Time is of the essence
Original article:
Self-management education for adults with type 2 diabetes. A meta-analysis
of the effect on glycemic control. Norris SL, Lau J, Smith SJ, Schmid
CH, Engelgau MM. Diabetes Care 2002; 25: 1159–71.
Summary and Comment
This is a well-thought-out study of an important topic with implications for
diabetes health care professionals.
The authors’ meta-analysis of randomized controlled trials provides
definitive evidence of the efficaciousness of diabetes self-management
education (DSME; lifestyle- and knowledge-focused interventions) in
improving glycemic control. The results show that through DSME a reduction
of 0.76% can be attained in HbA1c (Table I), thus providing significant
benefit for patients with type 2 diabetes.
Table I: Results of the meta-analysis.
The authors rigorously researched their field, studiously excluding
studies which showed bias and isolating many variables which might affect
the efficacy of DSME. Their main finding of clinical note was a significant
association between improved glycemia and the independent variable, duration
of contact time between educator and patient. The authors extrapolated their
results to prove that 23.6 h of contact time are needed to achieve a 1%
decrease in HbA1c. This finding is crucial in respect to the recommendations
made by the United Kingdom Prospective Diabetes Study, which indicated that
a 1% decrease in HbA1c is associated with a considerable reduction in
comorbid diabetic complications.
This review, however, highlights the diminishing effect of DSME over time,
indicating the need for practitioners to offer long-term educational
interventions. But what should the characteristic feature of the
interventions be? Surprisingly, there appears to be no discriminatory
benefit in whether the educational focus is on knowledge or lifestyle, or
whether it is conducted in groups or on an individual basis. The results
show that a wide variety of techniques work in improving glycemic control,
but brief interventions, regardless of the number of contact points, are
less effective.
Notably, the meta-analysis identified a worrying trend in that one-third of
studies included in the review reported a dropout rate of more than 20%. In
view of this, together with an appreciation of the ‘temporal decline’ aspect
of such interventions, the importance of the long-term maintenance of
initial behaviour change should be a focus of research.
Summary and Comment:
Anne-Marie Felton, Chairman of the
Federation of European Nurses in Diabetes (FEND), London, UK
