3/1/2017 Behaviouralinterventionsfortype2diabetes:anevidencebasedanalysis.

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OntHealthTechnolAssessSer.20099(21):145.Epub2009Oct1.

Behaviouralinterventionsfortype2diabetes:anevidencebasedanalysis.
HealthQualityOntario.

Abstract
InJune2008,theMedicalAdvisorySecretariatbeganworkontheDiabetesStrategyEvidence
Project,anevidencebasedreviewoftheliteraturesurroundingstrategiesforsuccessful
managementandtreatmentofdiabetes.ThisprojectcameaboutwhentheHealthSystemStrategy
DivisionattheMinistryofHealthandLongTermCaresubsequentlyaskedthesecretariattoprovide
anevidentiaryplatformfortheMinistry'snewlyreleasedDiabetesStrategy.Afteraninitialreviewof
thestrategyandconsultationwithexperts,thesecretariatidentifiedfivekeyareasinwhichevidence
wasneeded.Evidencebasedanalyseshavebeenpreparedforeachofthesefiveareas:insulin
pumps,behaviouralinterventions,bariatricsurgery,hometelemonitoring,andcommunitybased
care.Foreacharea,aneconomicanalysiswascompletedwhereappropriateandisdescribedina
separatereport.ToreviewthesetitleswithintheDiabetesStrategyEvidenceseries,pleasevisitthe
MedicalAdvisorySecretariatWebsite,
http://www.health.gov.on.ca/english/providers/program/mas/mas_about.html,DIABETESSTRATEGY
EVIDENCEPLATFORM:SummaryofEvidenceBasedAnalysesContinuousSubcutaneousInsulin
InfusionPumpsforType1andType2AdultDiabetics:AnEvidenceBasedAnalysisBehavioural
InterventionsforType2Diabetes:AnEvidenceBasedAnalysisBARIATRICSURGERYFOR
PEOPLEWITHDIABETESANDMORBIDOBESITY:AnEvidenceBasedSummaryCommunity
BasedCarefortheManagementofType2Diabetes:AnEvidenceBasedAnalysisHome
TelemonitoringforType2Diabetes:AnEvidenceBasedAnalysisApplicationoftheOntarioDiabetes
EconomicModel(ODEM)toDeterminetheCosteffectivenessandBudgetImpactofSelectedType
2DiabetesInterventionsinOntario
OBJECTIVE: Theobjectiveofthisreportistodeterminewhetherbehaviouralinterventionsare
effectiveinimprovingglycemiccontrolinadultswithtype2diabetes.
BACKGROUND: Diabetesisaseriouschronicconditionaffectingmillionsofpeopleworldwideandis
thesixthleadingcauseofdeathinCanada.In2005,anestimated8.8%ofOntario'spopulationhad
diabetes,representingmorethan816,000Ontarians.Thedirecthealthcarecostofdiabeteswas
$1.76billionintheyear2000andisprojectedtorisetoatotalcostof$3.14billionby2016.Muchof
thiscostarisesfromtheseriouslongtermcomplicationsassociatedwiththediseaseincluding:
coronaryheartdisease,stroke,adultblindness,limbamputationsandkidneydisease.Type2
diabetesaccountsfor9095%ofdiabetesandwhiletype2diabetesismoreprevalentinpeople
aged40yearsandolder,prevalenceinyoungerpopulationsisincreasingduetoariseinobesityand
physicalinactivityinchildren.DatafromtheUnitedKingdomProspectiveDiabetesStudy(UKPDS)
hasshownthattightglycemiccontrolcansignificantlyreducetheriskofdevelopingserious
https://www.ncbi.nlm.nih.gov/pubmed/23074526 1/4
3/1/2017 Behaviouralinterventionsfortype2diabetes:anevidencebasedanalysis.PubMedNCBI

complicationsintype2diabetics.Despitephysicians'andpatients'knowledgeoftheimportanceof
glycemiccontrol,Canadiandatahasshownthatonly38%ofpatientswithdiabeteshaveHbA1C
levelsintheoptimalrangeof7%orless.Thisstatistichighlightsthecomplexitiesinvolvedinthe
managementofdiabetes,whichischaracterizedbyextensivepatientinvolvementinadditiontothe
supportprovidedbyphysicians.Anenormousdemandis,therefore,placedonpatientstoself
managethephysical,emotionalandpsychologicalaspectsoflivingwithachronicillness.Despite
differencesinindividualneedstocopewithdiabetes,thereisgeneralagreementforthenecessityof
supportiveprogramsforpatientselfmanagement.Whiletraditionalprogramsweredidacticmodels
withthegoalofimprovingpatients'knowledgeoftheirdisease,currentmodelsfocusonbehavioural
approachesaimedatprovidingpatientswiththeskillsandstrategiesrequiredtopromoteand
changetheirbehaviour.Severalmetaanalysesandsystematicreviewshavedemonstrated
improvedhealthoutcomeswithselfmanagementsupportprogramsintype2diabetics.Theyhave
all,however,eitherlookedataspecificcomponentofselfmanagementsupportprograms(i.e.self
managementeducation)orhavebeenconductedinspecificpopulations.Mostreviewsarealso
qualitativeanddonotclearlydefinetheinterventionsofinterest,makingfindingsdifficulttointerpret.
Moreover,heterogeneityintheinterventionshasledtoconflictingevidenceonthecomponentsof
effectiveprograms.Thereisthusmuchuncertaintyregardingtheoptimaldesignanddeliveryof
theseprogramsbypolicymakers.EVIDENCEBASEDANALYSISOFEFFECTIVENESS:
RESEARCHQUESTIONS: Arebehaviouralinterventionseffectiveinimprovingglycemiccontrolin
adultswithtype2diabetes?Istheeffectivenessoftheinterventionimpactedbyintervention
characteristics(e.g.deliveryofintervention,lengthofintervention,modeofinstruction,interventionist
etc.)?
INCLUSIONCRITERIA: EnglishLanguagePublishedbetweenJanuary1996toAugust2008Type2
diabeticadultpopulation(>18years)Randomizedcontrolledtrials(RCTs)Systematicreviews,or
metaanalysesDescribingamultifacetedselfmanagementsupportinterventionasdefinedbythe
2007SelfManagementMappingGuide(1)Reportingoutcomesofglycemiccontrol(HbA1c)with
extractabledataStudieswithaminimumof6monthfollowup
EXCLUSIONCRITERIA: StudieswithacontrolgroupotherthanusualcareStudieswithasample
size<30Studieswithoutaclearlydefinedintervention
OUTCOMESOFINTEREST: PRIMARYOUTCOME: glycemiccontrol(HbA1c)

SECONDARYOUTCOMES: systolicbloodpressure(SBP)control,lipidcontrol,changeinsmoking
status,weightchange,qualityoflife,knowledge,selfefficacy,managingpsychosocialaspectsof
diabetes,assessingdissatisfactionandreadinesstochange,andsettingandachievingdiabetes
goals.
SEARCHSTRATEGY: AsearchwasperformedinOVIDMEDLINE,MEDLINEInProcessandOther
NonIndexedCitations,EMBASE,theCumulativeIndextoNursing&AlliedHealthLiterature
(CINAHL),TheCochraneLibrary,andtheInternationalAgencyforHealthTechnologyAssessment
(INAHTA)forstudiespublishedbetweenJanuary1996andAugust2008.Abstractswerereviewed
byasingleauthorandstudiesmeetingtheinclusioncriteriaoutlinedabovewereobtained.Dataon
populationcharacteristics,glycemiccontroloutcomes,andstudydesignwereextracted.Reference
https://www.ncbi.nlm.nih.gov/pubmed/23074526 2/4
3/1/2017 Behaviouralinterventionsfortype2diabetes:anevidencebasedanalysis.PubMedNCBI

listswerealsocheckedforrelevantstudies.Thequalityoftheevidencewasassessedasbeing
eitherhigh,moderate,low,orverylowaccordingtotheGRADEmethodology.
SUMMARYOFFINDINGS: Thesearchidentified638citationspublishedbetween1996andAugust
2008,ofwhich12mettheinclusioncriteriaandonewasametaanalysis(Garyetal.2003).The
remaining11studieswereRCTs(9wereusedinthemetaanalysis)andonlyonewasdefinedas
small(totalsamplesizeN=47).SUMMARYOFPARTICIPANTDEMOGRAPHICSACROSS
STUDIES:Atotalof2,549participantswereincludedinthe11identifiedstudies.Themeanageof
participantsreportedwasapproximately58yearsandthemeandurationofdiabeteswas
approximately6years.Moststudiesreportedgenderwithameanpercentageoffemalesof
approximately67%.Oftheelevenstudies,twofocusedonlyonwomenandfourincludedonly
Hispanicindividuals.Allstudiesevaluatedtype2diabetespatientsexclusively.STUDY
CHARACTERISTICS:Thestudieswereconductedbetween2002and2008.Approximatelysixof11
studieswerecarriedoutwithintheUSA,withtheremainingstudiesconductedintheUK,Sweden,
andIsrael(samplesizerangedfrom47to824participants).Thequalityofthestudiesrangedfrom
moderatetolowwithfourofthestudiesbeingofmoderatequalityandtheremainingsevenoflow
quality(basedontheConsortChecklist).Differencesinqualityweremainlyduetomethodological
issuessuchasinadequatedescriptionofrandomization,samplesizecalculationallocation
concealment,blindinganduncertaintyoftheuseofintentiontotreat(ITT)analysis.Patientswere
recruitedfromseveralsettings:sixstudiesfromprimaryorgeneralmedicalpractices,threestudies
fromthecommunity(e.g.viaadvertisements),andtwofromoutpatientdiabetesclinics.Ausualcare
controlgroupwasreportedinnineof11ofthestudiesandtwostudiesreportedsometypeof
minimaldiabetescareinadditiontousualcareforthecontrolgroup.INTERVENTION
CHARACTERISTICS:Alloftheinterventionsexaminedinthestudiesweremappedtothe2007Self
managementMappingGuide.Theinterventionsmostoftenfocusedonproblemsolving,goalsetting
andencouragingparticipantstoengageinactivitiesthatprotectandpromotehealth(e.g.modifying
behaviour,changeindiet,andincreasephysicalactivity).Allofthestudiesexaminedcomprehensive
interventionstargetedatleasttwoselfcaretopics(e.g.diet,physicalactivity,bloodglucose
monitoring,footcare,etc.).Despitethehomogeneityintheaimsoftheinterventions,therewas
substantialclinicalheterogeneityinotherinterventioncharacteristicssuchasduration,intensity,
setting,modeofdelivery(groupvs.individual),interventionist,andoutcomesofinterest(discussed
below).DURATION,INTENSITYANDMODEOFDELIVERY:Interventiondurationsrangedfrom2
daysto1year,withmanyfallingintotherangeof6to10weeks.Therestoftheinterventionsfellinto
categoriesof2weeks(2studies),6months(2studies),or1year(3studies).Intensityofthe
interventionsvariedwidelyfrom6hoursover2days,to52hoursover1yearhowever,themajority
consistedofinterventionsof6to15hours.Bothindividualandgroupsessionswereusedtodeliver
interventions.Groupcounsellingwasusedinfivestudiesasamodeofinstruction,threestudies
usedbothindividualandgroupsessions,andonestudyusedindividualsessionsasitssolemodeof
instruction.(ABSTRACTTRUNCATED)

PMID:23074526 PMCID:PMC3377516

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https://www.ncbi.nlm.nih.gov/pubmed/23074526 3/4
3/1/2017 Behaviouralinterventionsfortype2diabetes:anevidencebasedanalysis.PubMedNCBI

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