind-ers. Other studies failed to demonstrateimprovements with interventions(41,46,63). Malone et al. (64) found a sig-nificant decrease in foot ulcer and ampu-

tation rates, although this study hadsignificant methodological inadequacies.

Lifestyle behaviorsMost studies that examined dietarychanges were positive for self-reportedchanges, including improvements in di-etary carbohydrate or fat intake(38,39,6570) (Table 3), a decrease in ca-loric intake (39,67), and an increase inconsumption of lower glycemic-indexfoods (71). A few studies demonstratingimproved dietary changes found corre-sponding improvements in weight(38,66,72) or glycemic control (31). Onlytwo studies failed to show improvementin diet: one had an 18-month follow-upand an intervention delivered every 3months (35), and the other (73) notedimproved dietary habits during the inter-vention but no significant difference at 6months.

Studies measuring physical activityoutcomes had variable results. Hanefeldet al. (65) demonstrated an increase inactivity at 5 years with a didactic interven-tion. Among studies with shorter fol-low-up duration, Wood (54) noted anincrease in physical activity at 4 months,Glasgow et al. (74) found an increase inthe number of minutes of activity 3months after an intensive intervention,and Wierenga (75) found improved phys-ical activity after five intervention sessionsat 4 months. Five studies found nochanges in physical activity comparedwith control groups (30,40,69,76,77). Itis unclear what factors might account forsuccess in some studies and not in others.

Psychological and quality-of-lifeoutcomesFour studies examined psychological out-comes (Table 3) (33,40,74,78); improve-ments were noted in problem solving (74)and anxiety levels (33). Quality of life wasexamined in three studies. Kaplan et al.(79) noted an increase in quality of life at18 months for an intervention subgroupthat received intensive counseling onboth diet and physical activity. Two stud-ies of brief interventions failed to demon-strate improved quality of life (60,67).

Glycemic controlStudies that focused on glycemic controlare described in Table 4 and Fig. 1. Bothcontrol and intervention study groupstended to have improved glycated hemo-globin measures (29,31,32,36,48,49,60,

Norris and Associates


Table 2Effect of self-management training on knowledge, attitudes, and self-care skills

Referencen, F/U interval,and mean age Interventions Outcomes Comments

1. Didactic, knowledge, and information interventions33 n 5 60; F/U immediate, 4

weeks; ?ageI: Four weekly group sessions;

individual as neededC: Started same education 4 weeks

later

Increased knowledge I vs. C at 4weeks, P , 0.01

No BL statistics; I more visits than CAttrition 29%, dropouts not equal to

completers at BLLow participation rate, but NSD

participants and nonparticipants34 n 5 345; F/U immediate;

58 yearsI: Nine multimedia education classes

over 1.5 yearsC: Usual care

Increased knowledge I vs. C,P 5 0.0073

NSD behavior score;NSD foot lesions

No mention blinding assessorLow participation rate;

nonparticipants older, more males

35 n 5 77; F/U 618 monthsfrom BL; 33 years

I: 5-day IP teaching: didactic,individual F/U q3 months, phoneaccess; instruction in self-adjustment insulin

C: 5-day IP traditional education 1written information; 3 3 1.5-hsessions; q3 months F/U

Increased knowledge both C andI, I . C, P , 0.01 at 12 months

Increased urine testing I and C(NSD between groups)Knowledge not correlated with BS

control

No BL comparison statisticsNo attrition informationNo blinding for diet historyLow recruitment rate and no

information on nonparticipants

42 n 5 30; F/U immediate;59 years

I: 15-min video featuring local HCWin Spanish

Increased knowledge in I, effect sizemoderate (0.61)

No BL comparison of demographicsUnclear if assessor blinded

C: Pretest only, then viewed video Convenience sampleI had no pretest to avoid bias from

retesting47 n 5 51; F/U 12 months

from BL; 53 yearsI: Three weekly didactic, small group

sessions q4 months 1 q2 monthsvisit with doctor

NSD knowledge between groups I more visits than CNo information on participation rates

C: Visit with doctor q2 months51 n 5 40; F/U immediate;

60 yearsI: 1-h individual education based on

patients prioritiesC: 1 h individual education based on

educators priorities

Increased knowledge both groups,P , 0.0001, NSD between groups

Unclear if assessor blindedConsecutively referred patientsType of DM unclear

52 n 5 111; F/U 23 months;56 years

I: One-page drug information sheetgiven to patients attending clinic

Both groups increased knowledge;NSD between groups

C: Usual care57 n 5 31; F/U 1 week; HbA1c

F/U 2 months; 65 yearsI: Four weekly TC after hospital

discharge: identify deficits andteach

I more frequent SMBG and increasedhypoglycemic prevention,P , 0.05

I more contact than CUnclear if assessor blindedNo information on nonparticipants

C: No TC or other contact2. Collaborative, knowledge, and information interventions26 n 5 80; F/U 6 months from

BL; 53 yearsI: Group sessions: didactic and

discussions; no details of durationor frequency; F/U every 3 months

Increased knowledge in I vs. C,P , 0.01

Attrition 25%, no comparisondropouts to completers

C: Care at general medical clinicevery 3 months

27, 28 n 5 532; F/U 1214months; 57 years

I: Average 2.4 sessions 3 1.5 h over2 months 1 home visit, TC F/U,contracting, skill exercises, goal-setting; over 26 months

C: Usual care

Achievement of some knowledge,skill, and self-care objectives in Ivs. C, P , 0.05

I more visits than CAttrition 51%, differences dropouts

and completersNo blinding assessorLow participation rate

29 n 5 238; F/U 3, 6, 12months from BL; 56 years

I-1: 13 individual sessions in 12months

Increased knowledge I-3 at 3 and 6months, P , 0.05

BL differences: I-2 better educated,I-1 longer duration DM

I-2: Three-day interactive course 1F/U 3 and 9 months 1 twoindividual sessions

I-3: Six or more individual sessionsbased on cognitive behaviortheory, TC F/U over 12 months

I more visits than CDropouts longer duration DM than

completersUnclear if study population

represents target population

C: 2 3 1-hour group education30 n 5 46; F/U immediate, 6

months; 66 years1: 8 3 2-hour small group sessions

over 3 months; problem- andparticipant-focused

C: One-day didactic teaching

Increased knowledge at 6 months Ivs. C, P , 0.05

I more visits than CMore C excluded due to poor controlNo mention blinding assessorNonparticipants older and heavier


I-1: Computer knowledge assessmentprogram (KAP) 1 interactivecomputer teaching (60 min)

I-2: KAP (2040 min) 1 feedbackI-3: KAP only

Increased knowledge all I, P , 0.05(within group)

Randomization by year and birthmonth (no details given)

I more contact than CNIDDM results reported here (49%

of total study population IDDM)C: No intervention

Continued on following page



Table 2Continued


40, 60 n 5 558; F/U 6 months;45 years

I-1: Collaborative education byHCW, 3 h/week 3 4 weeks

I-2: Same education, led by fellowpatient

C: No interventionI based on Fishbein and Ajzen Health

Belief Model

Increased knowledge both I,P , 0.001;

Increased DM locus of control,P , 0.001

Improved attitude and frequencySMBG both I, P , 0.05

Increased self-adjustment of insulinboth I, P , 0.01

Hospitals randomizedI more visits than CUncertain blinding assessor


I: 1-h computer-based drill withfeedback including explanation ofcorrect answer

Increased knowledge in I vs. C,P 5 0.005

NSD attitudes toward the drill

No BL comparisonsVolunteer study population

C: As for I, but right/wrong feedbackonly

I and C received 14-min instructivevideo before computer drill

46 n 5 471; F/U 6, 12 monthsfrom BL; 52 years

I: Home visits, teaching based onneeds assessment, maximum 12visits

C: Usual care

Increased knowledge at 6 months,P 5 0.001

NSD foot appearance score at 6months


70% of eligible participated

Increased medication skills at 6months, P 5 0.04 and urinetesting, P 5 0.01

48 n 5 82; F/U 6 months fromBL; 56 years

I-1: 11 3 2-h didactic weekly course1 1 individual session

Increased knowledge for all threegroups; NSD between groups

No BL statistics comparing groupsI more visits than C

I-2: 11-week course 1 threeindividual sessions: barriers andsupport

C: Usual care

NSD health locus of control Attrition 40%, no comparisondropouts to completers

Volunteer study population


I: CAI, 4 3 1-h sessions: didactic,some feedback and testing

C: Didactic group teaching; 4 3 3-h

Increased knowledge both groups;NSD between groups

No BL group comparison statisticsLow participation rate, no informa-

tion on nonparticipants or dropouts54 n 5 107; F/U 1, 4 months;

60 yearsI: 2 3 2-h group didactic 1 practice

1 feedback 1 usual careC: Usual care: individual education

based on perceived patient needBoth in IP setting

Increased compliance to insulininjection time for I at 4 months,P 5 0.05

Randomized by hospital numberNo blinding assessorNo information on participation rates


I-1: Three-day program 1 groupsession with pharmacist

NSD change in knowledge between Iand C or between I-1 and I-2

No BL comparisonI more contact than C

I-2: Three-day program 1 individualsession with pharmacist; TC F/U

Improved attitudes/perceptionstowards medications in

23% had unusable data for SMBG

C: Standard center 3-day educationprogram

I vs. C, P , 0.05NSD attitudes to SMBG

56 n 5 53; F/U 35 weeks;63 years

I: 2 3 5-min TC in 5 weeks; focusknowledge and skills

NSD overall knowledge Attrition 25%, no comparisondropouts to completers

C: 2 3 15-min individual visits in 5weeks, same content

Both groups individual educationimmediately before intervention

59 n 5 60; F/U 3 months fromBL; 55 years

I: Three-day group education, withF/U of four TC and one home visit;reinforce knowledge and skills

Frequency SMBG I . C,P , 0.0001

I more contact than CUnclear if study populationrepresents target population

C: Three-day group education98 n 5 22; F/U 32 weeks from

BL; 61 yearsI: Weekly to biweekly home visits:

nutrition, exercise, foot care,SMBG; by nursing students

C: Usual care

NSD knowledge between groupsIncreased self-care competency in

I vs. C, P 5 0.003


No mention blinding assessorUnclear if study population

represents target population99 n 5 56; F/U 6 months;

64 yearsI: Monthly 3 6 group sessions:

behavior modification (contracts,feedback), and general knowledge

C: Usual care

Increased knowledge at 6 months,P 5 0.0003

I more contact than CAttrition 32%, no comparison

dropouts to completersParticipation rate 37%, no

comparison participants tononparticipants


I: Education on importance of eyeexamination: booklet, video; oneinteractive TC

C: Usual care

Increased rate of retinal examinationin I (OR 5 4.3, 95% CI 2.47.8)




Table 2Continued

Referencen, F/U interval,

mean age Interventions Outcomes Comments

3. Lifestyle interventions31 n 5 40; F/U 6 months from

BL; 35 yearsI-1: Lunch demonstrationsI-2: Videotape educationC: Dietitian instruction and written

informationThree visits total for all groups over 6

months

Increased knowledge in I-1 and I-2,P , 0.001

No mention blinding assessorStudy population selected by

researchers; low participation rateType of diabetes unclear (insulin

dependent)


I: Five group sessions over 6 months,focus on weight loss

Increased knowledge I . C,P , 0.001

C: Individual education on weightloss by dietitian; 3 or more visits in12 months


I: Diet guide: guidelines, nutritiongoals, food logs

C: Traditional exchange list teachingBoth groups taught at 3 3 2.25-h

weekly sessions

NSD diet principals; Increasedapplied nutrition knowledgeI . C, P , 0.01

Attitude to life and diet, and dietknowledge improved I and C,P , 0.05

Attrition 21%, no information ondropouts

Unclear how patients recruited


I: Two sessions: dietitian and CAIC: 2 3 30-min sessions: dietitian

onlyTeaching for both over ;1 month

Increased exchange list knowledgefor I, P , 0.05; NSD C

No BL statisticsUnclear if blinding assessorType of DM unclear

39 n 5 105; F/U immediate,12 months; 45 years

I: Interactive computer program ondiet; 90 min/month over 6 months

C: Wait listed for IBoth groups received 5 days of

teaching

Increased knowledge for I,P , 0.0001; NSD for C

I more contact than CAttrition appears to be 76% at 12

months F/UNo comparison dropouts to

completersNo mention blinding assessorNo information on patient

recruitmentCrossover design


I: Culturally appropriate flashcards:diet, SMBG; delivered by lay HCW

Increased knowledge, self-care inI vs. C, P , 0.05

I more contact than CIntensity of intervention unclear

C: Usual care49 n 5 41; F/U 6 months;

61 yearsI: Psychologist-led group sessions on

PA and dietC: Didactic lectures on diet and DMBoth groups 10 3 1-h sessions over

6 months

Increased knowledge for bothgroups, P , 0.05, NSD betweengroups

Dropouts (22%) had higher mean BS;equal number dropouts I and C

Low participation rate, noinformation on nonparticipants


I: 5 3 90-min weekly sessions bynurse: diet, PA, barriers, social andgroup support

C: No information on care received

Improved health attitudes I vs. C,P 5 0.015

NSD perceptions of health relating toDM

No BL statisticsVolunteer study populationNumber of visits uncertain


I: 12 3 1.5-h weekly (didactic)sessions, then 6 3 1.5-h biweeklyparticipatory sessions; based onsocial action theory

Increased nutrition knowledge at 3months; NSD from BL at 6 months

I more visits than CMore C dropouts, no comparison

dropouts to completersVolunteer study population

C: One didactic class and twomailings


I: 3 3 1.5-h individual learningactivity packages with dietinformation, goals, activities

C: 3 3 1.5-h didactic lectures

Increased knowledge for 1 at 5months, P , 0.05


Volunteer study population from DMeducation program

83 n 5 596; F/U immediate, 6months; 51 years

I: More nutrition content, follow foodpyramid

C: Usual education, given meal planBoth I and C: 5 3 2-h weekly group

sessions

NSD attrition, knowledge, self-carebetween choice/no choice groups

NSD knowledge, self-care betweenI and C

Randomized into choice/no choice ofprogram, then I and C

Attrition 28%, dropouts younger,more male

No mention blinding assessorPhysician-referred patients or

volunteers95 n 5 120; 12 months from

BL; 61 yearsI: Group education (diet, PA, BS

control) q3 months 3 4C: Usual care

Increased knowledge in I,P , 0.001

I more contact than CUnclear if study population





66,68,74,78,8083) (Fig. 1). All studieswere unblinded. In 14 studies, an im-provement was noted in glycemic controlin the intervention group compared withthe control group (26,28,32,33,47,48,50,

65,71,76,79,8487). Percentage changein glycated hemoglobin ranged from 26to 14% in the intervention groups andfrom 33 to 115% in the control groups.In three studies, glycated hemoglobin de-

creased more in the control group(61,80,83), although the difference wassignificant in only one study (80).

Length of follow-up after completionof an intervention seemed to have a major

Table 2Continued


4. Skills teaching interventions41 n 5 70; F/U 6

months; 59 yearsI: 9 h over 4 weeks: participatory foot

care based on cognitive motivationtheory

C: Usual DM teaching: 14 h didactic/3 days, including 1 h foot care

Increased knowledge both groups at 6months, I . C, P , 0.001

Increased compliance foot care routines at 6months, I . C, P 5 0.012

Compliance correlates with decreased footproblems, P 5 0.002

Decreased food problems both I and C, NSDbetween groups at 6 months

Compliance correlates with decreased footproblems, P 5 0.002


45 n 5 34; F/U 8 weeks;37 years

I: Self-study course on self-controland self-management SMBG, over4 weeks

C: Usual care

Increased knowledge and skills for I . C,P , 0.01

Increased SMBG goal adherance rate morefor I than C, P , 0.01

No BL statisticsAttrition 26%, no comparison

dropouts to completersCommunity recruitment; participants

self-selectedType of DM unclear

53 n 5 50; F/U 1month; 73 years

I: 24-min instructional video ontechnique SMBG

Increased knowledge both groups, NSDbetween groups

No mention blinding assessor

C: Group didactic instruction ontechnique SMBG

No improvement SMBG technique I or C

58 n 5 30; F/Uimmediate;55 years

I: SMBG instruction for 30 min byeducator

C: Self-instruction SMBG for 30 min

Decreased error BS measurement in I,P , 0.01

62 n 5 395; F/U 12months from BL;60 years

I: Group foot education with F/U 33over 3 months; chart reminders forproviders, provider guidelines

C: Usual care

Decreased serious foot lesions in I at 1 year,P 5 0.05

I had more appropriate foot care behaviors,P , 0.05

Physicians examined I feet more often atoffice visits, P , 0.001

Randomized by practice teamI more contact than CLow participation rate; no


63 n 5 50; F/U 6months; adult

I: Additional participatory teachingon foot care

Self-care practices increased both groups, nostatistics

Randomized by week enteringprogram; no BL comparisons

C: Usual education, with routine,didactic foot education

Both groups: 5 days of OP DMeducation

Increased knowledge foot care for C only,P 5 0.02

NSD physical assessment feet I or C

Attrition 35% I, 44% C, nocomparison dropouts tocompleters

No mention blinding assessorNo demographic data; type of DM

unclear64 n 5 203; F/U 13

months I, 9 monthsC; ?age

I: 1-h didactic group education onfoot care

C: No education

Decreased foot ulcer rate, P , 0.005Decreased amputation rate, P , 0.025NSD infection rate

Randomized on SSNNo information on dropoutsNo mention blinding assessorNo information on nonparticipantsType of DM unclear

5. Coping skills interventions85 n 5 64; F/U 6 weeks;

50 yearsI: 6 3 2-h weekly group sessions:

patient empowerment, goal-setting, problem solving, stressmanagement

C: Wait listed

Increased 4/8 self-efficacy subscales, betweengroup difference, P , 0.02

No BL comparisons; 18 patients notrandomly assigned

I more contact than CVolunteer study population64% DM2HbA1c measured immediately after

program for C, 6 weeks after for I86 n 5 32; F/U 2 years;

68 yearsI-1: Six weekly sessions 1 18

monthly support group sessions:coping, discussion, education

Increased knowledge maintained for I-1 at 2years, P , 0.05

C is nonrandomized comparisongroup

More visits for I-1 . I-2 . CI-2: Six-week sessions only; wait list

for support groupC: Usual care

No information on attritionUnclear if study population

represents target populationType of DM unclear

BL, baseline; BS, blood sugar; BP, blood pressure; C, C-1, C-2, control groups; CAI, computer-assisted instruction; CHO, carbohydrate; D/SBP, diastolic/systolicblood pressure; DM, diabetes mellitus; DM2, type 2 diabetes; FBS, fasting blood sugar; F/U, follow-up; HCW, health-care worker; I, I-1, I-2, I-3, intervention groups;IP, inpatient; NSD, no significant difference; OP, outpatient; PA, physical activity; q, every; RN, registered nurse; SD, significant difference; TC, telephone call.



Table 3Effect of self-management training on lifestyle behaviors, psychological outcomes, and quality of life


1. Didactic, knowledge, and information interventions33 n 5 60; F/U

immediate, 4weeks; ?age

I: Four weekly group sessions: individualas needed

C: Started same education 4 weeks later

Decreased anxiety at 4 weeks I vs. C,P , 0.05

NSD depression score

No BL statisticsI more visits than CAttrition 29%, dropouts not equal

completers at BLLow participation rate, but NSD

participants and nonparticipants35 n 5 77; F/U 6 to

18 months fromBL; 33 years

I: Five days IP teaching: didactic,individual F/U q3 months, phoneaccess; instruction in self-adjustmentinsulin

C: Five days IP traditional education 1written information; 3 3 1.5-hsessions; q3 months F/U

NSD diet adherence at 18 months No BL comparison statisticsNo attrition informationNo blinding for diet historyLow recruitment rate and no


65, 109 n 5 1,139; F/U 5years; 46 years

I-1: Didactic individual and groupsessions q3 months: focus on diet, PA,smoking, BP, and BS control

I-2: I-1 1 clofibric acidC: Usual care at DM clinics; q34

months

Increased polyunsaturated fats in Ivs. C, P , 0.01

Increased PA in I vs. C, P , 0.01

No mention blinding assessorLow participation rate, no

information on nonparticipantsClofibric acid arm double-blinded

2. Collaborative, knowledge, and information interventions30 n 5 46; F/U

immediate, 6months; 66 years

I: 8 3 2-h small group sessions over3 months; problem- and participant-focused

NSD exercise I more visits than CMore C excluded due to poor controlNo mention blinding assessor

C: One day didactic teaching Nonparticipants older and heavier40, 60 n 5 558; F/U 6

months; 45 yearsI-1: Collaborative education by HCW,

3 h/week 3 4 weeksNSD hypoglycemic reactions,

anxiety, PAHospitals randomizedI more visits than C

I-2: Same education, led by fellowpatient

Uncertain blinding assessor

C: No interventionI based on Fishbein and Ajzen Health

Belief Model54 n 5 107; F/U 1,

4 months; 60 years1: 2 3 2-h group didactic 1 practice 1

feedback 1 usual careIncreased exercise I vs. C at 1 and 4

months, P 5 0.05Randomized by hospital numberNo binding assessor

C: Usual care: individual educationbased on perceived patient need

Both in IP setting

No information on participation rates

98 n 5 22; F/U 32weeks frombaseline; 61 years

I: Weekly to biweekly home visits:nutrition, exercise, foot care, SMBG;by nursing students

C: Usual care

NSD food assessment, 3-day dietaryrecall, functional health statusbetween groups



represents target population3. Lifestyle interventions31 n 5 40; F/U 6

months from BL;35 years

I-1: Lunch demonstrationsI-2: Videotape educationC: Dietitian instruction and written

informationThree visits total for all groups over 6

months

Decreased CHO variation in I-1 andI-2, P , 0.01

No mention blinding assessorStudy population selected by

researchers; low participation rateType of diabetes unclear (insulin

dependent)

38 n 5 32; F/Uimmediate;53 years

I: Two sessions: dietitian and CAIC: 2 3 30-min sessions: only dietitianTeaching for both over approximately 1

month

Decreased % fat intake I, P , 0.005;NSD C

No BL statisticsUnclear if blinding assessorType of DM unclear

39 n 5 105; F/Uimmediate, 12months; 45 years

I: Interactive computer program on diet;90 min/month over 6 months

C: Wait listed for IBoth groups received 5 days teaching

Decreased caloric and fat intake forthose in I with initial high intake,P , 0.05


months F/U, no comparisondropouts to completers

No mention blinding assessorNo information on patient recruitmentCrossover design


I: Advice to decrease fat to ,30% totalcalorie intake

C: Advice to decreased CHO to ,40%total calorie intake

Both individual counseling by dietitian,three home visits

Decreased fat and cholesterol intake,increased CHO for I, betweengroup difference,P , 0.001




Table 3Continued


67, 68, 104 n 5 206; F/U 12months from BL;62 years

I: Single visit: focus on diet; goal-setting,interactive video on barriers; F/U q3months

C: Usual care q3 months

Improvement in I vs. C at 12 monthsfor food habits, 4-day food record,kcal/day, % calories from fat,P , 0.05

Unclear if food record reviewersblinded

Low participation rate; participantsdiffer from nonparticipants

69, 82, 89,103

n 5 86; F/U 15, 27months from BL;53 years

I: Six individual visits at 2-monthintervals: intensive therapy for weight,BS control, diet, PA; then q3 monthsvisits


Fat intake ,30% of total energy,I . C at 15 months, P , 0.05

NSD energy intakeNSD physical activity, Vo2max at

15 months

I more visits than CNo mention blinding assessorNo information on nonparticipants

Both groups got 3 visits/3 months basiceducation before randomization


I: Educational videos, personal andfamily support q2 weeks for 6 months1 3 h counseling by dietitian

C: Review session 3 3

Decreased self-reported fat intake,P 5 0.0002

NSD self-reported total food or fiberintake

I more contact than C

71 n 5 60; F/U 12weeks from BL;55 years

I: Individualized advice on low glycemicindex foods

C: Standard, individualized diet advice

Consumption of lower glycemicindex foods I . C, P , 0.01

No mention blinding assessorUnclear how much intervention time

72 n 5 78; F/U 2months;4275 years

I-1: 5 3 2-h weekly education: calories,fat, fiber

I-2: I-1 1 goal setting, problem-solving,feedback

C: Wait listed for I

Decreased calories and % fat F/U forI-2 at immediate and 2 months,P , 0.01

Decreased calories for I-1 at 2months, P , 0.05

No BL informationI more visits than CMore attrition in C, no comparison

dropouts to completersUnclear if assessor blindedUnclear how study population

recruited73 n 5 70

F/U immediate 6months; 42 years

I: Monthly (or more) meetings: diet andPA prescription, feedback, behaviormodification

C: Usual care, wait listed for I

Decreased total fat intake atimmediate F/U, I vs. C,P 5 0.047

Deterioration of diet improvementsat 6 months

Incomplete BL statisticsI more visits than CNo mention blinding assessorVolunteer study population; cross-

over designType of DM uncertain (IDDM)

74 n 5 102; F/U 3, 6months from BL;67 years

I: Ten weekly sessions: problem-solving,increased self-efficacy; diet and PAfocus


Increased problem-solving for I at 3and 6 months; between group,P , 0.05

Randomization blocked bymedication

I more visits than CVolunteer study population

75 n 5 66; F/U 4months; 3086years

I: Five 3 90-min weekly sessions bynurse: diet and PA, barriers, social andgroup support

Improved health practices (diet, PA)I vs. C, P 5 0.015

No BL statisticsVolunteer study populationNumber of visits uncertain

C: No information on care received76 n 5 64; F/U 3, 6


I: 12 3 1.5-h weekly (didactic) sessions,then 6 3 1.5-h biweekly participatorysessions; based on social action theory

Increased PA 3 months; NSD 6months


dropouts to completersC: One didactic class and two mailings Volunteer study population


I-1: 16 weekly sessions of behavioralmodification: calorie logs, group PA,monetary incentives

I-2: 16 weekly didactic sessions:nutrition and PA

C: Four monthly didactic sessions

Improved eating and PA all groups at4 months, NSD between groups;regression toward BL at 16 m butremained significant


78, 97 n 5 79; F/Uimmediate;68 years

I-1: 10 3 60-min diet education sessionsover 4 months; adapted for elderly

I-2: I-1 1 peer support: group sessions;modeling, reinforcement

C: Usual care

Peer support levels correlated withweight loss, glycemic control,P , 0.05

Randomized by siteNo BL comparisons or attrition

informationI more visits than CCommunity recruitment; volunteer

study population83 n 5 596; F/U

immediate, 6months; 51 years



sessions

NSD physical function betweenchoice/no choice groups orbetween I and C


Attrition 28%, dropouts younger,more male

No mention blinding assessorPhysician-referred patients or

volunteers93 n 5 70; F/U 6


I: 22 h over 11 weeks, interactiveteaching based on cognitivemotivational theory

C: Didactic teaching, 14 h over 3 daysFocus for both I and C: diet and foot care

Increased dietary CHO but NSDbetween groups

Decreased % fat for both groups at 1month, I . C, P 5 0.004





effect on outcomes, and studies with a fol-low-up period of #6 months tended todemonstrate greater effectiveness (3133,48,50,71,76,84). Few studies had fol-low-up periods longer than 1 year afterthe last intervention contact, and theseshowed mixed effects on glycemic con-trol. The positive studies were either veryintensive interventions (79) or had a highattrition rate, leaving a very select group atfollow-up (28). Studies with prolongedinterventions (follow-up periods .1 yearand regular contacts with the interventionsubjects during that time) also had mixedresults. Two studies (47,65) demon-strated improved glycemic control, al-though generalizability of these studies isdifficult due to a low participation rate(65) and a lack of information on studyparticipation (47). Ten others producedno significant effects, despite regular pa-tient contact (29,34,35,67,69,82,86,8890).

For knowledge and information in-

terventions, the method of deliveryseemed to have a relationship to glycemiccontrol. Compared with didactic inter-ventions, collaborative interventions pro-duced somewhat more favorable results,particularly if interventions were repeti-tive and ongoing (26,28,48,50,76,84,86).

Most studies focusing on changes inlifestyle generally failed to show improve-ments in glycemic control compared withcontrol groups (36,39,43,49,66,67,70,7274,77,78,81 83,88,90 95), but afew studies (31,71,79,84) showed im-proved glycemic control in researcher-selected or volunteer populations withfollow-up ,6 months. Improved glyce-mic control was associated with weightloss in some studies (28,47,48,76,79) andnot others (31,65,71,84). Increased phys-ical activity levels were associated withimproved glycemic control in one study(65), although another study noted no

changes in physical activity despite im-provements in glycemic control (76).

Improved glycemic control and in-creased knowledge were not consistentlycorrelated. Although a number of studiesdemonstrated an increase in knowledgewith an improvement in glycemic control(2628,3133,50), others demonstratedimproved metabolic control with nochange in knowledge (47,76), and eightstudies demonstrated increased knowl-edge but no significant improvement inglycemic control (29,34 36,40,49,80,88). Two of three studies focusing oncoping-skills training produced improve-ments in glycemic control (85,86); theseinvolved frequent group support meet-ings.

Computers have been used recentlyas an educational tool in a number ofstudies, and effects on glycemic controlhave been mixed: positive results in threestudies (32,39,50) and negative results inanother study (67,68). Additionally, vid-

Table 3Continued


95 n 5 20; 12 monthsfrom BL; 61 years

I: Group education (diet, PA, BS control)q3 months 3 4

C: Usual care

NSD quality of life I more contact than CUnclear if study population

represents target population106 n 5 53; F/U 16

weeks from BL;55 years

I-1: Nutrition education: 16 weeklysessions; exchange system diet, goal-setting

I-2: Nutrition education: four monthlysessions; exchange system diet, goal-setting

C: Behavior modification: 16 weeklyvisits; calorie-counting diet, goal-setting

Decreased caloric intake and %calories from fat in I and C,P , 0.001; NSD between groups

I-2 more visits than CVolunteer study populationI-1 and I-2 combined in analysis, as

NSD between groups

107 n 5 152; F/U 10, 14weeks from BL;.50 years

I: 10 3 2-h sessions over 14 weeks,culturally sensitive video; nutritionfocus

C: No intervention

Decreased intake kcal/d C males,P 5 0.04

Decreased cholesterol intake Cfemales, P 5 0.013

No BL comparisonsI more visits than CAttrition 30.2%No information on dropoutsNo information on blinding assessorVolunteer study population

4. Skills teaching interventions90 n 5 50; F/U 1 year

from BL; 54 yearsI: Focused on relationship weight loss

and BS control; monetary incentivesReduction in medications both

groups, NSD between groupsVolunteer study population

C: Weight loss programBoth groups: 12 weekly meetings, then

monthly 3 6, F/U in 3 months;behavioral weight control program

Decreased caloric intake C,P , 0.004

Decreased depression both groups,NSD between groups

5. Coping skills interventions86 n 5 32; F/U 2 years;

68 yearsI-1: Six weekly sessions 1 18 monthly

support group sessions: coping,discussion, education

Increased quality of lifeDecreased stress I-1 vs. C at 6

months P , 0.05

C is nonrandomized comparisongroup

More visits for I-1 . I-2 . CI-2: Six weekly sessions only; wait list for

support groupC: Visual care

No information on attritionUnclear if study population

represents target populationType of DM unclear

BL, baseline; BS, blood sugar; BP, blood pressure; C, C-1, C-2, control groups; CAI, computer-assisted instruction; CHO, carbohydrate; D/SBP, diastolic/systolicblood pressure; diabetes mellitus; DM2, type 2 diabetes; FBS, fasting blood sugar; F/U, follow-up; HCW, health-care worker; I, I-1, I-2, I-3, intervention groups; IP,inpatient; NSD, no significant difference; OP, outpatient; PA, physical activity; q, every; RN, registered nurse; SD, significant difference; TC, telephone call.



Table 4Effect of self-management training on glycemic control


1. Didactic, knowledge, and information interventions33 n 5 60; F/U

immediate, 4weeks, ?age

I: Four weekly group sessions; individualsessions as needed

C: Started same education 4 weeks later

Decreased HbA1c at 4 weeks I vs. C,P , 0.05

I more visits than CNo BL statisticsAttrition 29%, dropouts not equal

to completers at BLLow participation rate, but NSD

participants and nonparticipants34 n 5 345; F/U

immediate; 58years

I: Nine multimedia education classesover 1.5 years

C: Usual care

NSD HbA1c or FBS No mention blinding assessorLow participation rate;

nonparticipants older, more male35 n 5 77; F/U 618


I: Five days IP teaching: didactic,individual F/U q3 months, phoneaccess; instruction in self-adjustmentinsulin

C: Five days IP traditional education 1written information; 3 3 1.5-hsessions; q3 months F/U

Decreased FBS for C and I at 1month, NSD between groups

NSD from BL at 6 months

No BL comparison statistics;no attrition information;No blinding for diet history

Low recruitment rate and noinformation on nonparticipants


I: Three weekly didactic, small groupsessions q4 months 1 q2 months visitwith doctor

Decreased HbA1c and FBS in I vs. C,P , 0.05

Exact values not given

I more visits than CNo information on participation rates

C: Visit with doctor q2 months57 n 5 31; F/U 1 week,

HbA1c F/U 2months; 65 years

I: Four weekly TC after hospitaldischarge: identify deficits and teach

C: No TC or other contact

NSD HbA1c between groups I more contacts than CUnclear if assessor blinded

No information on nonparticipants65, 109 n 5 1,139; F/U 5

years; 46 yearsI-1: Didactic individual and group

sessions q3 months; focus on diet, PA,smoking, BP and BS control

I-2: I-1 1 clofibric acidC: Usual care at DM clinics; q34 months

Decreased FBS in I vs. C, P , 0.01 No mention blinding assessorLow participation rate, no

information on nonparticipantsClofibric acid arm double-blinded

2. Collaborative, knowledge, and information interventions26 n 5 80; F/U 6 months

from BL; 53 yearsI: Group sessions: didactic and

discussions; no details duration orfrequency; F/U q3 months

C: Care at general medical clinicq3 months

Decreased FBS in I vs. C at 6 months(9.7 vs. 6.4 mmol/l), P , 0.01


27, 28 n 5 532; F/U 1214months; 57 years

I: Average 2.4 sessions 3 1.5-h over 2months 1 home visit, TC F/U,contracting, skill excercises,goal-setting; over 26 months

C: Usual care

Decreased HbA1c in I (0.43%),P , 0.05, increased in C (0.35%)

Decreased FBS I vs. C, P , 0.05

I more visits than CAttrition 51%, differences

dropouts and completersNo blinding assessorLow participation rate

29 n 5 238; F/U 3, 6,12 months post BL;56 years

I-1: 13 individual sessions in 12 monthsI-2: Three-day group interactive course

1 F/U 3 and 9 months 1 2 individualsessions

I-3: Six or more individual sessionsbased on cognitive behavioral theory,TC F/U over 12 months

C: 2 3 1-h group education

Decreased HbA1c for all groups at allF/U intervals

NSD between groups

BL differences: I-2 better educated;I-1 had longer duration DM

I more visits than CDropouts longer duration DM than

completersUnclear if study population


30 n 5 46; F/Uimmediate,6 months; 66 years

I: 8 3 2-h small group sessions over 3months; problem- and participant-focused

NSD HbA1c at 6 months More C excluded due to poor controlI more visits than CNo mention blinding assessor

C: One-day didactic teaching Nonparticipants older and heavier32 n 5 174; F/U 46

months; 57 yearsI-1: Computer knowledge assessment

program (KAP) 1 interactivecomputer teaching (60 min)

I-2: KAP (2040 min) 1 feedbackI-3: KAP onlyC: No intervention

Decreased HbA1c I-2 (21.3%,P , 0.05) and I-3 (20.08%,P , 0.05)

Randomization by year and monthbirth (no details given)

I more contact than CNIDDM results reported here (49%

of total study population IDDM)

40, 60 n 5 558; F/U 6months;45 years

I-1: Collaborative education by HCW,3 h/week 3 4 weeks

I-2: Same education led by fellow patientC: No interventionI based on Fishbein and Ajzen Health

Belief Model

NSD HbA1c at 6 months Hospitals randomizedI more visits than CUncertain blinding assessor

48 n 5 82; F/U 6months post BL;56 years

I-1: 11 3 2-h weekly didactic course1 1 individual session

I-2: 11-week course 1 three individualsessions: barriers and support

C: Usual care

FBS and HbA1c decreased for I-1 andI-2 at 3 and 6 months, P , 0.05

No BL statistics comparing groupsI more visits than CAttrition 40%, no comparison





Table 4Continued


50 n 5 40; F/U 3months; 57 years

I: CAI, 4 3 1-h session: didactic, somefeedback and testing

C: Didactic group teaching; 4 3 3-h

Decreased GHb I (relative change11%), P , 0.05, increased C(14%), P , 0.05, between groupdifference, P 5 0.001

No BL group comparison statisticsLow participation rate, no information

on nonparticipants or dropouts

54 n 5 1.07; F/U 1,4 months; 60 years

I: 2 3 2-h group didactic 1 practice1 feedback 1 usual care

NSD BS at 4 months Randomized by hospital numberNo blinding assessor

C: Usual care: individual educationbased on perceived patient need

Both in IP setting

No information on participation rates


I-1: Three-day program 1 group sessionwith pharmacist

NSD % change in BS betweenI and C

No BL comparisonsI more contact than C

I-2: Three-day program 1 individualsession with pharmacist; TC F/U

23% had unusable data for SMBG

C: Standard center 3-day educationprogram


I: Three-day group education, with F/Uof 4 TC and 1 home visit; reinforceknowledge and skills

NSD HbA1c between groups I more contact than CUnclear if study population represents

target populationC: Three-day group education

87 n 5 247; F/U12 months fromBL; 54 years

I: 12 weekly sessions over 3 months;Spanish videos, followed by 14group support sessions in 9 months,by lay HCW

C: Wait listed for the intervention

Decreased GHb 1.7% in I, increased0.3% in C

Decreased FBS 18.9 mg/dl in I,increased 3.9 in C

No BL comparisonI more contact than CNo information on attritionNo mention blinding assessorNo statistics

96 n 5 156; F/U ?immediate;58 years

I-1: Patient selects behavior forimprovement

I-2: Behavioral strategies to increasecompliance

I-3: Behavioral strategies 1instruction on behavioral analysis

C: Routine care with consistent F/Uby RN:

I-1,2,3 based on social cognitive theoryI over 13 months

NSD GHb I and C No information on attritionVolunteer study populationNumber of patient contacts unclearF/U interval unclear

98 n 5 22; F/U 32weeks frombaseline; 61 years

I: Weekly to biweekly home visits:nutrition, exercise, foot care,SMBG; by nursing students

C: Usual care

NSD GHb or BS at 32 weeks Attrition 24%, no comparisondropouts to completers


represents target population99 n 5 56; F/U 6

months; 64 yearsI: Monthly 36 group sessions:

behavior modification (contracts,feedback), general knowledge

C: Usual care

Decreased GHb immediate F/U I andC (P ,0.05), NSD betweengroups; NSD at 6 months

Decreased FBS I at immediate F/U,NSD between groups

I more contact than CAttrition 32%, no comparison dropouts

to completersParticipation rate 37%, no comparison

participants to nonparticipants3. Lifestyle interventions31 n 5 40; F/U 6


I-1: Lunch demonstrationsI-2: Videotape educationC: Dietitian instruction and written

informationThree visits total for all groups

over 6 months

Decreased HbA1c I-1 (22.4%,P , 0.025) and I-2 (23.3%,P , 0.001)

Decreased HbA1c correlated withdecreased CHO variation, P , 0.02

No mention blinding assessorStudy population selected by researchers;

low participation rateType of diabetes unclear (insulin

dependent)


I: Five group sessions over 6 months,focus on weight loss

Decreased HbA1c I at 6 months,P , 0.001; NSD I vs. C at 1 year

C: Individual education on weight lossby dietitian; 3 or more visits in 12months

39 n 5 105; F/Uimmediate,12 months; 45years

I: Interactive computer program on diet;90 min/month over 6 months

C: Wait listed for IBoth groups received 5 days of teaching

NSD HbA1 or fructosamine atimmediate F/U

Decreased HbA1 at 18 months(10.8 to 9.6, P , 0.001)


months F/U; no comparisondropouts to completers

No mention blinding assessorCrossover designNo information on patient recruitment


I: Culturally appropriate flashcards: diet,SMBG; delivered by lay HCW

Decreased HbA1c in I (20.34%,P . 0.05)


C: Usual care Intensity of intervention unclear




Table 4Continued


49 n 5 41, F/U 6 months;61 years

I: Psychologist-led group sessions onPA and diet

Decreased HbA1c for I and C, NSDbetween groups

Dropouts (22%) had higher mean BS;equal number dropouts I and C

C: Didactic lectures on diet and DMBoth groups 10 3 1-h sessions over

6 months

Decreased mean BS at 6 months for I,between group difference, P , 0.05

Low participation rate, no informationon nonparticipants


I: Advice to decrease fat to ,30%total calorie intake

C: Advice to decrease CHO to ,40%total calorie intake

Both I and C received individualcounseling by dietitian; threehome visits

NSD HbA1c between groupsNSD fasting plasma glucose between

groups

67, 68, 104 n 5 206; F/U 12 monthsfrom BL; 62 years

I: Single visit: focus on diet; goal-setting, interactive video onbarriers, F/U q3 months


NSD HbA1c at 12 months Unclear if food record reviewers wereblinded

Low participation rate; participants differfrom nonparticipants

69, 82, 89,103

n 5 86; F/U 15,27 months from BL;53 years

I: Six individual visits at 2-monthintervals; intensive therapy forweight, BS control, diet, PA; thenq3 months visits

Decreased FBS for I . C at 15months, P 5 0.02; NSD27 months

NSD HbA1c 15 and 27 months

I more visits than CNo mention blinding assessorNo information on nonparticipantsI more contact than C

C: Usual care q23 monthsBoth groups 3 visits/3 months basic

education before randomization70 n 5 75; F/U 12 months

from BL; 61 yearsI: Educational videos, personal and

family support q2 weeks for 6months 1 3 h counseling bydietitian

NSD GHb

C: Review session 3 371 n 5 60; F/U 12 weeks

from BL; 55 yearsI: Individualized advice on low

glycemic index foodsDecreased FBS I and C, significant

only for I, P , 0.05No mention blinding assessorUnclear how much intervention time

C: Standard, individualized dietadvice

Decreased fructosamine I vs. C,P , 0.05


I-1: 5 3 2-h weekly education:calories, fat, fiber

NSD GHb No BL informationI more visits than C

I-2: I-1 1 goal setting, problem-solving, feedback

More attrition in C, no comparisondropouts to completers

C: Wait listed for I Unclear if assessor blindedUnclear how study population recruited


I: Monthly (or more) meetings: dietand PA prescription, feedback,behavior modification

C: Usual care; wait listed for I

NSD HbA1 immediate or 6 months Incomplete BL statisticsI more visits than CNo mention blinding assessorVolunteer study populationCrossover designType of DM uncertain (IDDM)

74 n 5 102; F/U 3, 6months from BL;67 years

I: 10 weekly sessions: problem-solving, increased self efficacy, dietand PA focus


Decreased HbA1c in I and C at 3months (0.5%), NSD betweengroups, return to BL at 6 months

Randomization blocked bymedication



I: 12 3 1.5-h weekly (didactic),sessions then 6 3 1.5-h biweeklyparticipatory diet and exercisesessions, based on socialaction theory

Decreased HbA1c at 3 months(21.5%) and 6 months (21.1%),P , 0.01



C: One didactic class and twomailings

77 n 5 53; F/U 16 weeks,16 months from BL;55 years

I-1: 16 weekly sessions: behavioralmodification, calorie logs, groupPA, monetary incentives

Decreased FBS and HbA1c allgroups at 16 weeks, P , 0.01,NSD between groups


I-2: 16 weekly didactic sessionsnutrition and PA

NSD FBS and HbA1c at 16 months

C: Four monthly didactic sessions78, 97 n 5 79; F/U immediate;

68 yearsI-1: 10 3 60-min diet education

sessions over 4 months; adaptedfor elderly

Decreased HbA1c at 8 weeks, for I-2,P , 0.05, not maintained at16 weeks

Randomized by siteNo BL comparisons or attrition

informationI-2: I-1 1 peer support: group

sessions, modeling, reinforcementC: Usual care

I more visits than CCommunity recruitment; volunteer

study population




Table 4Continued


79, 100,101

n 5 76; F/U 3, 6,18 months from BL;54 years

I-1: Diet focus; goal-setting, modifyenvironment

I-2: PA focus with participationI-3: Diet 1 PAC: Didactic teachingAll groups: 10 3 2-h weekly

sessions: I based on behavior andcognitive modification strategies

Decreased BS I-1 vs. C at 6 months,P , 0.037; NSD HbA1c

Decreased HbA1c 13 vs. C at 18months (difference 1.8%, P , 0.05)

Randomized by group meetingattended



I: 3 3 1.5-h individual learningactivity packages with dietinformation, goals, activities

C: 3 3 1.5-h didactic lectures

Decreased HbA1c in C (4.5%) at 5months, P , 0.05; NSD I group


Volunteer study population from DMeducation program

81, 102 n 5 247; F/U 6 monthsfrom BL; 57 years

I: Three or more individual visitswith dietitian, over 6 weeks,following practice guidelines

C-1: One visit producing nutritioncare plan

C-2: Nonrandomized comparisongroup; no intervention

Decreased FBS and HbA1c I at 6months, P , 0.001; decreased C-1,P , 0.01; NSD between I and C-1

Nonrandomized C-2C less time with dietitianAttrition 28% for lab studies, unclear

if dropouts equal completers at BLVolunteer study population or

physician-referred



Decreased HbA1c in C (0.9%,P 5 0.035)



sessions

Patient choice had no effect Attrition 28%, dropouts younger,more male

No mention blinding assessorPhysician-referred patients or volunteers


I: Six monthly sessions on dietC: Usual care; wait listed

Decreased postprandial BS at 6months in I vs. C, P 5 0.009

No BL statisticsI more visits than CAttrition 47%, but dropouts equal

completers at BLNo information on patient recruitmentType of DM unclear


I: Six individual sessions on diet, bynurse

Decreased FBS all groups, P , 0.01,NSD between groups

No BL statistics

C: Physician gave handout at initialvisit on weight loss

Both groups 6 visits/12 months

Decreased HbA1c C females and Imales, P , 0.001, NSD betweengroups

90 n 5 50; F/U 1 year fromB/L; 54 years

I: Focused on relationship weightloss and BS control; monetaryincentives

C: Weight loss program

NSD HbA1c at 1 year for I or C Volunteer study population

Both groups: 12 weekly meetings,then monthly 36, F/U in 3months; behavioral weight controlprogram

91 n 5 120; F/U 7,11 months from BL;54 years

I-1: Six monthly small-groupmeetings, diet and PA information;audio-visual materials culturallysensitive

NSD HbA1c between or withingroups at 7 or 11 months

I more visits than CAttrition 32% at 11 months, NSD

dropouts to completers

I-2: 1-h didactic 1 five monthlydiscussions on BS control

C: 1-h didactic only92 n 5 40; F/U immediate,

6 weeks; 54 yearsI: Behavioral group: 6 3 1.5-h

weekly meetings; cues for eating,daily record

Decreased BS immediate F/U for I,P , 0.05, NSD 6 weeks

NSD between groups for BS

I more visits than CUnclear how patients selected

C: Individual diet counseling, total1.25 h


I: 22 h over 11 weeks, interactiveteaching based on cognitivemotivational theory

C: Didactic teaching, 14 h over 3 daysFocus for both I and C: diet andfoot care

NSD FBS either groupDecreased fructosamine both groups

at 1 month, P , 0.0001, returnto BL at 6 months





eotapes have been used as adjuncts forteaching, with positive (31) and negative(91) results.

Cardiovascular disease risk factorsA large number of studies examined theeffects of diabetes self-management train-ing on risk factors for cardiovascular dis-ease, including body weight, serum lipid

levels, and blood pressure (Table 5). Thir-teen studies demonstrated positive effectson weight loss; the average weight loss forthese studies was ;2 kg (range 1.33.1)(28,36,38,47,66,72,74,76,80,82,84,89).Most studies with positive results in-volved regular contacts or reinforcementsessions (38,47,66,76,82,84) or veryshort follow-up periods (72,74), al-

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