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Reducing Risks in Diabetes Self-managementA CommentaryFrom Yale University School of Nursing, New Haven, Connecticut. Correspondence to Gail D'Eramo Melkus, EdD, C-NP, CDE, FAAN, Independence Foundation Professor, Yale University School of Nursing, 100 Church Street South, PO Box 2740, New Haven, CT 06536-0740; e-mail: Gail.Melkus{at}yale.edu. In this systematic review of published intervention studies from 1990 through 2007 on risk reduction for diabetes self-management, it is noted that persons with diabetes who receive diabetes self-management interventions are significantly more likely to receive preventive care services to reduce the risk of diabetes-related complications than persons not receiving such interventions. Research studies designed to test the effect of risk reduction behavior(s) consistently find at least one significantly improved outcome related to diabetes complications risk reduction, suggesting that if all patients were provided knowledge and behavior skills on what, why, and how, in the context of a structured diabetes care intervention, improved health outcomes may be realized. Conclusions of the Diabetes Control and Complications Trial and the United Kingdom Prospective Diabetes Study provide widely accepted evidence for targeting glycemic control and hypertension treatment. Findings of these major studies also prompted a focus shift in diabetes self-management education from diabetes-related complications prevention to improving behaviors targeting optimal glycemic control. In this systematic review, the majority of considered studies had HbA1c as a primary outcome, but a risk reduction perspective necessarily includes equal emphasis on diet, physical activity, and medications as a means to HbA1c reduction and prevention of complications. Diabetes complications education, screening, detection, and treatment are first the responsibilities of diabetes care providers and then a shared responsibility of patients and diabetes care providers. The systematic review on reducing risks in diabetes self-management shows that there is presently sufficient significant evidence to guide clinical practice. Evidence for the risk reduction behaviors contained in the American Association of Diabetes Educators (AADE) Self-Care Behavior standard for reducing risks already exists and currently is included in AADE and American Diabetes Association (ADA) clinical practice standards. For example, there is general acknowledgment by the public based on research evidence that smoking cessation is necessary to decrease risk of lung disease, heart attack, and stroke. Such findings have been translated into clinical practice, public health practices, and policy initiatives. However, there are still areas in which the practice evidence regarding risk reduction is not so clear. Although the facts for applying risk reduction behaviors are obvious to health care providers, how to best deliver them and achieve changes in behaviors is not as transparent. More is needed in the area of effectiveness studies to determine what the best approaches are to providing patients and families with risk reduction information: Who should deliver it? What approaches are most effective? What approaches are best for special populations such as elderly, children, low-income, and ethnic groups? How do patients receive and make sense of this information? How patients and families get diabetes complications risk reduction education and what they do with it needs further investigation for the benefit of all persons with diabetes. Many of the studies examined in this review were interventions that targeted multiple outcomes and used multifaceted strategies for the implementation and measurement of outcomes. The extent of percentage improvement across studies was the greatest for immediate postintervention outcomes to the least for long-term outcomes. This is a pattern often seen in providing education or self-management training to those with diabetes. These short-term bursts of improvement most likely result from targeted attention. However, it is accepted that knowledge does not translate into behavior change and that maintenance and sustainability of any behavior change, risk reduction included, is necessary for long-term outcomes that result in decreased morbidity and mortality and optimal quality of life. This information points to the importance of having evidence that informs our systems of care delivery to fully speak to the long-term nature of diabetes and the ongoing (not just one short intervention) risk reduction interventions that are needed. Diabetes educators and care providers are keenly aware of the importance of the aforementioned and therefore need data to support how to best assess patient risks, as well as how to most effectively establish goals and develop strategies to achieve, maintain, and sustain optimal outcomes. In service to such practice goals, particularly related to diabetes complications risk reduction, further research directed toward the development of systems of care that effectively partner primary care providers and diabetes and other specialty providers is necessary to ensure consensus and continuity of clinical care practices. This systematic review has highlighted that systems of care must also include diabetes education and behavioral counseling services because there is an associated increase in patients receiving and acting on risk reduction information. Further research, policy, and legislative work are needed to address the provision and reimbursement of comprehensive diabetes care, particularly related to the provision of behavioral interventions across the trajectory and stage of diabetes.
The Diabetes Educator, Vol. 33, No. 6,
1078-1079 (2007)
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