Improvements in HbA1c remain after 5 years – a follow up of an educational intervention focusing on patients’ personal understandings of type 2 diabetes
Introduction
The progressive nature of type 2 diabetes mellitus (DM2) makes it difficult to maintain metabolic control over time in many patients, despite lifestyle interventions and drug treatment [1]. Improved metabolic control through diet and physical activity alone or together with anti-diabetes drugs has been shown to significantly decrease the risk of complications [2], [3], [4]. In order to improve self-management it is important to support patients, through a process of understanding, acceptance and coping, a process where the diabetes team and the diabetes nurse in particular are important [5]. Self-management of DM2 is demanding and requires lifestyle changes, which presuppose resourceful patients who take charge, are innovative, have the inner strength and resources to meet challenges [6], [7]. Paterson et al. [8] in a meta-analysis of 47 qualitative studies, demonstrate that in order to adapt to and manage their illness, patients with diabetes have to balance between demands that are sometimes contradictory, i.e. to manage self-care and to live as normally as possible in order to maintain well-being. The meta-analysis also underlines the necessity of good diabetes management by taking conscious decisions and taking control over the disease and treatment. If patients decide to adopt, for example, exercise, glycated haemoglobin is improved [9], [10], [11].Traditional patient education among people with DM2, focusing on physiology, diet, physical activity, blood sugar testing and adherence to medication, has limited effect on glycaemic control and the results are discouraging, particularly in the longer term [1], [10], [12], [13], [14]. Knowledge about diabetes and treatment is not enough to induce behaviour change or improved clinical outcomes.
The few interventions that have been found effective are group-based and focused on cognitive reframing, self-management strategies, coping skills or exercise [9], [15]. Furthermore, patient-centred interventions together with organisational interventions concerning arrangements for regular follow-up have been effective in improving blood glucose levels, knowledge and body weight and also reducing the requirement for diabetes medication [16], [17].
In order to achieve long-term metabolic goals, patient-centredness as well as focusing on well-being and patients’ beliefs about health and illness are suggested in patient education, since this supports patients’ ability for self-management [18], [19], [20]. In a 1-year follow-up of a group-based intervention focusing on patients’ personal understanding of illness, we have previously demonstrated a lowering of HbA1c by 1% in the intervention group compared to controls. This positive effect was referred to more effective self management among the patients in the intervention group [18].
This study is a report of a 5-year follow-up of that study, aiming at evaluating whether diabetes care focusing on patients’ personal understanding of their illness is also effective in a long-term perspective with regard to metabolic control among patients with type 2 diabetes.
Section snippets
Study design and settings
The study is a randomised intervention study, and this paper reports its 5-year follow-up. The study was conducted within a Swedish primary health care district, which included 15 health care centres (HCCs) located both in rural and in urban areas. The Primary health care in the district is run by the county council and diabetes care is based on national guidelines and the St. Vincent declaration [21].
Results
The mean HbA1c at baseline was 5.71% (S.D. 0.76) in the intervention group and 5.78% (S.D. 0.71) in the control group. At the 5-year follow-up, the mean HbA1c in the intervention group still was 5.71% (S.D. 0.85) while it had increased to 7.08% (S.D. 1.71) among the controls. There were no differences in total cholesterol, HDL, LDL, triglycerides and BMI at the 5-year follow-up in 2005. The crude difference in HbA1c was 1.37 (p < 0.001). The adjusted difference with HbA1c in 2001 as covariate was
Discussion
In this study we have described how those patients with DM2 allocated to group sessions over 9 months, focusing on patients’ personal understanding of their illness, had better metabolic control after 5 years than patients with conventional diabetes care. The difference in HbA1c between groups was 1.37%, and could be interpreted as, for example, postponing insulin treatment for 5–6 years, according to the UKPDS study [2], which reports that 1% is the average increase in HbA1c over 4 years.
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Conflicts of interest statement
The authors do not have any conflicts of interest in connection with this manuscript.
Acknowledgement
The Swedish Diabetes Association funded the study.
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