this meta-analysis was conducted to assess the effect of educational and behavioral interventions on body weight and glycemic control in type 2 diabetes.
MEHODS
Studies selected for analysis were published randomized controlled trials that evaluated educational and behavioral interventions (no drug interventions) in type 2 diabetes (sample size 210). These criteria were applied to searches of electronic databases and relevant bibliographies. Data were independently abstracted by 2 reviewers and adjudicated by consensus.
RESULTS
Of the 63 articles that met the inclusion criteria, 18 provided enough information for pooled estimates of glycohemoglobin (total Ghb, HbA1, or HbA1 C). These 18 studies yielded 2720 participants (sample sizes of 18 to 749). Interventions ranged from 1 to 19 months; follow-up ranged from 1 to 26 months. Glycohemoglobin was reduced by a mean of 0.43%. When results were stratified by quality score, glycohemoglobin was -0.50% and -0.38% for studies with high and low quality scores, respectively. When weighting studies by sample size, fasting blood glucose was reduced by 24 mg/dL and weight by 3 lbs.
CONCLUSIONS
Previous educational and behavioral interventions in type 2 diabetes have produced modest improvements in glycemic control. Future research should refine such interventions and improve methodology.
Get full access to this article
View all access options for this article.
References
1.
1. National Diabetes Data Group. Risk factors for noninsulin-dependent diabetes. In: Diabetes in America. 2nd ed.Bethesda, Md: National Institutes of Health, National Institute of Diabetes and Digestive and Kidney Diseases; 1995:179-220. NIH publication95-1468.
2.
2. Carter JS, Pugh JA, Monterrosa A.Non-insulin dependent diabetes mellitus in minorities in the United States. Ann Intern Med.1996;125:221-232.
3.
3. Padgett D, Mumford E, Hynes M, Carter R.Metaanalysis of the effects of educational and psychosocial interventions on management of diabetes mellitus. J Clin Epidemiol. 1988;41:1007-1030.
4.
4. Brown SA. Studies of educational interventions and outcomes in diabetic adults: a meta-analysis revisited. Patient Educ Counsel. 1990; 16:189-215.
5.
5. Brown SA. Meta-analysis of diabetes patient education research: variations in intervention effects across studies. Res Nurs Health. 1992;15:409-419.
6.
6. Wing RR, Goldstein MG, Acton KJ, et al. Behavioral science research in diabetes: lifestyle changes related to obesity, eating behavior, and physical activity. Diabetes Care. 2001; 24:117-123.
7.
7. Glasgow RE, Hiss RG, Anderson RM, et al. Report of the Health Care Delivery Work Group: behavioral research related to the establishment of a chronic disease model for diabetes care. Diabetes Care. 2001; 24:124-130.
8.
8. Brown SA. Effects of educational interventions in diabetes care: a meta-analysis of findings. Nurs Res.1988;37:223-230.
9.
9. Detsky AS, Naylor CD, O'Rourke K, McGeer AJ, EAbbe KA. Incorporating variations in the quality of individual randomized trials into meta-analysis. J Clin Epidemiol. 1992;45:265-265.
10.
10. Goodman SN. Metaanalysis in health services research. In: Armenian H, Shapiro SS, eds. Research Methods in Health Services Research. New York: Oxford University Press; 1998: 229-259.
11.
11. Petitti D.Meta-Analysis, Decision Analysis, and Cost-Effectiveness Analysis: Methods for Quantitative Synthesis in Medicine. 1st ed.New York: Oxford University Press; 1994.
12.
12. Dickerson K, Berlin JA. Meta-analysis: state-of-thescience. Epidemiologic Rev.1992;14:154-176.
13.
13. The Handbook of Research Synthesis. New York: Russell Sage Foundation; 1994.
14.
14. Systematic Reviews in Health Care: Meta-analysis in Context. 2nd ed.London: BMJ Publishing Group; 2001.
15.
15. Agurs-Collins TD, Ten Have TR, Kumanyika SK, Adams-Campbell LL. A randomized controlled trial of weight reduction and exercise for diabetes management in older African-American subjects. Diabetes Care. 1997;20:1503-1511.
16.
16. Aikens JE, Kiolbasa TA, Sobel R.Psychological predictors of glycemic change with relaxation training in non-insulin-dependent diabetes mellitus. Psychother Psychosom. 1997;66:302-306.
17.
17. Allen BT, DeLong ER, Feussner JR. Impact of glucose self-monitoring on non-insulin-treated patients with type 11 diabetes mellitus. Randomized controlled trial comparing blood and urine testing. Diabetes Care. 1990;13:1044-1050.
18.
18. Anderson RM, Funnell MM, Butler PM, Arnold MS, Fitzgerald JT, Feste CC. Patient empowerment: results of a randomized controlled trial. Diabetes Care. 1995; 18:943-949.
19.
19. Arseneau DL, Mason AC, Wood OB, Schwab E, Green D.A comparison of learning activity packages and classroom instruction for diet management of patients with non-insulin-dependent diabetes mellitus. Diabetes Educ.1994;20:509-514.
20.
20. Aubert RE, Herman WH, Waters J, et al. Nurse case management to improve glycemic control in diabetic patients in a health maintenance organization: a randomized controlled trial. Ann Intern Med.1998;129:605-612.
21.
21. Barth R, Campbell LV, Allen S, Jupp JJ, Chisholm DJ. Intensive education improves knowledge, compliance, and foot problems in type 2 diabetes. Diabetic Med. 1991;8:111-117.
22.
22. Bloomgarden ZT, Karmally W, Metzger MJ, et al. Randomized, controlled trial of diabetic patient education: improved knowledge without improved metabolic status. Diabetes Care. 1987;10:263-272.
23.
23. Boehm S, Schlenk EA, Raleigh E, Ronis D.Behavioral analysis and behavioral strategies to improve selfmanagement of type 11 diabetes. Clin Nurs Res. 1993;2:327-344.
24.
24. Campbell EM, Redman S, Moffitt PS, Sanson-Fischer RW. The relative effectiveness of educational and behavioral instruction programs for patients with NIDDM: a randomized trial. Diabetes Educ. 1996;22:379-386.
25.
25. Campbell LV, Barth R, Gosper JK, Jupp JJ, Simons LA, Chisholm DJ. Impact of an intensive educational approach to dietary change in NIDDM. Diabetes Care. 1990;13:841-847.
26.
26. Corkery E, Schechter CB, Palmer C, Frisher L, Foley ME, Roman SH. Effect of a bicultural community health worker on completion of diabetes education in a Hispanic population. Diabetes Care. 1996;20:254-257.
27.
27. D'Eramo-Melkus GA, Wylie-Rosett J, Hagan JA. Metabolic impact of education in NIDDM. Diabetes Care. 1992;15:864-869.
28.
28. Estey AL, Tan MH, Mann K.Follow-up intervention: its effect on compliance behavior to a diabetes regimen. Diabetes Educ. 1990;16:291-295.
29.
29. Falkenberg MG, Elwing BE, Goransson AM, Hellstrand BE, Riis UM. Problem oriented participatory education in the guidance of adults with non-insulintreated type 11 diabetes mellitus. Scand J Primary Health Care. 1986;4:157-164.
30.
30. Franz MJ, Monk A, Barry B, et al. Effectiveness of medical nutrition therapy provided by dietitians in the management of non-insulindependent diabetes mellitus: a randomized, controlled clinical trial. J Am Diet Assoc. 1995;95:1009-1017.
31.
31. Genev NM, McGill M, Hoskins PL, et al. Continuing diabetes education by telephone. Diabetic Med. 1990;7:920-921.
32.
32. Glasgow RE, Toobert DJ, Mitchell DL, Donnelly JE, Calder D.Nutrition education and social learning interventions for type 11 diabetes. Diabetes Care. 1989;12:150-152.
33.
33. Glasgow RE, Toobert DJ, Hampson SE, Brown JE, Lewinsohn PM, Donnelly J.Improving self-care among older patients with type 11 diabetes: the "Sixty Something..." Study. Patient Educ Counsel. 1992;19:61-74.
34.
34. Glasgow RE, La Chance PA, Toobert DJ, Brown J, Hampson SE, Riddle MC. Long-term effects and costs of brief behavioural dietary intervention for patients with diabetes delivered from the medical office. Patient Educ Counsel. 1997;32:175-184.
35.
35. Greenfield S, Kaplan SH, Ware JE Jr, Yano EM, Frank HJ. Patients' participation in medical care: effects on blood sugar control and quality of life in diabetes. J Gen Intern Med. 1988;3:448-457.
36.
36. Hassell J, Medved E.Group/audiovisual instruction for patients with diabetes. Learning achievements and time economics. J Am Diet Assoc.1975;66:465-470.
37.
37. Hawthorne K, Tomlinson S.One-to-one teaching with pictures-flashcard health education for British Asians with diabetes [see comments]. Br J Gen Pract.1997;47:301-304.
38.
38. Hayes TM, Harries J.Randomised controlled trial of routine hospital clinic care versus routine general practice care for type 11 diabetics. Br Med J (Clin Res ed.). 1984;289:728-730.
39.
39. Heller SR, Clarke e, Daly H, et al. Group education for obese patients with type 2 diabetes: greater success at less cost. Diabetic Med. 1988;5:552-556.
40.
40. Henry JL, Wilson PH, Bruce DG, Chisholm DJ, Rawling PJ. Cognitive-behavioural stress management for patients with non-insulin dependent diabetes mellitus. Psychol Health Med. 1997;2:109-117.
41.
41. Hopper SV, Miller JP, Birge C, Swift J.A randomized study of the impact of home health aides on diabetic control and utilization patterns. Am J Public Health. 1984;74:600-602.
42.
42. Hurwitz B, Goodman C, Yudkin J.Prompting the clinical care of non-insulin dependent (type 11) diabetic patients in an inner city area: one model of community care. Br Med J. 1993;306:624-630.
43.
43. Jones PM. Use of a course on self-control behavior techniques to increase adherence to prescribed frequency for self-monitoring of blood glucose. Diabetes Educ. 1990;16:296-303.
44.
44. Kaplan RM, Hartwell SL, Wilson DK, Wallace JPEffects of diet and exercise interventions on control and quality of life in non-insulin-dependent diabetes mellitus. J Gen Intern Med. 1987;2:220-228.
45.
45. Koproski J, Pretto Z, Poretsky L.Effects of an intervention by a diabetes team in hospitalized patients with diabetes. Diabetes Care. 1997;20:1553-1555.
46.
46. Kumana CR, Ma JT, Kung A, Kou M, Lauder 1. An assessment of drug information sheets for diabetic patients: only active involvement by patients is helpful. Diabetes Res Clin Pract. 1988;5:225-231.
47.
47. Lane JD, McCaskill CC, Ross SL, Feinglos MN, Surwit RS. Relaxation training for NIDDM. Predicting who may benefit. Diabetes Care. 1993;16:1087-1094.
48.
48. Ligtenberg PC, Hoekstra JB, Bol E, Zonderland ML, Erkelens DW. Effects of physical training on metabolic control in elderly type 2 diabetes mellitus patients. Clin Sci.1997;93:127-135.
49.
49. Malone JM, Snyder M, Anderson G, Bernhard VM, Holloway GA Jr, Bunt TJ. Prevention of amputation by diabetic education. Am J Surg. 1989;158:520-523.
50.
50. Miller CK, Jensen GL, Achterberg CL. Evaluation of a food label nutrition intervention for women with type 2 diabetes mellitus. J Am Diet Assoc. 1999;99:323-328.
51.
51. Morgan BS, Littell DH. A closer look at teaching and contingency contracting with type 11 diabetes. Patient Educ Counsel. 1988;12:145-158.
52.
52. Morrish NJ, Cohen DL, Hicks B, Keen H.A controlled study of the effect of computer-aided analysis of home blood glucose monitoring on blood glucose control. Diabetic Med. 1989;6:591-594.
53.
53. Mulrow C, Bailey S, Sonksen PH, Slavin B.Evaluation of an audiovisual diabetes education program: negative results of a randomized trial of patients with non-insulin-dependent diabetes mellitus. J Gen Intern Med. 1987;2:215-219.
54.
54. Rabkin SW, Boyko E, Wilson A, Streja DA. A randomized clinical trial comparing behavior modification and individual counseling in the nutritional therapy of non-insulin-dependent diabetes mellitus: comparison of the effect on blood sugar, body weight, and serum lipids. Diabetes Care. 1983;6:50-56.
55.
55. Raz 1, Soskolne V, Stein PInfluence of small-group education sessions on glucose homeostasis in NIDDM. Diabetes Care. 1988;11:67-71.
56.
56. Rettig BA, Shrauger DG, Recker RR, Gallagher TF, Wiltse H.A randomized study of the effects of a home diabetes education program. Diabetes Care. 1986;9:173-178.
57.
57. Ridgeway NA, Harvill DR, Harvill LM, Falin TM, Forester GM, Gose OD. Improved control of type 2 diabetes mellitus: a practical education/behavior modification program in a primary care clinic. South Med J. 1999;92:667-672.
58.
58. Rost KM, Flavin KS, Cole K, McGill JB. Change in metabolic control and functional status after hospitalization. Impact of patient activation intervention in diabetic patients. Diabetes Care. 1991;14:881-889.
59.
59. Sadur CN, Moline N, Costa M, et al. Diabetes management in a health maintenance organization. Efficacy of care management using cluster visits. Diabetes Care. 1999;22:2011-2017.
60.
60. Sawicki PT, Didjurgeit U, Muhlhauser 1, Berger M.Behaviour therapy versus doctor's anti-smoking advice in diabetic patients. J Intern Med.1993;234:407-409.
61.
61. Scott RS, Beaven DW, Stafford JM. The effectiveness of diabetes education for non-insulin-dependent diabetic persons. Diabetes Educ. 1984:36-39.
62.
62. Smith DE, Heckemeyer CM, Kratt PP, Mason DA. Motivational interviewing to improve adherence to a behavioral weight-control program for older obese women with NIDDM. Diabetes Care. 1997;20:52-54.
63.
63. Smith DM, Weinberger M, Katz BPA controlled trial to increase office visits and reduce hospitalizations of diabetic patients. J Gen Intern Med.1987;2:232-238.
64.
64. Tu K, McDaniel G, Gay JT. Diabetes self-care knowledge, behaviors, and metabolic control of older adults-the effect of a posteducational follow-up program. Diabetes Educ.1993; 19:25-30.
65.
65. Vanninen E, Uusitupa M, Siitonen 0, Laitinen J, Lansimies E.Habitual physical activity, aerobic capacity and metabolic control in patients with newly-diagnosed type 2 (non-insulindependent) diabetes mellitus: effect of 1-year diet and exercise intervention. Diabetologia. 1992;35:340-346.
66.
66. Vinicor F, Cohen SJ, Mazzuca SA, et al. DIA-BEDS: a randomized trial of the effects of physician and/or patient education on diabetes patient outcomes. J Chron Dis. 1987;40:345-356.
67.
67. Ward WK, Haas LB, Beard JC. A randomized, controlled comparison of instruction by a diabetes educator versus self-instruction in self-monitoring of blood glucose. Diabetes Care. 1985;8:284-286.
68.
68. Weinberger M, Kirkman MS, Samsa GE et al. A nurse-coordinated intervention for primary care patients with non-insulindependent diabetes mellitus. J Gen Intern Med. 1995;10:59-66.
69.
69. Wheeler LA, Wheeler ML, Ours P, Swider C.Evaluation of computer-based diet education in persons with diabetes mellitus and limited educational background. Diabetes Care. 1985;8:537-544.
70.
70. White N, Carnahan J, Nugent A, Iwaoka T, Dodson MA. Management of obese patients with diabetes mellitus: comparison of advice education with group management. Diabetes Care. 1986;9:490-496.
71.
71. Wing RR, Epstein LH, Nowalk MFKoeske R, Hagg S.Behavior change, weight loss, and physiological improvements in type 11 diabetic patients. J Counsel Clin Psychol. 1999;53:111-122.
72.
72. Wing RR, Epstein LH, Nowalk MP, Scott N, Koeske R, Hagg S.Does self-monitoring of blood glucose levels improve dietary compliance for obese patients with type 11 diabetes?Am J Med.1986;81:830-836.
73.
73. Wing RR, Epstein LH, Paternostro-Bayles M, Kriska A, Nowalk MP, Gooding W.Exericise in a behavioural weight control programme for obese patients with type 2 (non-insulin-dependent) diabetes. Diabetologia. 1988;31:902-909.
74.
74. Wing RR, Marcus MD, Epstein LH, Jawad A.A "family-based" approach to the treatment of obese type 11 diabetic patients. J Consult Clin Psychol. 1991;59:156-162.
75.
75. Wise PH, Dowlatshahi DC, Farrant S, Fromson S, Meadows KA. Effect of computer-based learning on diabetes knowledge and control. Diabetes Care. 1986;9:504-508.
76.
76. Wood ER. Evaluation of a hospital-based education program for patients with diabetes. J Am Diet Assoc.1989;89:354-358.
77.
77. Sadur C, Moline N, Costa M, et al. Diabetes management in a health maintenance organization (HMO): efficacy of cluster visits. Diabetes. 1997; 46(suppl 1).
78.
78. Kebbi 1, Slocum W, Dunbar V, Phillips L.HbA1 c improves more with followup in a diabetes clinic than in a primary care clinic. Diabetes. 1998;47(suppl 1).
79.
79. Nadeau J, Koski K, Yale J, Strychar 1.The impact of introducing dietary sucrose in the diabetic meal plan of free-living subjects with type 2 diabetes. Diabetes. 1998;47(suppl 1).
80.
80. Thompson D, Kozak S.Insulin adjustment by a diabetes nurse educator improves HbA1 c levels in poorly controlled insulin requiring diabetics. Diabetes. 1998;47(suppl 1).
81.
81. Aubert R, Herman W, Peterson B, Koplan J.The use of nurse case management improves glycemic control in HMO patients with diabetes mellitus: a randomized control trial. Diabetes. 1998;47(suppil).
82.
82. Scott T, Aubert R.The relationship between glycemic control and quality of life among HMO patients with diabetes mellitus in a randomized trial. Diabetes. 1998;47(suppl 1).
83.
83. Brown S, Hanis C.A border health initiative for Mexican Americans with type 2 diabetes. Diabetes. 1999;48(suppl 1).
84.
84. Konen J, Summerson J, Bell R, Curtis L, Benfield D, Dignan M.Can a health promotion and therapeutic diabetes care program reverse or delay the progression of microalbuminuria in patients with type 2 diabetes mellitus?Diabetes. 1999; 48(suppl 1).
85.
85. Hiss R, Gillard M, Armbruster B, McClure L.Evaluations of community-based diabetes patients-effect of feedback to patients and physicians. Diabetes. 1999; 48(suppl 1).
86.
86. Thaler L, Gallina D, Dunbar V, Phillips L, El-Kebbi 1.Impact of rapid turnaround HbA1 c on glycemic control in patients with type 2 diabetes. Diabetes. 1999;48(suppl 1).
87.
87. Piette J, Weinberger M, McPhee S, et al. Automated calls with nurse follow-up improves diabetes self-care and glycemic control. Diabetes. 1999;48(suppl 1).
88.
88. Piette J, Weinberger M, McPhee S, et al. The impact of automated calls with nurse follow-up on patient-centered outcomes of diabetes care. Diabetes. 1999; 48(suppl 1).
89.
89. Mulvihill M, Hovell M, Schade D, et al. Effects of a culturally tailored diabetes prevention intervention for low SES Latino women on fitness, exercise, BMI, nutrition/exercise knowledge and dietary fat avoidance. Diabetes. 1999;48(suppl 1).
90.
90. Yale J, Venuta T, Gougeon R.Influence of visit frequency in a weight loss program for type 2 diabetes. Diabetes. 1999; 48(suppl 1).
91.
91. Norris SL, Engelgau MM, Narayan KM. Effectiveness of self-management training in type 2 diabetes: a systematic review of randomized controlled trials. Diabetes Care. 2001;24:561-587.
