The Effect of a Structured Behavioral Intervention on Poorly Controlled Diabetes

Abstract

Background Although maintaining near normal glycemia delays onset and slows progression of diabetes complications, many diabetes patients and their physicians struggle to achieve glycemic targets. Best methods to support patients as they follow diabetes prescriptions and recommendations are unclear. Methods To test the efficacy of a behavioral diabetes intervention in improving glycemia in long-duration, poorly-controlled diabetes, we randomized 222 adults with diabetes (49% type 1, 53±12 years old, 18±12 years duration, hemoglobin A1c=9.0±1.1%) to attend 1) a 5-session manual-based, educator-led structured group intervention with cognitive behavioral strategies (structured behavioral arm), 2) educator-led attention-control group education program (group attention control), or 3) unlimited individual nurse and dietitian education sessions for 6 months (individual control). Outcomes were baseline, and 3, 6, and 12-month post-intervention hemoglobin A1c levels (primary), frequency of diabetes self-care, 3-day pedometer readings, 24-hour diet recalls, average number of glucose checks, physical fitness, depression, coping style, self-efficacy, and quality of life (secondary). Results Linear mixed modeling found that all groups improved hemoglobin A1c (p<0.001). However, the structured behavioral arm improved more than group and individual control arms (3-month HbA1c change: −0.8% versus −0.4% and −0.4%; groupXtime interaction p-value=0.04). Further, type 2 participants improved more than type 1 participants (type of diabetesXtime interaction p-value=0.04). Quality of life, glucose monitoring, and frequency of diabetes self-care did not differ by intervention over time. Conclusions A structured, cognitive behavioral program is more effective than two control interventions in improving glycemia in adults with long-duration diabetes. Educators can successfully utilize modified psychological and behavioral strategies. (ClinicalTrail.gov registration number: NCT000142922)

2017 National Standards for Diabetes Self-Management Education and Support

“…The curriculum must be dynamic (5,97,(111)(112)(113). Recent education research endorses the inclusion of practical problem-solving approaches and collaborative care, addressing psychosocial issues, behavior change, and strategies to sustain self-management efforts (40, [114][115][116][117][118][119][120].…”

“…Evidence-based communication strategies such as collaborative goal setting, action planning, motivational interviewing, shared decision making, cognitive behavioral therapy, problem solving, selfefficacy enhancement, teach-back, and relapse-prevention strategies are also effective (120,(136)(137)(138)(139). It is crucial to develop action-oriented behavior change goals and objectives (130,140).…”

The Use of Language in Diabetes Care and Education

“…Ritholz et al (80) found that people with diabetes are less likely to discuss self-care information because of a fear of being judged and feeling shame. A randomized controlled trial (n 5 222) demonstrated a mean 1-point A1C lowering when people with type 2 diabetes were taught how to reframe self-blame using more neutral, fact-based messages (84).…”

Implementation of collaborative goal setting for diabetes in community primary care

“…Despite the widespread support for CGS as a strategy for providing diabetes self-management support in primary care, evidence has focused largely on its use as part of group medical visits [16], comprehensive diabetes self-management classes [17], or counseling provided by certified diabetes educators [18]. Only one randomized controlled trial, using the LWD intervention, has examined implementation and effectiveness of CGS in individual, primary care sessions [19].…”