DM Full Guideline (2010) - VA/DoD Clinical Practice Guidelines Home

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Evaluation of the patient’s progress towards the goals
VA/DoD Clinical Practice Guideline
for the Management of Diabetes Mellitus
3. The education component should be tailored to the patient’s needs and provided by healthcare professionals
who are most knowledgeable in the topic. Regardless of setting, availability of a multidisciplinary team
approach is highly desirable and could include, but is not limited to, a dietitian, certified diabetes educator,
registered nurse, pharmacist, psychologist, exercise physiologist, physical therapist, social worker,
endocrinologist, behaviorist, ophthalmologist, optometrist, physician, podiatrist, other healthcare
professionals and paraprofessionals, or other specialized physicians based on the individual patient’s needs.
4. The use of approaches such as group visits and telehealth should be considered in providing education.
DISCUSSION
DSME is the cornerstone of care for all individuals with diabetes who want to achieve successful health-related
outcomes. The National Standards for DSME are designed to define quality diabetes self-management education
that can be implemented in diverse settings and will facilitate improvement in healthcare outcomes (Mensing et al.,
2000). These standards are reviewed and revised approximately every 5 years by key organizations and federal
agencies within the diabetes education community to reflect advances in scientific knowledge and healthcare. The
most recent revision was approved in March 2007 (Funnell et al., 2009) and identified the following as essential
curricula components for DSME:
• Describing the diabetes disease process and treatment options
• Incorporating appropriate nutritional management
• Incorporating physical activity into lifestyle
• Using medications (if applicable) to achieve glycemic targets
• Monitoring blood glucose, monitoring blood or urine ketones (when appropriate), and using the results to
improve control
• Preventing, detecting, and treating acute complications
• Preventing, detecting, and treating chronic complications
• Developing personal strategies to identify and address psychosocial issues and concerns
• Developing personal strategies to promote health and behavior change
• Promoting preconception, pregnancy, and gestational diabetes management when applicable.
While the importance of a multi-disciplinary approach has been demonstrated (Borgermans et al., 2009),
demonstration of the effectiveness of each of the components of a comprehensive program awaits further study.
However, their inclusion is recommended based on expert opinion and research. Because research on educational
interventions is complex, expensive, and time consuming, few studies have addressed the effectiveness of such
programs (Jacobson et al., 1983; Merritt et al., 1983; Miller & Goldstein, 1972; Rubin et al., 1998). Moreover, it is
difficult to assess the unique contribution of education independent of other factors (Colagiuri & Eigenmann, 2009).
Primary care staff members have limited time to provide in-depth education. It is critical, however, to provide
immediate education that will help ensure the patient’s safety until in-depth DSME can be obtained. Appendix M-1:
Core Competencies (Survival Skills) for Patients with Diabetes, details the core competency content.
Several studies have demonstrated the benefits and the limits of self-management training in type 2 diabetes. Ellis et
al. (2004) conducted a systematic review (meta-analysis and meta-regression) of articles published from 1990
through 2000. Twenty-one RCTs with 2439 participants were included. Educational techniques represented included
didactic teaching, dictated goal setting, negotiated goal setting, situational problem solving, cognitive reframing, and
“other” unique teaching methods. The significant heterogeneity notwithstanding, this meta-analysis indicated that
patient education improves glycemic control in patients with diabetes (net change in HbA 1 c was 0.32). Change from
baseline to post intervention HbA 1 c was greater for intervention group and was significant for as long as 52 weeks,
depending upon the type of analysis used. The meta-regression suggests that several attributes of patient education
seem to predict improved glycemic control including face-to-face interaction, cognitive reframing teaching methods,
and programs that integrated an exercise component.
Norris et al., (2001) reviewed a total of 72 studies and reported a positive effect on knowledge, frequency and
accuracy of self-monitoring, self-reported dietary habits, and glycemic control for studies with short follow-up.
Effects on lipids, physical activity, weight, and blood pressure were variable. With longer follow-up, interventions
that used regular reinforcement were sometimes effective in improving glycemic control. No studies demonstrated
the effectiveness of self-management training on cardiovascular morbidity or mortality. The American College of
Physicians (ACP) Journal Club review of the Norris 2001 systematic review noted that DSME is a broad term that
Module M: Self-management Page 109