Influence of the Duration of Diabetes on the Outcome of a Diabetes Self-Management Education Program

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1 Originl Article Clinicl Cre/Eduction pissn eissn D I A B E T E S & M E T A B O L I S M J O U R N A L Influence of the Durtion of Dibetes on the Outcome of Dibetes Self-Mngement Eduction Progrm Seung-Hyun Ko 1, Sin-Ae Prk 1, Je-Hyoung Cho 1, Sun-Hye Ko 1, Kyung-Mi Shin 1, Seung-Hwn Lee 1, Ki-Ho Song 1, Yong-Moon Prk 2, Yu-Be Ahn 1 1 Division of Endocrinology & Metbolism, Deprtment of Internl Medicine, 2 Deprtment of Preventive Medicine, The Ctholic University of Kore College of Medicine, Seoul, Kore Bckground: Dibetes eduction nd lifestyle modifiction re criticl components in controlling blood glucose levels of people with type 2 dibetes. Until now, vilble dt on the effectiveness of eduction with respect to the durtion of dibetes re limited. We investigted whether dherence to lifestyle behvior modifiction prompted by dibetes eduction ws influenced by the durtion of dibetes. Methods: Two hundred nd twenty-five people with type 2 dibetes were recruited for n intensive, collbortive, group-bsed dibetes eduction progrm with nnul reinforcement. We divided the ptients into two groups bsed on the durtion of their dibetes prior to the eduction progrm ( 1 yer [] vs. 3 yers []). Dietry hbits, physicl ctivity, nd the frequency of blood glucose self-monitoring were evluted with questionnire prior to eduction nd t the follow-up endpoint. Results: The men follow-up period ws 32.2 months. The men hemoglobin A1c (A1C) vlue ws significntly lower in the group. Self-cre behviors, mesured by scores for dietry hbits (P=0.004) nd physicl ctivity (P<0.001), were higher t the endpoint in the group thn in the group. Logistic regression nlysis reveled tht longer dibetes durtion before eduction ws significntly ssocited with men A1C levels greter thn or equl to 7.0% (53 mmol/mol). Conclusion: Dibetes durtion influenced the effectiveness of dibetes eduction on lifestyle behvior modifiction nd glycemic control. More-intense, regulr, nd sustined reinforcement with encourgement my be required for individuls with longstnding type 2 dibetes. Keywords: Blood glucose; Dibetes mellitus, type 2; Eduction; Lifestyle modifiction INTRODUCTION Dibetes eduction nd lifestyle modifiction re criticl for controlling blood glucose levels in people with type 2 dibetes [1-4]. Dibetes self-mngement eduction leds ptients to optimise metbolic control, prevent nd mnge complictions, nd improve their qulity of life in cost-effective mnner [5]. People with dibetes need to dopt behviors tht help them ctively engge in self-mnging their dibetes. Generlly, ptient eduction is regrded s n importnt tretment modlity for type 2 dibetes mellitus, nd the beneficil effects of eduction hve been demonstrted in terms of improved glycemic sttus, improved self-cre, reduced mputtion risk, incresed well-being, nd reduced crdiovsculr disese (CVD) risk fctors in short-term follow-up prospective studies [6-10]. Recently, 4-yer study demonstrted tht intensive lifestyle intervention could produce sustined weight loss nd improvement in CVD risk fctors in type 2 dibetes ptients [11]. We hve previously reported the long-term beneficil effects of structured intensive dibetes eduction progrms on Corresponding uthor: Yu-Be Ahn Division of Endocrinology & Metbolism, Deprtment of Internl Medicine, St. Vincent s Hospitl, The Ctholic University of Kore College of Medicine, 93 Jungbu-dero, Pldl-gu, Suwon , Kore E-mil: ybhn@ctholic.c.kr Received: Sep. 26, 2011; Accepted: Jn. 16, 2012 This is n Open Access rticle distributed under the terms of the Cretive Commons Attribution Non-Commercil License ( which permits unrestricted non-commercil use, distribution, nd reproduction in ny medium, provided the originl work is properly cited. Copyright 2012 Koren Dibetes Assocition

2 Dibetes durtion influence on self-mngement progrm glycemic control nd lifestyle chnges. We found tht regulr nd sustined reinforcement with encourgement is required to mintin optiml metbolic control nd to compel ptients to mintin better physicl ctivity frequency, dietry hbits, nd self-monitoring of blood glucose (SMBG), especilly in insulin-treted type 2 dibetes ptients [12]. Therefore, emphsis should be plced on supporting ptients in effective selfmngement nd on the concomitnt use of hypoglycemic gents. This should be ccomplished through ptient eduction provided by professionl helth cre providers. Dibetes is typiclly progressive chronic disese, nd chronic illness is often emotionlly stressful, leding to both physicl nd psychologicl ftigue. Ptients with chronic illness relize tht they should dhere to strict lifestyle modifictions nd fer the development of complictions following the dibetes dignosis. There re severl stress fctors in dibetic ptient s dily life tht cn eventully led to burnout symptoms [13]. Burnout might influence the clinicl outcome or self-cre behviors of ptients with type 2 dibetes, nd the severity of these symptoms my depend on the durtion of dibetes. However, prior to this study, vilble dt on the effectiveness of eduction on self-cre behviors with respect to the durtion of dibetes hve been limited. If the effect of dibetes eduction on self-cre behviors differs with respect to dibetes durtion, the eduction curriculum should be individulized, or reinforcement should be focused on prticulr ptient groups. The objective of this study ws to investigte whether ctive intervention with dibetes eduction progrm for lifestyle modifictions influences the clinicl outcomes for type 2 dibetes ptients with respect to dibetes durtion. The primry outcome ws the ptient s dherence to lifestyle modifictions nd mintennce of self-cre behviors, nd the second outcome ws the glycemic control sttus fter pproximtely 3 yers. METHODS Ptients People with type 2 dibetes who hd not received ny previous, systemtic dibetes eduction were continuously recruited from the university-ffilited dibetes center of St. Vincent s Hospitl between Jnury 2007 nd December To investigte the effect of dibetes durtion on the effectiveness of dibetes eduction, we divided the ptients into two groups: those who hd less thn 1 yer of dibetes durtion before dibetes eduction (, recently dignosed ptients) nd those with more thn 3 yers () of dibetes durtion prior to eduction. We excluded ptients whose dibetes durtion ws between 13 nd 24 months so s to clssify the ptients into two distinct groups. Ptients were excluded if they were older thn 70 yers of ge, mentlly ill, unble to undertke the recommended physicl ctivity, did not gree to join the eduction progrm, or hd ny severe medicl illnesses, such s sepsis, severe infection, hypoglycemi, or shock. Written informed consent ws obtined from ll prticipnts. Approvl from the St. Vincent s Ethics Committee ws given. Structured dibetes eduction progrm We developed nd set-up n intense, collbortive dibetes eduction progrm bsed on the Buchrest-Dusseldorf study nd the Dibetes Prevention Progrm (DPP) [14,15]. The progrm ws designed for group eduction, consisted of 5 to 10 ptients per tem, nd ws conducted on n outptient bsis. The eduction tem ws run by dibetologist, certified dibetes eductors, including nurse nd dieticin, psychologist, nd fmily medicine doctor. The curriculum lsted pproximtely 6 hours per dy. The curriculum ws covered during five sessions to provide n understnding of dibetes mellitus nd to tech prticipnts how to use the glucometer nd self-monitoring of glucose levels, injection techniques, sick-dy cre, mel plnning, physicl ctivity, foot inspection, nd how to mnge hypoglycemi. The eductionl techniques were ptient-centered nd involved gol setting nd situtionl problem solving methods in fce-to-fce setting. The ptients were encourged to ctively interct with the provider in ech session. The diet eduction progrm ws designed using the DPP nd the Food Pyrmid guidelines s references [16,17]. The curriculum ws structured to ddress the knowledge, skills, nd ttitudes tht would encourge, support, nd promote selfmngement skills leding to long-term behvior mintennce, including diet hbits, food choice, diet plnning, nd physicl ctivity. We mde ech session hnds-on experience, such s SMBG nd diet choice in lunch buffet in front of dieticin. The fmily members of prticipnts were invited to ttend the progrm. All of the prticipnts with dibetes were followed-up 2 weeks fter progrm completion nd every 3 months therefter on n outptient bsis. When the ptients visited the out- 223

3 Ko S-H, et l. ptient clinic, the physicin reviewed their SMBG dt nd lifestyle behviors by sking questions nd encourged the ptients to mintin their improved lifestyle behviors. Bsed on these dt, the physicin djusted their dosge of hypoglycemic gents nd mde pproprite suggestions. If ptient did not visit our clinic for ny reson, the eduction nurse tried to contct the ptient by telephone or e-mil. For reinforcement, ll of the prticipnts were invited to ttend reinforcement eduction nnully. Re-eduction comprised single session lsting pproximtely 3 hours, which included review of self-mngement nd the presenttion of new topics, such s dibetes complictions, obesity, nd dyslipidemi (Tble 1). Mesurements Blood pressure, body weight, nd blood glucose levels were mesured t ech visit. Hypertension ws defined s systolic blood pressure of t lest 140 mm Hg, distolic blood pressure of t lest 90 mm Hg, or history of tretment of hypertension. The fsting blood glucose (FBS) level ws mesured nnully, nd glycted hemoglobin levels (high-performnce liquid chromtogrphy method; reference rnge 4.4% to 6.4%; Bio-Rd, Montrel, Quebec, Cnd) were checked 2 or 3 times per yer. Screening for microlbuminuri ws performed by mesuring the lbumin-to-cretinine rtio in rndom spot collection [1]. Dibetic retinopthy ws ssessed from retinl photogrphs t bseline, nd the findings were reviewed by n ophthlmologist. The outcomes were the men vlue nd chnges in the A1C fter eduction (Tble 1). Dietry hbits, physicl ctivity, nd the frequency of SMBG were evluted using questionnire before eduction nd t the follow-up endpoint. Ech prmeter ws scored using five-point scle bsed on the verge sttus of the individul during the prior 6 months, using the following criteri [12]: A. Dietry hbits ( How well do you follow your recommended mel pln? ). 1) irregulr diet with unlimited sncks; 2) irregulr with intermittent sncks; 3) pproprite mel clories, regulr diet with some sncks (>2 times/dy or >300 kcl/dy of excess intke); 4) pproprite mel clories, but few sncks ( 1 time/dy, or 100 to 300 kcl/dy of excess clorie); 5) tightly controlled, with no intermittent sncks; B. Physicl ctivity ( How often do you undertke t lest 20 minutes of physicl ctivity, equivlent in intensity to brisk wlking? ). 1) never; 2) <30 min/wk (weekly); 3) <60 min/wk (1 to 2 times per week); 4) <120 min/wk (3 to 4 times per week); 5) dily, >150 min/ wk; C. SMBG frequency ( How often do you check your glucose levels? ). 1) never; 2) monthly; 3) weekly; 4) 3 to 4 times/ wk; 5) dily [18]. Sttisticl nlysis We used SPSS version 11.5 (SPSS Inc., Chicgo, IL, USA) for the sttisticl nlysis, with 0.05 level of significnce. Clinicl chrcteristics nd prmeters were expressed s the mens± stndrd devitions or numbers (percentges). A χ 2 test ws performed to test for differences between the proportions of the vribles, nd t-test ws performed to evlute the differences between the mens of two vribles. In prticulr, we compred the ptients complince with diet, SMBG, nd physicl ctivity using χ 2 test nd weighted the dt using lestsqure methods to discern trends. Multiple logistic regression nlysis ws used to investigte the effect of dibetes durtion before eduction on pproprite dibetes control during the study period ( men A1C level of less thn 7.0%). Vribles with P vlues <0.25 in the univrite test were selected s co- Tble 1. Study design nd follow-up Months Screening V Questionnire V V Eduction V Reinforcement V V V Clinic visit V V V V V V V V V V V V V A1C V V V V V V V Lbortory mesurement V V Questionnire for lifestyle behviors, including dietry hbits, physicl ctivity, nd frequency of self-monitoring of blood glucose using fivepoint scle. 224

4 Dibetes durtion influence on self-mngement progrm vrites for the multivrite model. RESULTS Clinicl chrcteristics nd behviorl outcomes before eduction After pre-screening, 225 people with type 2 dibetes (101 mle nd 124 femle) were enrolled in this study. The men ge nd dibetes durtion of ll of the ptients were 51.6±10.1 yers nd 3.5±5.4 yers, respectively. One hundred nd ninety-five (86.7%) ptients were followed up t the endpoint, nd their men follow-up time ws 32.2 months (Fig. 1). We divided the ptients into two groups bsed on the durtion of their dibetes dignoses before prticipting in the dibetes eduction ( [n=135] vs. [n=90]). The men ges nd dibetes durtions of the ptients were 50.2±10.6 yers nd 0.36±0.3 months, respectively, for the group, nd 53.6±8.9 yers nd 8.5±5.0 yers, respectively, for the group. Descriptive chrcteristics of the study ptients, including ge, sex, durtion of dibetes, body mss index (BMI), nd lbortory sttus, re summrized in Tble 2. Age, durtion of dibetes, nd the percentge of ptients with dibetic retinopthy were ll significntly higher in the group. Behviorl outcomes fter eduction Before eduction, self-cre behviors, including the frequency of SMBG (P=0.937), physicl ctivity (P=0.256), nd dietry Eligible t prescreening (n=274) 1 yer (n=135) 1 yer (n=115, 85.2%) Eduction (n=225) Completed outcomes (n=195, 86.7%) Exclusion (n=49) 3 yer (n=90) 3 yer (n=80, 88.9%) Fig. 1. Enrollment of ptients with type 2 dibetes mellitus nd the study design. Dt represent the number (%) of ptients. hbits (P=0.575), were not different between the group nd the group (Fig. 2A). Before completing the eduction progrm, only 51 (22.7%), 82 (36.4%), nd 15 (6.7%) ptients Tble 2. Bseline chrcteristics between groups Chrcteristic (n=135) (n=90) P vlue Age, yr 50.2± ± Sex, M/F 64/71 38/ BMI, kg/m ± ± Dibetic durtion, yr 0.6± ±4.9 <0.001 Hypertension 45 (33.3) 38 (42.2) Smoking 41 (30.4) 17 (18.9) Alcohol 48 (35.6) 24 (26.7) Retinopthy 7 (5.2) 24 (26.7) <0.001 Dibetic control Diet & exercise only 32 (23.7) 4 (4.4) OHA 99 (73.3) 80 (88.9) Insulin±OHA 4 (3.0) 6 (6.7) Lbortory mesurements t bseline Fsting glucose, mmol/l 9.7± ± Cretinine, mmol/l 0.08± ± Cholesterol, mmol/l 5.0± ± Triglyceride, mmol/l 1.9± ± HDL-C, mmol/l 1.1± ± A1C, % 8.9± ± A1C, mmol/mol 74±3 80± Postprndil glucose, mmol/l 16.5± ± Microlbuminuri, µg/mg cretinine Lbortory mesurements t follow-up visit 13.1± ± Fsting glucose, mmol/l 7.46± ± Cretinine, mmol/l 0.07± ± Cholesterol, mmol/l 4.55± ± Triglyceride, mmol/l 1.51± ± HDL-C, mmol/l 1.18± ± A1C, % 7.07± ±1.7 <0.001 A1C, mmol/mol 54±8 66±5 <0.001 Postprndil glucose, mmol/l 12.6± ± Microlbuminuri, µg/mg cretinine 12.3± ± Vlues re presented s men±stndrd devition or numbers (%). BMI, body mss index; OHA, orl hypoglycemic gent; HDL-C, high density lipoprotein cholesterol; A1C, glycted hemoglobin. 225

5 Ko S-H, et l. Physicl ctivity Diet SMBG Physicl ctivity Diet SMBG Percentge of ptients Percentge of ptients P=0.256 P=0.575 P=0.973 A P< P=0.004 P=0.096 Fig. 2. Chnges in the scores of lifestyle behviors during the study period with respect to the durtion of dibetes before eduction. (A) Before eduction. (B) After eduction. Diet hbit: Score 1, irregulr diet with unlimited sncks; 2, irregulr with intermittent sncks; 3, pproprite mel clories, regulr diet with some sncks (>2 times/dy or >300 kcl/dy of excess intke; 4, pproprite mel clories, but few sncks ( 1 time/dy, or 100 to 300 kcl/dy of excess clorie); 5, tightly controlled, with no intermittent sncks. Self-monitoring of blood glucose (SMBG): Score 1, never; 2, monthly; 3, weekly; 4, 3 to 4 times/wk; 5, dily. Physicl ctivity: 1, never; 2, <30 min/wk (weekly); 3, <60 min/wk (1 to 2 times per week); 4, <120 min/wk (3 to 4 times per week); 5, dily, >150 min/wk. The P vlues denote the differences between the groups ( vs. ) t the given time point. B hd scores greter thn or equl to four for dietry hbits, physicl ctivity, nd SMBG, respectively. After the structured eduction progrm with regulr reinforcement for pproximtely 3 yers, the scores of ll three items showed remrkbly improvement in ll of the ptients. Dietry hbits, physicl ctivity, nd SMBG scores were greter thn four or equl to four in 109 (55.9%), 113 (57.9%), nd 99 (50.8%) ptients, respectively. However, there were significnt differences between the nd groups in the dherence to self-cre behviors t the follow-up endpoint. The dherence to dietry hbits (P=0.004) nd physicl ctivity (P<0.001) ws significntly more sustined in the recently dignosed ptients. However, the SMBG scores did not differ between the two groups (P=0.096) (Fig. 2B). A multiple logistic regression nlysis reveled tht longer dibetes durtion before eduction ws significntly ssocited with men A1C level greter thn 7.0% (53 mmol/mol) during the follow-up period ( vs. ; odds rtio, 3.361; 95% confidence intervl, to 6.787; P=0.001) fter djusting for ge, BMI, hypertension, smoking hbits, lcohol consumption, presence of retinopthy or microlbuminuri, dibetes mediction, A1C, dietry hbits, physicl ctivity, nd frequency of SMBG in the bseline ssessment (Tble 3). In this study, the durtion of dibetes ws n independent risk Tble 3. Multiple logistic regression nlysis of men A1C level higher thn 7.0% (53 mmol/mol) during the follow-up period Chrcteristic OR (95% CI) P vlue Age, yr ( ) Dibetic durtion, yr ( ) Hypertension, yes vs. no ( ) Smoking, yes vs. no ( ) BMI ( ) Retinopthy, yes vs. no ( ) Mediction, yes vs. no ( ) Bseline A1C ( ) Microlbuminuri, yes vs. no ( ) A1C, glycted hemoglobin; OR, odds rtio; CI, confidence intervl; BMI, body mss index. fctor for n unsuccessful glycemic control sttus even fter structured dibetes eduction with regulr reinforcement. Glycemic control in both groups for 3 yers The A1C levels before the eduction progrm were not different 226

6 Dibetes durtion influence on self-mngement progrm Men A1C (%) A1C (%) A Time (mo) B Fig. 3. Men hemoglobin A1c (A1C) levels in both groups. (A) Men vlues during the study period. (B) Chnges in A1C levels in both groups. Dt re presented s the men±stndrd devition., dibetes durtion of less thn 1 yer before dibetes eduction or in recently dignosed ptients;, dibetes durtion of more thn 3 yers before eduction. P<0.05 vs. group. between the two groups (Tble 1). Six months fter the eduction progrm, the A1C levels were remrkbly decresed from bseline vlues in both groups ( vs. group, -2.64±2.3 vs ±1.7 percentge points, respectively; P<0.005 with respect to the bseline level in ech group; P=0.065 between groups t 6 months). The men A1C vlue during the study period ws significntly lower in the group thn in the group (7.04±1.2% vs. 8.16±1.6% [53±10 mmol/mol vs. 65±6 mmol/mol], respectively; P<0.005) (Fig. 3A). Sixty-two (45.9%) of the group members nd 15 (16.7%) of the group members reched the trget A1C level (men A1C 7.0% [53 mmol/mol]) during the follow-up period. The men A1C levels tht were mesured every 6 months were significntly lower in the recently dignosed ptients throughout the observtion period (Fig. 3B). DISCUSSION In this study, we investigted whether the effectiveness of structured dibetes eduction progrm ws influenced by dibetes durtion. Our results suggest tht people with type 2 dibetes mellitus who hd experienced longer dibetes durtion before prticipting in dibetes eduction showed lower dherence to physicl ctivity frequency nd dietry hbits, s well s elevted men A1C levels, even fter intensive dibetes eduction, s compred to the more recently dignosed ptients. A qulified eduction progrm is likely to be cost-effective intervention for ptients with type 2 dibetes mellitus. Dibetes self mngement eduction improves metbolic control, prevents nd mnges complictions, nd mximizes qulity of life in cost-effective mnner [10,19]. We hve previously reported the long-term effectiveness of structurl dibetes eduction progrm in ptients with type 2 dibetes mellitus [12]. We experientilly determined the importnce of welldesigned progrm nd regulr reinforcement; therefore, in this study we emphsized collbortive pproch nd regulr reinforcement. As the short-term nd long-term benefits of structured dibetes eduction progrms hve been clerly demonstrted, we investigted whether the durtion of dibetes before eduction would influence glycemic control sttus or lifestyle behviors in this study. We found tht lifestyle behviors, including dietry hbits, physicl ctivity, nd SMBG, were remrkbly improved fter the eduction progrm. Moreover, the dherence to dietry hbits nd physicl ctivity ws significntly more sustined in recently dignosed ptients following the structured eduction progrm with regulr reinforcement for pproximtely 3 yers. In this study, 58.5% of ptients exercised for more thn 120 minutes per week, nd 44.1% mintined good diet hbits. However, in spite of the structured eduction progrm nd reinforcement, the durtion of dibetes prior to eduction significntly influenced the dherence to self-cre behviors nd glycemic outcome. We found tht the progrm ws more effective in people with type 2 dibetes who hd been dignosed less thn 1 yer prior to the strt of the eduction progrm, nd the men A1C levels mesured every 6 months were significntly lower in recently dignosed ptients throughout the ob- 227

7 Ko S-H, et l. servtion period. Therefore, dibetes eduction should be delivered s soon s possible fter dignosis of type 2 dibetes mellitus. Moreover, somewht different strtegies pper to be necessry for ptients with longer dibetic durtion to chieve meningful dibetic eduction. Dibetes is lrgely self-mnged disese tht hs mjor psychosocil impct on the lives of ptients. Even for those who re very dherent to self-cre behviors, they re under the constnt thret of severe nd devstting dibetic complictions or bothersome symptoms throughout their lives [13]. Burn-out is n unfvorble consequence of long-term stress, nd this psychologicl rection is thought to increse the risk for the development of permnent physicl exhustion syndrome [20,21]. Asberg et l. [21] nd Lindstrom et l. [22] defined burn-out s combintion of emotionl ftigue, physicl wekness, nd cognitive symptoms. Ptients with type 2 dibetes re under stressful conditions relted to lifestyle modifictions or glycemic control throughout their lives; however, burn-out in ptients with type 2 dibetes, either emotionlly or physiclly, hs not been thoroughly studied. A recent study hs shown tht dibetes-relted stress is significntly correlted with longer dibetic durtion nd n uncontrolled glycemic sttus [23,24]. Dibetic ptients were usully stressed bout the future nd the possibility of serious complictions nd were frightened when they thought bout the difficulties of living with dibetes [23]. Therefore, to mintin ptients selfcre behvior, dibetes eductor needs to tke into ccount vrious socil, emotionl, nd psychologicl fctors, in ddition to their clinicl sitution. There re some limittions of our study. First, s the dibetic durtion increses, pncretic β-cell function grdully decrese; this decrese in β-cell function might ffect the men A1C results. Dibetic tretments were significntly different between the two groups. A greter number of ptients with longer dibetes durtion used insulin or orl hypoglycemic gents to control their dibetes. Second, vlidted reserch tools to estimte psychologicl, physicl, nd behviorl symptoms of clinicl burn-out should be used to define the influence of dibetic burn-out on self-cre behviors. Our future reserch will ddress this question. Third, chnges in lifestyle behvior cn be influenced by other fctors, such s eductionl sttus or the presence of job. However, ccording to our previous report, socioeconomic sttus, mritl sttus, fmily history of dibetes, or the presence of job did not hve n influence on the lifestyle behviors [25]. In conclusion, we found tht longer durtion of dibetes resulted in lower dherence to self-cre ctivities nd poorer glycemic control. We demonstrted tht intensive dibetes eduction in newly or recently dignosed dibetic ptients hs more fvorble clinicl outcomes, s compred to the outcomes of ptients with longer durtion of dibetes prior to eduction. Lifestyle modifictions re n essentil component of dibetes mngement. Dibetic eduction should help dibetic ptients mintin their lifestyle modifictions; however, dibetes burn-out or dibetes-relted stress influences their selfcre behviors. Therefore, dibetic ptients with long dibetic durtion need specil ttention from helth cre providers nd dibetes eductors. It is importnt to consider psychologicl nd emotionl support for type 2 dibetic ptients, especilly those with longer dibetes durtion or dibetic complictions, to mximize the effectiveness of dibetes eduction. CONFLICTS OF INTEREST No potentil conflicts of interest relevnt to this rticle were reported. REFERENCES 1. Americn Dibetes Assocition. Stndrds of medicl cre in dibetes: Dibetes Cre 2011;34 Suppl 1:S Assl JP, Muhlhuser I, Pernet A, Gfeller R, Jorgens V, Berger M. Ptient eduction s the bsis for dibetes cre in clinicl prctice nd reserch. Dibetologi 1985;28: Norris SL, Lu J, Smith SJ, Schmid CH, Engelgu MM. Selfmngement eduction for dults with type 2 dibetes: metnlysis of the effect on glycemic control. Dibetes Cre 2002; 25: Polonsky WH, Erles J, Smith S, Pese DJ, Mcmilln M, Christensen R, Tylor T, Dickert J, Jckson RA. Integrting medicl mngement with dibetes self-mngement trining: rndomized control tril of the Dibetes Outptient Intensive Tretment progrm. Dibetes Cre 2003;26: Gillett M, Dllosso HM, Dixon S, Brennn A, Crey ME, Cmpbell MJ, Heller S, Khunti K, Skinner TC, Dvies MJ. Delivering the dibetes eduction nd self mngement for ongoing nd newly dignosed (DESMOND) progrmme for people with newly dignosed type 2 dibetes: cost effectiveness nlysis. BMJ 2010;341:c Rubin RR, Peyrot M, Sudek CD. Effect of dibetes eduction 228

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