Sustaining short-term improvements over the long-term: Results from a 2-year diabetes self-management support (DSMS) intervention

Abstract

Aim

This study examined the long-term impact of a 24-month, empowerment-based diabetes self-management support (DSMS) intervention on sustaining health-gains achieved from previous diabetes self-management education (DSME).

Methods

Prior to the intervention, all participants received 6 months of mailed DSME consisting of weekly educational newsletters coupled with clinical feedback. The intervention consisted of 88 weekly group-based sessions that participants were encouraged to attend as frequently as they needed. Sessions were guided by participants’ self-management questions and also emphasized experiential learning, coping, goal-setting, and problem-solving. Baseline, 6-month, and 30-month assessments measured A1C, weight, body mass index (BMI), blood pressure, lipids, self-care behaviors, and QOL.

Results

This report is based on 60 African-American adults with type 2 diabetes (n = 89 recruited at baseline) who completed the study. Post 6-month DSME, participants demonstrated significant improvements for diastolic BP (p < 0.05), serum cholesterol (p < 0.001), healthy diet (p < 0.01), blood glucose monitoring (p < 0.05) and foot exams (p < 0.01). Post 24-month intervention, participants sustained the improvements achieved from the 6-month DSME and reported additional improvements for healthy diet (p < 0.05), carbohydrate spacing (p < 0.01), insulin use (p < 0.05), and quality of life (p < 0.05).

Conclusions

Findings suggest that an empowerment-based DSMS model can sustain or improve diabetes-related health gains achieved from previous short-term DSME.

Introduction

Diabetes self-management is central to effective diabetes care [1], [2], [3], [4]. Optimal diabetes self-management calls for initial diabetes self-management education (DSME) followed by ongoing diabetes self-management support (DSMS) [4]. According to the National Standards of Diabetes Education, DSME is defined as “the ongoing process of facilitating the knowledge, skill, and ability necessary for diabetes self-care,” and DSMS as “activities to assist the individual with diabetes to implement and sustain the ongoing behaviors needed to manage their illness” [4].

While compelling evidence demonstrates the positive impact of DSME interventions on diabetes-related health outcomes [5], [6], [7], [8], [9], without continued follow-up and support, these gains are not sustained over the long-term [2]. The short-lived benefits achieved from DSME programs may be attributed to characteristics of current models for DSME. First, DSME programs are typically time-limited. In fact, a meta-analysis of 31 RCTs examining the impact of DSME programs on glycemic control found 61% of studies (n = 19) described interventions that lasted 6 months or less [5]. Not surprisingly, short-term DSME programs will most likely produce short-term improvements. For instance, in a pilot study of 44 adults with type 2 diabetes in a primary care setting, Bastiaens et al. [10] examined the impact of a 5-session DSME program with one follow-up contact (at 3-months) on body mass index (BMI), glycemic control and quality of life (QOL). At 12-month follow-up, the group showed significant improvements in BMI, glycemic control, and QOL. However, at 18-month follow-up, the only improvement that persisted was for BMI suggesting the need for continued self-management support [10].

Current DSME models also tend to be structured and curriculum-driven [11], [12], [13], [14], often overlooking the heterogeneity of self-management needs and priorities across patients. These standardized interventions consist of a set number of sessions delivered in a pre-determined sequence with each session devoted to a specific self-management topic [11], [12], [13], [14]. While a standardized curriculum may be useful in the initial acquisition of core self-management concepts, this DSME model is not compatible with the complex and ever-changing challenges patients encounter over the long-term. In “real-world” settings, patients do not experience living with diabetes in a sequential order or in discrete categories.

To sustain diabetes-related health gains, effective models for long-term DSMS need to be ongoing and accessible to patients over the course of their lives in addition to being flexible to the unique and continually evolving needs of each patient. Thus, patient empowerment is an approach that is ideally suited for long-term DSMS [15], [16], [17], [18]. The principles of patient empowerment underscore (1) the proactive role of the patient in making daily self-management decisions, (2) a collaborative patient–provider relationship which assumes the provider in an advisory role to the patient who exercises final control of self-management decisions, and (3) the importance of patient-selected self-management goals in initiating and sustaining meaningful behavior change [19]. An empowerment-based DSMS model is designed to accommodate individual differences in self-management needs and to be responsive to how these needs change over time.

To test this empowerment-based DSMS model, this study specifically recruited participants who had received previous DSME (inclusion criteria). To ensure that all participants had a similar level of baseline knowledge, we provided participants with 6 months of mailed DSME designed to reinforce and/or enhance DSME received in the past. The 6-month DSME enhancement period was followed by Lifelong Management (LM), a 24-month empowerment-based DSMS intervention delivered in a group setting. While we recognize that 24 months is still considered “time-limited,” theoretically, this model could be designed to be ongoing with no defined endpoint. The objectives of this study were two-fold:

• To examine the short-term impact of a 6-month DSME enhancement period on clinical, self-care, and psychosocial outcomes.

• To examine the long-term impact of a 24-month empowerment-based DSMS intervention on sustaining the health-related gains achieved from previous DSME and a short-term, 6-month DSME enhancement period.