NIHR Signal Diabetes self-management education leads to better blood sugar control

Published on 23 March 2016

Diabetes self-management education can lead to greater, and clinically important, reductions in blood sugar levels than usual care or other control treatments. Self-management programmes were most effective in people with higher blood sugar levels to start with, and when they involved ten or more hours of contact time, although there was no indication that programmes running over a longer overall period of time were more effective.

The interventions were very diverse so the optimal intervention duration, provider, or contact hours is not clear. This review did not study cost-effectiveness either, so it is not possible to give advice on how interventions compared to each other or which might deliver value for money.

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Why was this study needed?

Around four million people in the UK are living with diabetes. Poor control of blood sugar levels is linked to serious complications including heart disease, stroke, blindness and amputations leading to disability. Effective management can reduce these risks but can induce healthcare costs through regular GP and specialist appointments. A marker of longer term (the previous 2 to 3 months) blood sugar level is the amount of glucose bound to haemoglobin in the blood – glycosylated haemoglobin or HbA1C. A normal non-diabetic HbA1C is 5.5% (<36mmol/l). For people with diabetes about 6.5% seems to be optimal.

Self-management has the potential to lower both the health risks and healthcare costs of diabetes whilst empowering individuals to take control of their condition.

This review compared the effectiveness of diabetes self-management education to either usual care or a minimal educational intervention, in people with type 2 diabetes.

What did this study do?

This systematic review included 118 randomised controlled trials in people aged 18 years and over with type 2 diabetes which reported HbA1C outcomes. Self-management interventions had aim to improve people’s knowledge, skills and ability to self-manage their blood glucose control. They used an informed decision making process that included goal setting. Despite this definition, the interventions were too diverse to be pooled for meta-analysis.

The majority of interventions were delivered to an individual (41.5%), through a single provider (60.2%), lasted an average of six months (range 1 to 36 months), and averaged 18 hours of contact time. Usual care or minimal educational interventions, the main comparison groups, were not described in detail and are likely to have varied trial to trial.

Trials investigating self-management in people with diabetes type 1 and type 2 were included as long as the type 2 findings were reported separately. The review included many relevant trials and assessed risk of bias for each. However, this was not taken into account in the findings, meaning the results reflect a mix of high and low quality studies.

What did it find?

  • Of 118 trials included, 61.9% reported a significant change in HbA1C. Average reduction was 0.74% through self-management education and 0.17% through usual care or minimal educational interventions; an average absolute reduction of 0.57%.
  • More studies reported significant reductions in blood glucose when interventions combined group and individual education, when there was contact times of ten hours or more, and when starting HbA1C was persistently high (9% or more).
  • For example, more studies delivering self-management education through a combination of group and individual education reported significant HbA1C reductions (85.7%), compared with group only (65.7%), individual only (53.1%) or remotely delivered programmes (41.7%).

What does current guidance say on this issue?

NICE guidelines (2015) recommend that people with type 1 or type 2 diabetes are offered education programmes that develop knowledge and skills that help them to self‑manage their condition. NICE recommends an HbA1C level of 6.5%, unless the person is using medication that may cause low blood sugar levels, in which case the target should be 7.0%.

What are the implications?

Based on a large number of high and low quality studies this review suggests that self-management education interventions are broadly more effective at reducing blood sugar levels in people with type 2 diabetes than usual care or minimal education interventions. The authors noted that the absolute improvement in HbA1C of 0.57% is clinically meaningful and in the range of improvements seen with several primary glycaemic control medications.

The interventions were very diverse so the optimal intervention duration, provider, or contact time is not yet clear, nor was it possible to identify any subgroup most or least likely to benefit.

Further work is needed in this area to identify the most effective interventions and the patients most likely to benefit.

Citation and Funding

Chrvala CA, Sherr D, Lipman RD. Diabetes self-management education for adults with type 2 diabetes mellitus: A systematic review of the effect on glycemic control. Patient Educ Couns. 2015. [Epub ahead of print].

This research was funded by the American Association of Diabetes Educators’ Education and Research Foundation.

Bibliography

Diabetes UK. Facts and stats. London: Diabetes UK, 2015.

NICE. Type 1 diabetes in adults: diagnosis and management. NG17. London: National Institute for Health and Care Excellence; 2015.

NICE. Type 2 diabetes in adults: management. NG28. London: National Institute for Health and Care Excellence; 2015.

National Institute of Diabetes and Digestive and Kidney Diseases. The A1C Test and Diabetes. Bethesda (MD): National Institutes of Health; 2014.

Why was this study needed?

Around four million people in the UK are living with diabetes. Poor control of blood sugar levels is linked to serious complications including heart disease, stroke, blindness and amputations leading to disability. Effective management can reduce these risks but can induce healthcare costs through regular GP and specialist appointments. A marker of longer term (the previous 2 to 3 months) blood sugar level is the amount of glucose bound to haemoglobin in the blood – glycosylated haemoglobin or HbA1C. A normal non-diabetic HbA1C is 5.5% (<36mmol/l). For people with diabetes about 6.5% seems to be optimal.

Self-management has the potential to lower both the health risks and healthcare costs of diabetes whilst empowering individuals to take control of their condition.

This review compared the effectiveness of diabetes self-management education to either usual care or a minimal educational intervention, in people with type 2 diabetes.

What did this study do?

This systematic review included 118 randomised controlled trials in people aged 18 years and over with type 2 diabetes which reported HbA1C outcomes. Self-management interventions had aim to improve people’s knowledge, skills and ability to self-manage their blood glucose control. They used an informed decision making process that included goal setting. Despite this definition, the interventions were too diverse to be pooled for meta-analysis.

The majority of interventions were delivered to an individual (41.5%), through a single provider (60.2%), lasted an average of six months (range 1 to 36 months), and averaged 18 hours of contact time. Usual care or minimal educational interventions, the main comparison groups, were not described in detail and are likely to have varied trial to trial.

Trials investigating self-management in people with diabetes type 1 and type 2 were included as long as the type 2 findings were reported separately. The review included many relevant trials and assessed risk of bias for each. However, this was not taken into account in the findings, meaning the results reflect a mix of high and low quality studies.

What did it find?

  • Of 118 trials included, 61.9% reported a significant change in HbA1C. Average reduction was 0.74% through self-management education and 0.17% through usual care or minimal educational interventions; an average absolute reduction of 0.57%.
  • More studies reported significant reductions in blood glucose when interventions combined group and individual education, when there was contact times of ten hours or more, and when starting HbA1C was persistently high (9% or more).
  • For example, more studies delivering self-management education through a combination of group and individual education reported significant HbA1C reductions (85.7%), compared with group only (65.7%), individual only (53.1%) or remotely delivered programmes (41.7%).

What does current guidance say on this issue?

NICE guidelines (2015) recommend that people with type 1 or type 2 diabetes are offered education programmes that develop knowledge and skills that help them to self‑manage their condition. NICE recommends an HbA1C level of 6.5%, unless the person is using medication that may cause low blood sugar levels, in which case the target should be 7.0%.

What are the implications?

Based on a large number of high and low quality studies this review suggests that self-management education interventions are broadly more effective at reducing blood sugar levels in people with type 2 diabetes than usual care or minimal education interventions. The authors noted that the absolute improvement in HbA1C of 0.57% is clinically meaningful and in the range of improvements seen with several primary glycaemic control medications.

The interventions were very diverse so the optimal intervention duration, provider, or contact time is not yet clear, nor was it possible to identify any subgroup most or least likely to benefit.

Further work is needed in this area to identify the most effective interventions and the patients most likely to benefit.

Citation and Funding

Chrvala CA, Sherr D, Lipman RD. Diabetes self-management education for adults with type 2 diabetes mellitus: A systematic review of the effect on glycemic control. Patient Educ Couns. 2015. [Epub ahead of print].

This research was funded by the American Association of Diabetes Educators’ Education and Research Foundation.

Bibliography

Diabetes UK. Facts and stats. London: Diabetes UK, 2015.

NICE. Type 1 diabetes in adults: diagnosis and management. NG17. London: National Institute for Health and Care Excellence; 2015.

NICE. Type 2 diabetes in adults: management. NG28. London: National Institute for Health and Care Excellence; 2015.

National Institute of Diabetes and Digestive and Kidney Diseases. The A1C Test and Diabetes. Bethesda (MD): National Institutes of Health; 2014.

Diabetes self-management education for adults with type 2 diabetes mellitus: A systematic review of the effect on glycemic control

Published on 15 December 2015

Chrvala, C. A.,Sherr, D.,Lipman, R. D.

Patient Educ Couns , 2015

OBJECTIVE: Assess effect of diabetes self-management education and support methods, providers, duration, and contact time on glycemic control in adults with type 2 diabetes. METHOD: We searched MEDLINE, CINAHL, EMBASE, ERIC, and PsycINFO to December 2013 for interventions which included elements to improve participants' knowledge, skills, and ability to perform self-management activities as well as informed decision-making around goal setting. RESULTS: This review included 118 unique interventions, with 61.9% reporting significant changes in A1C. Overall mean reduction in A1C was 0.74 and 0.17 for intervention and control groups; an average absolute reduction in A1C of 0.57. A combination of group and individual engagement results in the largest decreases in A1C (0.88). Contact hours >/=10 were associated with a greater proportion of interventions with significant reduction in A1C (70.3%). In patients with persistently elevated glycemic values (A1C>9), a greater proportion of studies reported statistically significant reduction in A1C (83.9%). CONCLUSIONS: This systematic review found robust data demonstrating that engagement in diabetes self-management education results in a statistically significant decrease in A1C levels. PRACTICE IMPLICATIONS: The data suggest mode of delivery, hours of engagement, and baseline A1C can affect the likelihood of achieving statistically significant and clinically meaningful improvement in A1C.

The HbA1C test is a blood test that provides information about a person’s average levels of blood glucose, also called blood sugar, over the past 3 months. The HbA1C test is sometimes called the A1C, haemoglobin A1c, or glycohaemoglobin test. The HbA1C test is one of the primary tests used for diabetes management and research.

Expert commentary

This review shows how essential diabetes self-management education is in enabling people with type 2 diabetes to manage their condition effectively, preventing serious and costly complications. The current policy environment is focused on improving quality of care, delivering it cost-effectively and supporting greater engagement in self-management.

This review shows that different modes of delivery all improve glycaemic control. Many questions remain about what interventions work best for which groups and how to deliver them cost effectively in local UK health economies. Yet this review shows that diabetes self-management education should be a core part of usual care. The next question is what can be done to deliver and encourage more people with diabetes to see the benefits themselves?

Bridget Turner, Director of Policy and Care Improvement, Diabetes UK