Behavioral programs for type 2 diabetes strengthened by delivery method and multifactorial content

1. From a systematic review, behavioral programs offering more than 11 contact hours led to clinically important improvements in patients with type 2 diabetes.

2. While lifestyle and diabetes self-management programs had equal effects on glycemic control, lifestyle programs had greater impact on BMI.

3. Programs tended to benefit those with poor glycemic control more than those with good control.

Evidence Rating Level: 1 (Excellent)

Study Rundown: The cost of diabetes management amounted to 11% of total healthcare expenditures in the US in 2012. Experts recommend that patients with diabetes adopt self-care practices to improve outcomes. Programs to support such behavior change include diabetes self-management education (DSME) and lifestyle (i.e., exercise and diet) programs. The goal of this study was to determine which combination of program components and delivery methods were most effective. The authors utilized a review of 132 randomized, controlled trials to measure impacts of programs on clinical outcomes, including HbA1c and Body Mass Index (BMI). Compared with usual care and active control groups, behavioral programs reduced HbA1c levels immediately following programming at 6 months and 12 months. However, these differences were not clinically substantial. Compared to usual care, improvements in BMI were significant at each of these time points. The majority of programs demonstrating benefit utilized in-person delivery. Program intensity, while contributing to success, seemed less important than individual delivery. Impact was notably more prominent in participant groups with higher baseline HbA1c and ethnic minority participants. Limitations to the review include moderate and high levels of bias among studies that had incomplete data or lack of blinding. Overall, this review shows the strengths and importance of behavioral programs to help treat type 2 diabetes.

Click to read the study published today in The Annals of Internal Medicine

Relevant Reading: Responding to the Challenged of Primary Diabetes Care Through the National Diabetes Education Program

In-Depth [systematic review and meta-analysis]: A total of 132 studies were selected that represented randomized, controlled trials comparing programs with usual medical management, and/or active controls. Programs were categorized by components and delivery factors, separating DSME, DSME plus support phase (i.e., clinical, psychosocial, behavioral), and lifestyle interventions. Significant decreases in HbA1c were defined as 0.4%. Baseline HbA1c ranged between 6.3-12.3%, BMI between 23.8-39.1 kg/m2, and disease duration between 1-18 yrs. Compared to usual care, estimated mean difference for HbA1c was -0.35 (95%CI -0.56 to -0.14) at end of intervention, -0.16 (95%CI -0.36 to 0.04) at 6 months, and -0.14 (95%CI -0.4 to 0.12) at 12 months. Compared to usual care, mean difference (MD) for BMI was significant at end of intervention (MD -0.51 kg/m2; 95%CI -0.66 to -0.36), 6 months (MD -0.21 kg/m2; 95%CI -0.32 to -0.01), and 12 months (MD -0.92 kg/m2; 95%CI -1.44 to -0.04). Mean difference results showed little benefit when baseline HbA1c <7%, and individuals <65 years old showed more HbA1c benefit compared to >65 years old (MD -0.31 vs -0.24). Effect on HbA1c was greater for groups with >75% minority (MD -0.42 compared to -0.16), but glycemic control was worse in minority groups compared with majority white groups (HbA1c baseline 8.80% vs 7.60%).

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