Are outcomes from diabetes self-management education sustained? A randomized controlled trial [abstract]
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Our purpose was to determine if improved outcomes from individual education for patients with diabetes were sustained. 623 adults with glycosylated hemoglobin (A1c) >7% and long duration of diabetes were randomly assigned to receive individual education (IE), group education (GE), or usual care (UC). GE (4 2-hour sessions) used US Diabetes Conversation Maps. IE (3 1-hour sessions) used a needs assessment to individualize content, and included review and discussion of glucose logs and individualized behavioral goal setting with follow-up. Results of A1c tests, survey instruments [Problem Areas in Diabetes (PAID), Diabetes Self-Efficacy (DES), Recommended Food Score (RFS), and Physical Activity], and medication intensification were evaluated at baseline and short-term (mean 6.8 months) and longer-term (12.8 months) follow-up using linear mixed models. Follow-up trajectories were plotted for a year using quarterly survey results and all A1c values in a random effects generalized additive model with smooth splines. Compared to UC, IE resulted in longer-term improved DES and PAID scores (DES, +0.11, P=.03 and PAID, -2.94, P=.04), but RFS and physical activity improvement trends were not sustained long-term. The A1c trajectory declined more steeply in IE than GE and UC for the first 150 days post randomization. The A1c reduction was not sustained and by 250 days, there was no treatment group A1c difference between intervention groups with a model fit likelihood ratio test for A1c intervention trends significant for three distinct non-linear trajectories (P=.02). GE resulted in no significant long-term change from UC. In summary, individual education resulted in sustained higher measures of self-efficacy and lower diabetes distress than UC. However, short-term improvements in glucose control, nutrition, and physical activity were not sustained. Patients may need individualized and continued support from educators to achieve lasting behavioral change and improved glucose control.