Diabetes education– key principles of individual or group participation

The Institute of Diabetes for Older People (IDOP)
Beds & Herts Postgraduate
Medical School
Bedfordshire, UK

Diabetes education–key principles of individual
or group participation

by A. J . Sinclair, United Kingdom

The importance of diabetes education in the management of patients, including the importance of monitoring, self-management approaches, and the skills of nurse practitioners has long been recognized by clinicians. Modern approaches in diabetes education must focus on multiple perspectives such as reducing complication rates and hospital admissions, but also on enhancing quality of life and well-being. While both individual (one on- one) and group educational approaches have been studied in the context of type 1 and type 2 diabetes management, more consistent benefits have been observed in type 1 diabetes subjects. Diabetes education for patients (and carers) in a group setting seems to have added advantages, but reinforcement and repeat teaching sessions are needed for longer-lasting effects. More well-designed studies in this area are needed.

Medicographia. 2013;35:35-39 (see French abstract on page 39)

Historically, pioneers of diabetes education included Dr Roma in Portugal a century ago, R. D. Lawrence in the United Kingdom, Joslin and Miller in the United States, and Assal in Switzerland. More recently, significant work in diabetes education, including some attention to psychological influences, has been provided by individuals such as Bradley, Anderson, Day, and Fox.1 These early developments recognized the importance of monitoring, self-management approaches, utility of nurse practitioners, and even 24-h telephone support. With this came the job specifications for diabetes nurse educators and specialist nurses. A stimulus for this drive was the view held by clinicians that diabetes self-care was a paramount objective to be achieved if hospital admission rates were to be tackled, if hypoglycemic and ketoacidotic episodes were to be avoided, and if early blindness was to be prevented. Indeed, any one of these events occurring was a marker of educational failure! It has even been suggested that educational methods may have played key roles in some of the outcome gains seen in the landmark intervention studies of the DCCT (Diabetes Control and Complications Trial)2 and the UKPDS (United Kingdom Prospective Diabetes Study).1,3

Modern-day approaches employ various learning models and methods, adult educational theory, life-long learning, behavioral modification, a better understanding of the psychological state of a patient, aligning educational initiatives with medical treatment, involvement of the family and carers, more insightful use of information technology to attain goals of care, and simulated medical education. In the United Kingdom, we have seen the emergence of two robust methods of diabetes educational learning. The first is DAFNE (Dose Adjustment For Normal Eating) which is a group program for adults with type 1 diabetes. DAFNE is based on regular glucose testing before meals and at bedtime, use of rapid-acting insulin with meals containing carbohydrates, and maintaining “background” insulin (long-acting insulin) levels each day (http://www.dafne. uk.com/). The second method has been designed to assist those with type 2 diabetes and is called the DESMOND program (Diabetes Education and Self-Management for Ongoing and Newly Diagnosed). It was developed within the UK National Health Service (NHS) (http://www.desmond-project. org.uk/).

Much of these newer methods are embraced within the ethos of structured patient education in diabetes which is supposed to be person-centered, theory-driven, evidence-based, and resource-effective. It is meant to be delivered by educators (usually multidisciplinary) who have received appropriate training and have the appropriate skill set and competencies to provide a program that meets the learning objectives of a wide range of patients and their carers.

It is thus accepted that diabetes education for patients (and probably carers) is an integral part of diabetes management and must be a consistent and ongoing process; it should be adapted to differing learning styles of patients, and allow a normal lifestyle as possible.4 Other key essential requirements include evaluating the learning needs of participants, varying teaching methods as necessary, and providing the choice of individual or group sessions. In this article, we shall examine some of the key generic aspects of diabetes education and how these may be seen as part of educational programs designed for the individual and for participants organized in groups. My focus is predominantly on type 2 diabetes mellitus, although many of these generic features apply to both type 1 and type 2 diabetes.

Primary goals of a diabetes education program

The primary goals of a diabetes education program directed towards people with diabetes are outlined in Box 1:
Box 1

Developing the learning environment

Several factors might have relevance in ensuring that the most optimal learning environment is present. It is mostly accepted that the learning program should be conducted where patients are most comfortable and, when possible, educators should use a problem-based learning approach. Thus, the program can be carried out in a patient’s home, in a local diabetes center, or in a general practitioner’s office. In Box 2 are listed 3 key factors which assist the learning strategy:
Box 2

Importance of behavioral change

Unless people with diabetes change their behavior to modify their lifestyle, attain control of their metabolic state, and learn the practical skills of diabetes self-care, the process of diabetes education will have failed. Some factors that have been identified that might influence behavioral change are shown in Box 3 and are based on the model of Ajzen and Fishbein (1980).5
Box 3

Other theories of behavior change, such as social cognitive theory by Bandura,6 have been invoked to explain individual behavior and structure interventions. The concept of “self-efficacy” has been used as a template to explain why personal behavior toward achieving goals can be affected so markedly by other influences, such as prior history of tackling the same or similar problems, outside persuading influences which could be emotional or work related, for example, and by the psychological state of the individual. Skinner, a behavioral psychologist, concluded that complex behavior change (as may be expected in self-managing diabetes) can only be realized if it results from a series of positive changes to smaller domains with simpler changes required, and that this process was likely to be more successful if individuals duplicated successful behaviors of others and these processes were reinforced.1 It should also be remembered that other behavioral programs may need to be activated to see the full benefits of the diabetes educational strategy (structured education), such as guidance relevant to physical activity, smoking cessation, and obesity.

Special characteristics of older patients and their learning styles

From a number of important standpoints, older people with diabetes present major, often unique challenges to diabetes educational programs.4 These may be associated with agerelated changes in sensory perceptions (vision, hearing), demographics, or short-term memory decline, and information processing times. Accompanying these may be changes in motor skills, social and family dynamics, and the level of medical comorbidities and functional loss.

Encouraging older people to take an active part in diabetes educational programs has not received the same focus of attention among health professionals who justly say that their attentions are mainly devoted to younger type 1 and type 2 subjects. Ensuring that safe and easy access is available to learning areas, emphasizing the importance of empowerment, involving family and carers, and asking for a level of active participation that utilizes to the maximum the cognitive and intellectual level of the patient are ways that increase the success rate of the educational process. Work in this area recently showed that a tailored telehealth program of diabetes education in older Hispanic American and African American subjects led to better adherence to therapy and improved glycated hemoglobin (HbA1c).7

Evidence for effective diabetes education

The benefit of diabetes educational intervention is not as clear cut as you may imagine. Indeed, for many years, the literature reported both successes and failures! Many studies focused on outcomes that could be measured relatively easily, such as level of glycemic control or blood pressure reduction. However, key components of diabetes self-care, such as reduction in severe hypoglycemia rate, reductions in hospitalization for foot care problems, and adherence rates to therapy were often ignored and methods used to assess/evaluate these were superficial or inaccurate or inappropriate. Varying methodological issues, duration of the intervention, quality and expertness of the educators were other factors that were not put into the “effectiveness” equation.

A systematic review of the clinical- and cost-effectiveness of patient educational models in both type 1 and type 2 diabetes8 was used as a basis of developing guidance in the United Kingdomin diabetes education. This review identified 24 studies (18 randomized controlled trials and 6 clinically controlled trials) in which the study design, methodology, and quality of reporting was relatively low. Only 2 studies reported cost-effectiveness outcomes. The results of the review are summarized as follows (Box 4):
Box 4
It was quite clear from this review, completed in 2002, that there was not enough evidence for type 2 diabetes and that more research was needed. In 2008, the authors provided an update of their first review.9 They concluded that education delivered by a team of educators, with some degree of reinforcement, may provide the best opportunity for improvements in patient outcomes.

Studies in type 1 diabetes since then have revealed several new insights. For example, this year, a published study of DAFNE in type 1 diabetes demonstrated that over a 12-month period, a structured education program delivered in routine clinical practice not only improves HbA1c while reducing the severe hypoglycemia rate and restoring hypoglycemia awareness, but also reduces psychological distress and improves perceived well-being.10

In type 2 diabetes, a meta-regression analysis,11 which looked at the benefits of quality improvement strategies on glycemic control in type 2 diabetes, demonstrated small to modest improvements in glycemic control. Interestingly, team changes and case management showed more robust improvements, especially for interventions in which case managers could adjust medications without awaiting physician approval. In an- other study, a telephone peer-delivered intervention study measured the effectiveness of the intervention to enhance self-efficacy in type 2 diabetes and its impact on clinical outcome.12 Unfortunately, at 6 months there were no statistically significant differences in self-efficacy scores, HbA1c, or other secondary outcome measures. Similarly, in a recently published study, no effect of motivational interviewing on metabolic status or on adherence to medication in people with screen detected type 2 diabetes was observed.13

A study published in 2008 assessed the effect of a structured, empowerment-based educational system (LAY or “Look After Yourself”) for patients with type 2 diabetes.14 The educational program was associated with early benefits in HbA1c levels, illness attitudes, and perceived treatment effectiveness; however, at 12 months, only illness attitudes (P=0.01), and self-monitoring (P=0.002) showed benefit. This was associated with only limited benefits in glucose control.

A recent Cochrane review15 of individual patient education for people with type 2 diabetes suggested a benefit of individual education on glycemic control when compared with usual care in a subgroup of those with a baseline HbA1c greater than 8%. The review did not demonstrate a significant difference between individual education and usual care. In the small number of studies comparing group and individual education, there appeared to be an equal influence on HbA1c at 12 to 18 months.

What to choose – individual or group education for your patient?

Often, the answer to this question will be determined by the patient and/or family, the professional preference of the physician, the quality of staff available to engage in teaching of the course, and available health resources.

A problem-based, frequent, one-on-one consultation is a more likely occurrence and has the advantage of an evolving relationship and adaptability over time to the needs of the patient, including complication occurrence, change in functional status and comorbidity levels, and change in personal circumstances, eg, death of a spouse or need for greater assistance. This traditional approach can work if the individual sessions with different members of the diabetes team are consistent in their messages and level of support.

Group teaching and learning in diabetes is widely encouraged and recommended by the National Institute for Health and Clinical Excellence (NICE) in its structured diabetes education guidance. A well-planned interactive session of patients in groups has the advantages of peer interaction, peer support, and a better use of staff and material resources. Subject numbers should be between 5 and 15 patients, educators should establish themselves as facilitators, and key objectives should be developed by the group. As recommended by Day,1 group based learning needs to be maintained to have longer-lasting effects.


Patient education models for diabetes still require greater innovation in order to meet the increasing demands of a population of people who are more informed and have higher expectations. Translating what we have learned thus far into effective outcomes needs to become a more consistent process, and back-translation of reactions and responses to learning to inform new research is also required.

Diabetes is a long-term condition that lends itself to a variety of care processes, some centered around chronic disease management, some around a patient-empowerment model, and some around behavioral modification. Diabetes educators need to consider all these approaches in their teaching styles, recognizing always that diabetes is often a complex illness paradigm where a multifaceted intervention may be more appropriate.

Linking diabetes education to patient-centered outcomes can be developed further with the use of, say, telehealth approaches, e-learning and other Web-based methods, but a strong emphasis on patient satisfaction, quality of life, maintaining functional status, and well-being is of paramount importance. _

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Keywords: behavioral change; diabetes education; learning; knowledge; type 1; type 2