The Need to Integrate Diabetes Education and Treatment

Re: Sone H, Ito H, Saito Y, Yamashita H, Ishibashi S, Katayama S, Abe R, Ohashi Y, Akanuma Y, Yamada N, JDC Study Group: The long-term effects of self-management education for patients with type 2 diabetes on glycemic control (Letter). Diabetes Care 2002; 25 : 2115 - 6; Sone H, Katagiri A, Ishibashi S, Abe R, Saito Y, Murase T, Yamashita H, Yajima Y, Ito H, Ohashi Y, Akanuma Y, Yamada N, JDC Study Group: Effects of lifestyle modifications on patients with type 2 diabetes: Japan diabetes complications study (JDCS) study design, baseline analysis and three year-interim report. Horm Metab Res 2002; 34 : 509 - 515.

Dr. Sone [1] [2] and colleagues report on results of diabetes self-management education (DSME) vs. usual diabetes care without DSME in 2205 adult patients over three years. The intervention consisted of intensive lifestyle management at each outpatient clinic visit and frequent telephone counseling by trained diabetes educators. The authors reported a mean HbA_1c reduction of 0.15 % in the lifestyle intervention group compared to a reduction of 0.1 % in the control group - a difference of only 0.05 %. Although their results were statistically significant, the degree of difference seems clinically trivial. Similarly disappointing results were reported by the meta-analysis of DSME interventions by Norris et al. [3]. These authors reported a mean decrease in HbA_1c of 0.76 % at immediate follow-up, but only a decrease of 0.26 % after four months follow-up. One or more of the following may explain the lack of better results in these trials:

Patients are refractory to DSME The DSME intervention is of poor quality or does not meet the needs of the patient. The medical treatment is poor, thereby nullifying any positive impact of the DSME. DSME and diabetes medical treatment is poorly integrated.

Dr. Mayer Davidson recently commented that DSME is necessary, but not sufficient to produce a good outcome [4]. We wholeheartedly agree. The best diabetes education program in the world cannot compensate for a poor medical regimen. Alternatively, a good medical regimen has no chance of success unless the patient understands it and is motivated to implement it. As diabetes care professionals, our challenge is to provide the best education and the best and most medically sound treatment in a seamless continuum of care. This requires continuous patient assessment from an educational, psychological, and medical standpoint. A cordial and mutually respective relationship among the various health care providers is essential so that ideas and treatment/education strategies can be freely shared. This was the model used in the intensive treatment arm of the Diabetes Control and Complications Trial [5]. To date, investigators have not yet designed a trial to measure the impact of ”integrated” diabetes education compared to diabetes care without diabetes education. We owe it to our profession and our patients to keep trying.

References

• 1 Sone H, Ito H, Saito Y, Yamashita H, Ishibashi S, Katayama S, Abe R, Ohashi Y, Akanuma Y, Yamada N, JDC S tudy. The long-term effects of self-management education for patients with type 2 diabetes on glycemic control (Letter).  Diabetes Care. 2002;  25 2115-2116
• 2 Sone H, Katagiri A, Ishibashi S, Abe R, Saito Y, Murase T, Yamashita H, Yajima Y, Ito H, Ohashi Y, Akanuma Y, Yamada N. JDC Study Group . Effects of lifestyle modifications on patients with type 2 diabetes: Japan diabetes complications study (JDCS) study design, baseline analysis and three year-interim report.  Horm Metab Res. 2002;  34 509-515
• 3 Norris S L, Lau J, Smith S J, Schmid C H, Engelgau M M. Self-management education for adults with type 2 diabetes.  Diabetes Care. 2002;  25 1159-1171
• 4 Davidson M B. Editor's comment: ”It ain't necessarily so.”  Diabetes Care. 2002;  25 2116
• 5 The diabetes control and complications trial research group . The effect of intensive treatment of diabetes on the development and progression of long-term complications in insulin-dependent diabetes mellitus.  N Engl J Med. 1993;  329 977-986