A new review examines their effectiveness, cost and methods of delivery and barriers to uptake.
By Prof Jane Speight
The health and well-being of people with diabetes depends on their ability to self-manage their condition. This includes self-care tasks such as dietary choices, physical activity, medication taking, glucose monitoring, carb counting, and ‘hypo’ management. International guidelines indicate that diabetes self-management skills are crucial, and education is key to developing these skills. A new review co-authored by Prof Jane Speight, published in The Lancet Diabetes and Endocrinology, summarises the evidence for structured diabetes self-management education (DSME) programs and discusses future areas for research.
DSME programs have existed for 10-20 years in many countries (e.g. UK, Australia), and up to 35 years in some other countries (e.g. USA, Germany). There is a wealth of evidence showing that DSME can improve blood glucose (HbA1c), and reduce rates of diabetes emergencies: severe hypoglycaemia (very low blood glucose) and diabetic ketoacidosis (DKA). Importantly, DSME offers a whole-person approach to self-management, addressing emotional concerns, social and cultural needs, health beliefs and family support. This means that DSME can also improve a range of psychological outcomes, e.g. quality of life, well-being, satisfaction, coping skills. However, DSME programs vary enormously in their content, duration, intensity, format, and tailoring to specific populations and cultural groups. So, it is not surprising that the effectiveness of DSME varies from program to program.
As diabetes is a long-term condition, it is important to understand whether the positive effects of DSME are sustained. Unfortunately, few studies have examined long-term outcomes (i.e. for more than one year). Several programs for adults with type 1 diabetes, including the DAFNE program, have demonstrated that psychological benefits are fully maintained but biomedical benefits are only partially maintained over periods of 4-7 years. This suggests that ‘refresher’ courses may be needed to ‘top-up’ education. In addition, ongoing support may be needed to help the person with diabetes to apply and sustain these complex self-care tasks. Importantly, DSME has been found to be very cost effective. A review of 26 studies found such cost savings, concluding that the benefits outweighed the intervention costs, e.g. 18% reduction in hospital admissions, and 21% reduction in ‘hospital bed days’.
Disappointingly, the review highlights that access to and uptake of DSME programs by people with diabetes varies hugely across the world, and needs to be improved. Importantly, those from vulnerable and hard-to-reach groups are least likely to attend. This means that DSME may not be accessible to those people who would benefit most. Although there are financial, medical and logistical reasons for low uptake, the key barriers were a) health professionals not recommending DSME (i.e. believing that education would not help the person with diabetes), and b) people with diabetes believing that they had no need for education.
The review concludes that evidence-based DSME programs are beneficial and cost-effective, but significant efforts are needed to encourage and improve attendance.
Chatterjee S, Davies MJ, Heller SR, Speight J, Snoek FJ, Khunti K. Structured education programmes in type 1 and type 2 diabetes: a narrative review and current innovations. The Lancet Diabetes and Endocrinology, 2018; 6(2): 130-142