Originl Article http://dx.doi.org/10.4093/dmj.2011.35.6.580 pissn 2233-6079 eissn 2233-6087 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 Effect on Glycemic, Blood Pressure, nd Lipid Control ccording to Eduction Types Mi-Ju Choi 1, *, Seung-Hyun Yoo 2, *, Kum-Re Kim 1, Yoo-Mi Be 1, Sun-Hee Ahn 1, Seong-Shin Kim 1, Seong-Ah Min 1, Jin-Sun Choi 1, Seung-Eun Lee 1, Yeo-Jin Moon 1, Eun Jung Rhee 2, Cheol-Young Prk 2, Won Young Lee 2, Ki Won Oh 2, Sung Woo Prk 2, Sun Woo Kim 2 1 Dibetes Center, 2 Division of Endocrinology nd Metbolism, Deprtment of Internl Medicine, Kngbuk Smsung Hospitl, Sungkyunkwn University School of Medicine, Seoul, Kore Bckground: Dibetes self-mngement eduction nd reinforcement re importnt for effective mngement of the disese. We investigted the effectiveness of interctive smll-group eduction on glycemic, blood pressure, nd lipid levels. Methods: For this study, 207 type 2 dibetes ptients with suboptiml glycemic control (HbA1c levels >6.5%) were enrolled. The conventionl eduction group received n existing eduction progrm from April to November in 2006, nd the interctive eduction group received new smll-group eduction progrm from December 2006 to July 2007. The two groups were comprtively nlyzed for chnges in blood sugr, glycted hemoglobin, lipid, nd blood pressure t bseline, 3, 6, nd 12 months nd the proportion of ptients chieving trget gols t 12 months. Results: After 12 months of follow-up, HbA1c levels in the interctive eduction group were significntly lower thn in the conventionl eduction group (6.7% vs. 6.4%, P<0.001). Fsting nd 2 hour postprndil glucose concentrtions, totl cholesterol, nd low density lipoprotein cholesterol were significntly lower in the interctive eduction group thn in the conventionl eduction group. The proportion of ptients tht chieved trget gols ws significntly higher in the interctive eduction group. Conclusion: The smll-group eductionl method improved nd re-estblished the existing group eductionl method. This finding suggests tht the importnce of eduction ppers to be relted to the method by which it is received rther thn the eduction itself. Thus, the use of smll-group eductionl methods to supplement existing eductionl methods estblished for diverse ge levels should be considered in the future. Keywords: Achievement; Dibetes mellitus; Eduction INTRODUCTION The current globl prevlence of dibetes in dult popultion hs been estimted to be 5.1% since 2003 nd is expected to increse to pproximtely 6.3% by 2025 [1]. Dibetes is mjor risk fctor for leding cuses of deth such s crdiovsculr nd cerebrovsculr disese nd is ccompnied by multiple complictions, which hve negtive effect on the fmily nd society. Additionlly, s the cost of treting dibetes nd its complictions hve incresed continuously, countries hve mde extensive efforts in preventing nd mnging dibetes [2]. In most cses, complete recovery fter the onset of dibetes is difficult; thus, it is chronic disese tht requires continuous, lifelong therpy nd self-mngement. In ddition, severl lrge-scle studies hve proven tht strict glycemic control nd mngement of comorbidity such s hypertension, dyslipidemi cn reduce the occurrence of dibetes compliction nd Corresponding uthor: Cheol-Young Prk Division of Endocrinology nd Metbolism, Deprtment of Internl Medicine, Kngbuk Smsung Hospitl, Sungkyunkwn University School of Medicine, Seoul 110-746, Kore E-mil: cydoctor@chol.com Received: Dec. 30, 2010; Accepted: My 31, 2011 *Mi-Ju Choi nd Seung-Hyun Yoo contributed eqully to this study s first uthors. This is n Open Access rticle distributed under the terms of the Cretive Commons Attribution Non-Commercil License (http://cretivecommons.org/licenses/by-nc/3.0/) which permits unrestricted non-commercil use, distribution, nd reproduction in ny medium, provided the originl work is properly cited. Copyright 2011 Koren Dibetes Assocition
Effect on dibetes control ccording to eduction types mortlity rte [3-5]. Therefore, it is recommended tht ptients strt dibetic mediction in conjunction with therpeutic lifestyle modifiction s soon s possible. As known in the previous studies, it is more effective to motivte nd educte ptients so tht they cn understnd the disese itself nd mnge their blood glucose level, insted of simply providing mediction [6-8]. Enhncing effective self-mngement skill is n importnt prt of dibetes mngement, thus, dibetes eduction is necessry nd required s the bsis for dibetes cre. The Study Group on Dibetes Mellitus of the World Helth Orgniztion (WHO) stted tht The foundtion of dibetes mngement is educting ptients nd their fmilies on the subject. The Americn Dibetes Assocition s mission sttement of eduction progrm is Eduction is n ongoing process with the ultimte gol of positive behviorl chnge. Dibetes eduction is gretly beneficil in ptients nd furthermore, provides socil nd economic benefits to society s whole [9]. In other words, the most effective solution in terms of preventing nd controlling chronic dibetic compliction is ptients ctive prticiption in dibetes mngement, both of which cn be possibly chieved through ongoing ptient eduction nd trining [10,11]. However, it is difficult to expect effectiveness of the most dibetic eduction progrm with one or two sessions conducted in this country [12]. Recently, vrious individul or group eduction progrms for ptients hve been offered in severl hospitls, nd hve shown improvement in HbA1c levels, self-mngement indictors, ptient stisfction nd knowledge, shortening of hospitliztion period, nd reduction in leg mputtion rtes fter the ppliction of these eduction progrms [13,14]. However, the mjority of these studies ssessed the short-term effects of eduction on glucose control but not long-term effects fter eduction. In this study, we compred two progrms between the existing eduction progrm of unilterl informtion delivery versus intensive, interctive eduction progrm for smll number of ptients, regrding their effects on short- nd longterm improvement of dibetes mintennce indictors. METHODS Study popultion This study is conducted on the ptients who were not ble to chieve trget HbA1c level ccording to the tretment guideline for dibetes from Koren Dibetes Assocition [15] (with HbA1c levels rnging 6.5% to 9.0%) nd who could be followed for over one yer. Ptients were devided into two groups bsed on the eduction methods. A totl of 101 ptients hd received conventionl group eduction between April 2006 nd November 2006, nd 106 ptients hd received new type of smll-group eduction between December 2006 nd July 2007. Mesurement of covrites We collected ptient chrcteristics such s gender, ge, height, weight, durtion of dibetes, nd history of orl hypoglycemic gents, nti-hyperlipidemic gents, or ntihypertensive drugs, or insulin therpy. We mesured the fsting plsm glucose, 2-hour postprndil glucose, HbA1c, totl cholesterol, triglycerides, high density lipoprotein cholesterol (HDL-C) nd low density lipoprotein cholesterol (LDL-C), nd blood pressure t bseline nd 3, 6, nd 12 months fter eduction. During eduction, the proportion of ptients chieving trgeted tretment gols ws estimted by exmining medicl records. The medicl records were reviewed retrospectively. Dibetes eduction methods The two types of teching methods re s follows. Conventionl eduction () Approximtely 30 in-ptients nd out-ptients were included nd group eduction ws offered in two wys: dibetes eduction executed by doctor, nd dibetes mngement executed by nurse for one nd hlf hours followed by one-on-one nutritionl session. Interctive eduction () ws consisted of pproximtely 10 people. A nurse, dietitin, nd physicl therpist composed n eduction tem nd offered 2.5-hour eduction sessions. Endocrine specilists were responsible for the entire eduction system including prescribing medicines nd encourging stffs. Nurses provided eduction for the ptients to understnd nd mnge dibetes, so ptients could get overview of disese nd verify exmintion levels, methods for mnging nd self-monitoring of blood glucose, mngement of hypoglycemi, foot mintennce, mngement for specil dys, nd dy-to-dy ctivities so s to mintin their dily lives by themselves. Nutritionists emphsized the importnce of dibetes-oriented diets nd educted ptients on proper diet nd clinicl exercise specilist 581
Choi M-J, et l. thought how to exercise for dibetes. Written eduction imed t developing deeper understnding of the progrm nd complementry eduction vi Q & A were lso given. After performing smll group eduction nd one-on-one privte nutritionl eduction, ptients received primry nd secondry sought mngement. Blood glucose exmintions (HbA1c, blood lipid levels, nd blood pressure mesurements) were performed in the outptient clinic t 3, 6, nd 9 months fter receiving eduction. Bsed on the bove exmintion results, dibetes mngement instructionl flyer ws sent out to those ptients. Reserchers/eductors ttempted to generte n interest in dibetes mngement indictors. Sttisticl nlysis The crosstb method ws used to estimte the proportion of ptients who chieve the gols of dibetes mngement for both groups. The indictors for dibetes mngement were comprtively nlyzed between the two groups t bseline nd 3, 6, nd 12 months fter eduction. P vlue less thn 0.05 ws considered to be sttisticlly significnt. All sttisticl nlyses were conducted using SPSS version 17.0 (SPSS Inc., Chicgo, IL, USA). RESULTS The bseline chrcteristics of the two groups re shown in Tble 1. There were no significnt differences between two groups in sex, ge, durtion of dibetes, the rte of using insulin, orl hypoglycemic or ntihypertensive gents. A greter percentge of ptients in the group reported nti-hyperlipidemic gents use (P<0.001) (Tble 1). The men ge of the group nd group ws 56.5±12.1, nd 55.5±10.6, respectively. The men durtion of dibetes for the group nd group ws 5.03±2.3, nd 5.1±2.6, respectively nd they were not significntly different. Improvements of mngement indictors from eductionl methods Anlyticl results of dibetes mngement indictors in the group nd the group t bseline nd 12 months fter eduction re shown in Tble 2. Over the 1-yer follow up period, the fsting plsm glucose levels significntly dropped from 144.2±30.2 mg/dl to 122.8±19.2 mg/dl in the group nd from 158.7±49.5 mg/dl to 129.2±25 mg/dl in the group, significntly. Compring two groups, the group showed Tble 1. Bseline chrcteristics of prticipnts by group Chrcteristic (n=101) (n=106) P vlue Sex, M/F 52/49 (52/48) 64/42 (60/40) 0.198 Age, yr 56.5±12.1 55.5±10.6 0.538 Dibetes durtion, yr 5.03±2.3 5.1±2.6 NS Fsting plsm glucose, mg/dl Postprndil glucose, mg/dl 158.7±49.5 144.2±30.2 0.012 219.8±74.5 212.1±71.6 0.453 HbA1c, % 7.5±0.7 7.5±0.8 0.885 Totl cholesterol, mg/dl 199.5±37.8 198.4±41.2 0.844 Triglyceride, mg/dl 191.8±114.5 188.5±152.9 0.860 HDL-C, mg/dl 50.2±11.1 44.3±10.1 0.000 LDL-C, mg/dl 113.0±30.8 123.1±32.0 0.023 SBP, mm Hg 126.0±17.7 128.6±14.0 0.262 DBP, mm Hg 80.0±11.2 80.7±9.6 0.651 No. of people treted with Dibetes nd exercise only Orl hypoglycemic gents Use of nti-hyperlipidemic gent 3 (3) 1 (0.9) NS 98 (97) 105 (99.1) No 43 (42.6) 21 (19.8) 0.000 Yes 58 (57.4) 85 (80.2) Use of insulin No 88 (87.1) 95 (89.6) NS Yes 13 (12.9) 11 (1.04) Use of ntihypertensive gent No 46 (45.5) 35 (33) NS Yes 55 (54.5) 71 (67) Vlues re presented s men±stndrd devition or number (%)., conventionl eduction group;, interctive eduction group; NS, not significnt; HbA1c, hemoglobin A1c; HDL-C, high density lipoprotein cholesterol; LDL-C, low density lipoprotein cholesterol; SBP, systolic blood pressure; DBP, distolic blood pressure. significntly greter improvement over the group (P = 0.040). The 2-hour postprndil glucose level for both the group nd the group decresed significntly from 219.8± 74.5 mg/dl t bseline to 175.6±48.8 mg/dl nd from 212.1± 71.6 mg/dl to 159.3±42.1 mg/dl, respectively, one yer fter eduction received. Compring drops of 2-hour postprndil glucose levels between the two groups showed tht the group hd significntly greter improvement thn the group (P=0.013). 582
Effect on dibetes control ccording to eduction types Tble 2. Chnges in biochemicl prmeters by group Prmeter (n=101) (n=106) Bseline 12 mo P vlue Bseline 12 mo P vlue Fsting plsm glucose, mg/dl 158.7±49.5 129.2±25.0 0.000 144.2±30.2 122.8±19.2 0.000 0.040 2-hr postprndil glucose, mg/dl 219.8±74.5 175.6±48.8 0.000 212.2±71.6 159.3±42.1 0.000 0.012 HbA1c, % 7.5±0.7 6.8±0.6 0.000 7.5±0.8 6.5±0.5 0.000 0.000 Totl cholesterol, mg/dl 199.5±37.8 168.5±34.7 0.000 198.4±41.2 157.1±38.2 0.000 0.026 Triglyceride, mg/dl 191.8±114.5 160.6±100.0 0.002 188.5±152.9 143.3±78.3 0.001 0.167 HDL-C, mg/dl 50.2±11.1 47.2±12.0 0.015 44.3±10.1 45.1±9.5 0.491 0.159 LDL-C, mg/dl 113.0±30.8 102.9±31.7 0.010 123.1±32.0 85.6±28.0 0.000 0.000 SBP, mm Hg 126.0±17.7 125.7±14.3 0.832 128.6±14.0 122.1±11.5 0.000 0.061 DBP, mm Hg 80.0±11.2 77.4±8.4 0.071 80.7±9.6 77.4±10.2 0.025 0.984 P vlue Vlues re presented s men±stndrd devition., conventionl eduction group;, interctive eduction group; HbA1c, hemoglobin A1c; HDL-C, high density lipoprotein cholesterol; LDL-C, low density lipoprotein cholesterol; SBP, systolic blood pressure; DBP, distolic blood pressure. P<0.05. A1C (%) 8.0 7.5 7.0 6.5 6.0 0 3 6 12 Months Fig. 1. Chnges in A1c levels over 12 months., conventionl eduction group;, interctive eduction group. P<0.05. The HbA1c levels of the group decresed significntly from 7.5±0.7% to 6.7±0.8% nd 6.6±0.6%, 3 nd 6 months fter eduction, respectively. However, fter 12 months, the HbA1c levels were slightly incresed to 6.8±0.6%. The HbA1c levels of the group showed stedy decrese, from 7.5±0.8% t bseline to 6.6±0.7%, 6.5±0.8%, nd 6.5±0.5% t 3, 6, nd 12 months fter eduction received, respectively. The group showed greter improvement compred to the group (P< 0.001) (Fig. 1). The lipid concentrtion between the two groups showed no significnt differences for HDL-C nd triglycerides. However, totl cholesterol prior to eduction were similr s 199.5±37.8 mg/dl nd 198.4±41.2 mg/dl, respectively, wheres totl cholesterol levels t 12 months fter eduction were significntly different between two groups (168.5±34.7 mg/dl for nd 157.1±38.2 mg/dl for ; P=0.026). The LDL-C concentrtion in the group prior to eduction ws 113.3±30.8 mg/dl nd 102.9±31.7 mg/dl t 12 months fter eduction. The LDL concentrtion in the group prior to eduction ws 123.1±32.0 mg/dl nd decresed to 85.6±28.0 mg/dl one yer fter eduction. After one yer, there ws significnt difference in LDL-C levels between the two groups (P<0.001). The percentge of ptients in the group tking cholesterol mediction ws significntly higher thn tht in the group. Although there ws significnt decresing trend in blood pressure for both groups, there ws no significnt difference between the groups. Achievement of trget gols According to the Americn Dibetes Assocition [16] nd the Interntionl Dibetes Federtion [17] criteri, the primry nd secondry (finl) trget gols were defined nd the proportion of ptients chieving dibetes mngement gols re shown in Tble 3. One yer fter eduction, the proportion of ptients tht chieve primrily trgeted fsting plsm glucose level ws incresing in both groups, but there ws no significnt difference between groups. For the secondry trget level, the proportion of ptients who chieved trget gol ws 11.9% for the group nd ws more thn doubled to 28.3% for group in fsting plsm glucose level one yer fter eduction. The proportion of ptients who reched the trget 2-hour postprndil glucose levels in the primry mintennce gol showed incresing trends in both groups one yer fter educ- 583
Choi M-J, et l. Tble 3. Proportion of ptients chieving trget gols Trget gol Fsting plsm glucose, mg/dl 2-hr postprndil glucose, mg/dl, %, % Bseline 12 mo Bseline 12 mo <130 36.6 64.4 33.0 60.4 <110 8.9 11.9 10.4 28.3 <180 34.7 57.3 38.6 76.7 <145 14.9 31.3 14.9 35.9 HbA1c, % <7 27.7 70.3 30.2 75.5 Totl cholesterol, mg/dl <6.5 1.0 30.7 0 48.1 <200 49.0 80.2 50.0 86.8 Triglyceride, mg/dl <150 46.5 62.4 54.9 66.0 HDL-C, mg/dl M>40, F>50 54.5 56.4 47.2 51.9 LDL-C, mg/dl <100 34.7 49.0 19.8 71.7, conventionl eduction group;, interctive eduction group; HbA1c, hemoglobin A1c; HDL-C, high density lipoprotein cholesterol; LDL-C, low density lipoprotein cholesterol. tion. For the secondry mintennce gol, 31.3% of ptients in the group nd 35.9% of ptients in group reched the trget one yer fter eduction (Fig. 2). The proportion of ptients with HbA1c levels below the trgeted primry mintennce gol (<7.0%) incresed in both groups one yer fter eduction. The percentge of ptients chieving the secondry mintennce gol in the group ws 30.7%. The percentge in the group ws 48.1%, which is significntly higher thn tht for the group (Fig. 3). The proportion of ptient chieving the gol of blood lipid concentrtion incresed significntly in both groups one yer fter eduction. DISCUSSION In the previous study, it hs been demonstrted tht the effects of dibetes eduction ws fvorble on complince with medictions, exercise progrms, regulr checkups, s well s on significnt decreses in 2-hour postprndil glucose levels [18]. However, these promising results were produced using effective eduction nd studies showing the long-term effects of eduction were limited. The current dibetes eduction conducted in the most hospitls is being implemented to inptients, outptients, nd gurdins, using instructor-led trining for lrge group of ptients regrdless of their different eductionl levels. Although this eduction system help increse ptients knowledge bout the disese, simple knowledge trns- Percent (%) 70 60 50 40 30 20 10 0 Percent (%) FPG<130 Fig. 2. Proportion of ptients chieved trget gol for fsting plsm glucose (FPG) nd 2-hr postprndil glucose (PP2)., conventionl eduction group;, interctive eduction group. P<0.05. 80 70 60 50 40 30 20 10 0 FPG<110 HbA1c<7% Percent (%) mission is insufficient to motivte them. Becuse this eduction system is not personlized, even fter ptients received eduction, they hve difficulties in prcticing guidelines for dibetes mngement nd hs been filing to rech the trget glycemic gol nd, therefore, to prevent dibetes complictions [19,20]. Thus, developing new eductionl progrms is required. In this study, we ttempted to mke chnges to the trditionl teching system, to configure new trining progrm nd to evlute improvements of dibetes mngement indictors fter pplying these new eductionl methods. Although we could not find significnt short-term effects of (3 nd 6 months fter receiving eduction), we identified long-term improvements (12 months fter receiving eduction) on fsting plsm glucose, 2-hour postprndil glucose, HbA1c levels, totl cholesterol, nd LDL-C. HbA1c<6.5% Fig. 3. Proportion of ptients chieving trget gol for HbA1c., conventionl eduction group;, interctive eduction group. P<0.05. 90 80 70 60 50 40 30 20 10 0 PP2<180 PP2<145 584
Effect on dibetes control ccording to eduction types It is considered to be importnt eduction fctor to check ptients own lbortory results (e.g., blood glucose, HbA1c levels, nd lipid levels) in the result tble provided for group, nd to recognize the differences between trgeted gols nd their own levels. Additionlly, sending out the result tbles t 3, 6, nd 9 months fter receiving eduction gives the mening of re-eduction; recognizing the need for continuous mngement. At 3 nd 6 months fter receiving eduction, HbA1c levels for both groups showed the decresing trends. However, fter 12 months, HbA1c levels in the group showed n incresing trend, while the group continued to show decresing trend. Thus, for the improvement of long-term mintennce indictors, intervention with sustined, intensive dibetes eduction is considered necessry. Although the proportion of ptients who chieved their gol of HbA1c <7.0% were similr between two groups, more ptients in group chieved their trgeted gol of HbA1c <6.5%, s result of strict blood glucose control, thn those in group (48.1% nd 30.7%, respectively). In other words, this new eduction method yielded significnt improvements in strict nd long-term glycemic control. Dibetes eduction in Kore is currently tking plce in clinics nd public helth centers. The insurnce policies nd fees for helth cre service re unrelistic, so forming dedicted eduction unit nd developing qulified eduction progrm re difficult. Most provide perfunctory nd one-time eduction with one-wy communiction, nd it does not gurntee effectiveness of eduction. The weknesses of this study re: 1) it ws retrospective study using the medicl records of ptients; 2) comprison of the degrees of fulfillment of self-mngement between both groups nd chnges in the tretment regimen were not investigted one yer fter receiving eduction; 3) including only ptients who completed the one yer follow-up limited generliztion of our study findings. Bsed on this study, long-term followup survey could be plnned to determine the prolonged effects of this intensive eduction progrm nd to evlute self-mngement. Furthermore, experiences in dibetes eductors nd the effects of this eduction cn be shred nd this eduction cn be used s bsic mteril in developing new eductionl progrms in the future. CONFLICTS OF INTEREST No potentil conflict of interest relevnt to this rticle ws reported. ACKNOWLEDGMENTS This study ws supported by the eduction grnt of the Koren Dibetes Assocition, 2007. REFERENS 1. Interntionl Dibetes Federtion. Dibetes tls. 2nd ed. Brussels: Interntionl Dibetes Federtion; 2003. p17-71. 2. WHO Study Group on Prevention of Dibetes Mellitus. Prevention of dibetes mellitus: report of WHO Study Group. Genev: World Helth Orgniztion; 1994. 3. The Dibetes Control nd Complictions Tril Reserch Group. The effect of intensive tretment of dibetes on the development nd progression of long-term complictions in insulindependent dibetes mellitus. N Engl J Med 1993;329:977-86. 4. UK Prospective Dibetes Study Group. Tight blood pressure control nd risk of mcrovsculr nd microvsculr complictions in type 2 dibetes: UKPDS 38. BMJ 1998;317:703-13. 5. Cho NH. Dibetes epidemiology in Koren. J Koren Dibetes Assoc 2001;25:1-10. 6. Srkdi A, Rosenqvist U. Study circles t the phrmcy: new model for dibetes eduction in groups. Ptient Educ Couns 1999;37:89-96. 7. Orchrd TJ, Tempros M, Goldberg R, Hffner S, Rtner R, Mrcovin S, Fowler S; Dibetes Prevention Progrm Reserch Group. The effect of metformin nd intensive lifestyle intervention on the metbolic syndrome: the Dibetes Prevention Progrm rndomized tril. Ann Intern Med 2005;142:611-9. 8. Norris SL. Helth-relted qulity of life mong dults with dibetes. Curr Dib Rep 2005;5:124-30. 9. Keers JC, Groen H, Sluiter WJ, Boum J, Links TP. Cost nd benefits of multidisciplinry intensive dibetes eduction progrmme. J Evl Clin Prct 2005;11:293-303. 10. Tng TS, Gillrd ML, Funnell MM, Nwnkwo R, Prker E, Spurlock D, Anderson RM. Developing new genertion of ongoing: dibetes self-mngement support interventions-- preliminry report. Dibetes Educ 2005;31:91-7. 11. Funnell MM, Nwnkwo R, Gillrd ML, Anderson RM, Tng TS. Implementing n empowerment-bsed dibetes self-mnge- 585
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