Summary

A structured education programme was trialed with a group of patients with newly diagnosed type 2 diabetes. The outcomes of the so-called DESMOND programme were interesting - improvement in patient attitude, smoking cessation and weight loss, all of which should help the condition. Yet, after twelve months the programme did not have a significant impact upon blood glucose compared to standard management of diabetes.

Introduction

Type 2 diabetes is a chronic disease where doctor and patient work together to manage the condition. Many factors, such as keeping to a healthy weight, smoking cessation, adherence to medication, and level of physical activity, are really important in warding off complications. Therefore, you might expect patient education to be vital in good self-management. Several such programmes have been tested out. Yet the UK National Institute for Health and Clinical Excellence (NICE) has, so far, found little benefit to the patient. There is, however, some evidence that perhaps patient education with an element of cognitive reframing might be more successful. Cognitive reframing involves changing the way the patient thinks about their lifestyle and situation with the aim of reaching a more positive outlook. Therefore, UK-based researchers for the DESMOND collective decided to take a look at how patients might respond to such a programme.

What was done

The trial involved 207 general practices in England and Scotland, of which 102 took part in the DESMOND programme and the rest acted as a control group. Overall, 824 patients who had been diagnosed with type 2 diabetes within the previous four weeks took part. Trained professionals delivered the DESMOND programme over six hours during a 12 week period, using a patient-centered approach and focusing on control of lifestyle factors. The control group was allowed equal access time to health professionals, but this was not structured.

The researchers measured hemoglobin A1c levels, a standard measure of blood glucose control in diabetes, blood pressure, and body weight at four, eight and 12 months. Lipid profile and waist measurement were also measured. They also asked about smoking status, physical activity and quality of life. The patients' attitudes towards their diabetes were also explored, covering their understanding, perception of ability to control their condition, how serious they believed it was, and how distressing it felt.

What was found

Both groups lost weight, but the loss was significantly more in the DESMOND group. They both lowered their triglyceride levels too and again the decrease was greater in the DESMOND group. The other measures were reduced in both groups too, but there were no significant difference between them.

When it came to behavior and attitude, the differences between the two groups were more marked. Participants in the DESMOND group were three times more likely to quit smoking and had a greater level of physical activity. They also had a better understanding of their disease and a greater belief in their ability to control it.

What this study means

On the face of it, it may look as if DESMOND did not add anything to normal patient care in type 2 diabetes, because it did not produce any changes in blood glucose at the end of the study. But, as the researchers point out, there is more to successful long-term diabetes control than measurements of hemoglobin A1c . Improvements in weight loss and smoking cessation and, perhaps most of all, attitudes towards diabetes are likely to pay off over time in terms of reduced complications of the disease. Indeed, since NICE delivered judgment on patient education in diabetes, there have been two significant studies. One involved a five year follow-up and showed that education improved biochemical measures, such as hemoglobin A1c as well as patient attitudes. The second involved one center and 314 patients and showed similar results at 14 months. Therefore structured patient-centered education looks promising as a way of promoting effective self-management and positive outcomes in type 2 diabetes.