Structured Education in Type 2 Diabetes

Review of the Evidence for the Benefits of Structured Education in Type 2
Diabetes

INTRODUCTION

Globally, type 2 diabetes accounts for most deaths, sufferings, and burdens to individuals and health care services. There is a wealth of evidence to prove that high-quality structured diabetes self-management education (DSME) can significantly affect health outcomes and enhance patients’ quality of life.  This summative report aims at reviewing the evidence for the benefits of structured education in Type 2 diabetes. KNOWLEDGE DSME is the cornerstone to successful everyday diabetes management and can be transformative for individuals who have diabetes. This is evident in a systematic review of group-based education for patients with Type 2 diabetes in which 21 randomized controlled trials (RCTs) on diabetes structured education were assessed. This study revealed major improvement in participants’ knowledge about diabetes. Diabetes education is key for diabetes Prevention.

Lifestyle

People with diabetes can benefit from education about the disease and treatment, dietary changes, and exercise, with the goal of keeping both short-term and long-term blood glucose levels within acceptable bounds. In addition, given the associated higher risks of cardiovascular disease, lifestyle modifications are recommended to control blood pressure.

Weight loss can prevent progression from prediabetes to diabetes type 2, decrease the risk of cardiovascular disease, or result in a partial remission in people with diabetes. No single dietary pattern is best for all people with diabetes.

Healthy dietary patterns, such as the Mediterranean diet, low-carbohydrate diet, or DASH diet, are often recommended, although evidence does not support one over the others. According to the ADA, “reducing overall carbohydrate intake for individuals with diabetes has

demonstrated the most evidence for improving glycemia”, and for individuals with type 2 diabetes who cannot meet the glycemic targets or where reducing anti-glycemic medications is a priority, low or very-low-carbohydrate diets are a viable approach. For overweight people with type 2 diabetes, any diet that achieves weight loss is effective.

CLINICAL OUTCOME, SELF-MANAGEMENT, AND BEHAVIOR CHANGE

DSME programs have also shown major improvement in glycemic control and diabetes outcomes. Norris et al. [5] demonstrated that HbA1c levels decreased by 0.76% in participants who undertook DSME. Chala et al.  also reviewed existing literature and found similar reductions in HbA1c, with the greatest reduction of 0.88% in both individual and group settings for participants who completed
DSME. Nonetheless, in the former studies, the effect of  DSME was not sustainable long after intervention amongst participants compared to the latter.

This is quite substantial as the United Kingdom Prospective Diabetes Study (UKPDS) demonstrated that even a 0.9% decrease in HbA1c is associated with reductions in microvascular complications, diabetes-related mortality, and all-cause
mortality. In the UK, DESMOND’s (Diabetes Education and Self Management for Ongoing and Newly Diagnosed)
the intervention has yielded similar results. Khunti et al. reported a 1.49% decrease in HbA1c after 12 months and a sustained decrease after 3 years (-1.32%). However, there were no significant differences in other biomedical factors such as blood pressure and 10-year cardiovascular disease risk.

In similar terms, the reviews by DESMOND and 8 showed that greater exposure to structured education was linked to better glycemic control. An Italian-based intervention, ROMEO (Rethink Organization to iMprove Education and Outcomes), built on the efforts of these earlier studies to develop a lifestyle-change education program focusing on metabolic control, which was carried out over a longer duration of 2 years. The findings demonstrated that the participants in the ROMEO study had improved HbA1C, lipid profile, blood pressure, and BMI than in the control groups.

This suggests that an ongoing model of structured education may result in improvements in glycemic control and other biomedical factors, which can likely lead to fewer long-term complications.
In addition to improving health outcomes in individuals with type 2 diabetes, DESMOND’s programs also showed that structured education was beneficial in helping participants self-manage their diabetes and change health behaviors.

 SELF-DETERMINATION AND PSYCHOSOCIAL ADJUSTMENT

Khunti et al., in their research, has conclusively proven that well-structured education programs have contributed tremendously towards self-determination and mental adjustments in patients with diabetes. This is corroborated with the study from Essien et al., which indicated that DSME and social support positively affect self-efficacy and patient empowerment.

There are also studies suggesting that DSME has proven to promote healthy coping mechanisms and decrease diabetes-related distress and depression in their studies evidence significant improvement of quality of life for participants with diabetes-related stress after completing the DSME.

LONG-TERM OUTCOMES

Although many studies have shown that structured education can cause significant improvement in lifestyle, clinical and psychosocial outcomes, its role in preventing diabetes complications is an area of emerging research. An early study by Nicolucci et al. showed that complications such as; critical limb ischemia, amputation, chronic renal failure, dialysis treatment, proliferative retinopathy, and blindness could occur approximately 4 times more often in diabetic individuals with no education.

A more recent study that looked at the effects of glycemic control and incidence of cardiovascular complications showed that Patient Empowerment Programme participants were associated with lower incidence of first micro-vascular event and nephropathy.

The population-based cohort analysis study of the Patient Empowerment Programme by Wong et al. in obese type 2 diabetes patients again revealed that Patient Empowerment Programme participants had lesser incidence rates of all-cause mortality and first macro-vascular or micro-vascular disease events from diabetes.

A systematic review of literature from 2001 to 2011 by Nazar et al. revealed that diabetes complications could be minimized by developing enhanced diabetes knowledge and education to treat diabetes at the right time. This can, in turn, reduce morbidity and mortality amongst patients with diabetes.

These studies further explored that amputation rates can be reduced through DSME, which can result in huge cost savings. A long-term study with 13 years of follow-up investigated the impact gender may have on diabetes outcomes and found that structured education could reduce mortality and morbidity in women but not in men.

UTILISATION OF HEALTH CARE SERVICES

Although there is a wealth of evidence to prove that DSME can improve health outcomes and life quality for individuals with Type 2 diabetes, there is minimal recent research to prove that DSME can minimize healthcare services.

Norris et al., in a systematic review of five studies, only reported one study that experienced a reduction in emergency room visits four months after receiving DSME. Their findings from four other studies on admissions outcomes and hospital length of stay showed no major difference between participants who had DSME and the control group.

Greisinger et al. reviewed one study covering hospitalizations between 1993 and 2001 and concluded that patients with low income served by primary healthcare could react differently to these services than patients with highincome. There was no significant reduction in the use of eye specialist services, as reported by Norris et al.

DELIVERY MODE AND COST-EFFECTIVENESS

DSME can be delivered by nurses, physicians, specialists, and other healthcare professionals in hospitals, communities, outpatient clinics, diabetes centers, and primary care settings. DSME can be delivered as a group or one-to-one session depending on the individual’s needs. According to systematic review studies carried out by Chrvala et al. and Van Netten et al. both groups and individual education have shown significant improvements in participants‘ clinical outcomes and lifestyle changes.

According to Van Netten et al. the yearly cost for each participant without labor and admin in the X-PERT structured program was £26. On average, one medication costs £433 yearly. However, after completing the DSME with people having better outcomes, it is estimated that the cost for medication savings was £56,723 for 432 diabetic patients. Hence, over £367 million could be saved yearly if all 2.8 million patients with diabetes in the UK participated in XPERT programs.

CONCLUSION

In conclusion, this essay has examined the review of the benefits of structured education in type 2 diabetes about increasing patients’ knowledge, self-management, behavior change, clinical outcome, healthcare service utilization, long-term outcomes, psychological adjustment, and self-determination. It looked into the effectiveness of the delivery modes of type 2 diabetes structured education and discussed the cost-effectiveness and socio-economic implication of type 2 diabetes structured education.

In the studies reviewed, there is no concrete evidence that diabetes structured education may reduce healthcare services and 10-year cardiovascular risk. Nonetheless, there is substantial evidence that diabetes structured education can improve the general health outcome of individuals with type 2 diabetes, especially in areas such as physical activities, diet, medication adherence, smoke cessation, glycemic control, as well as the psychosocial well-being of the individual with type 2 diabetes. Diabetes structured education can also
reduce the huge cost on both individuals and health care services.

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Citation: Jain R, Olejas S, Edwards A, Feh AR, Iqbal M, et al. (2019) Review of the Evidence for the Benefits of Structured Education in Type 2 Diabetes. Int J Diabetes Current Res, 1(2): 29-32.