Behavioral Programs for Diabetes Mellitus

Aerobic Fitness Test which estimates relative maximal oxygen consumption, Plotnikoff et al., 209
found improved fitness levels from supplementing DSME and support with a physical activity
intervention (88 subjects; SMD, 0.62; 95% CI, 0.19 to 1.05).
Measurement of medication adherence was undertaken using various tools including the
SDSCA, 138,171 the Hill-Bone Compliance Scale, 168,175 and the Morisky Adherence Scale. 253 A
significant effect for medication adherence—in favor of the usual care group—was maintained
from end of intervention to 12-month followup in one trial (191 subjects; SMD, -0.50; 95% CI -
0.79 to -0.21); 238 other studies comparing behavioral programs to usual care found no difference
at end of intervention or 6-month followup. Comparisons with active controls also found no
difference at any followup timepoint.
Health Outcomes: Quality of Life, Micro- and Macrovascular
Complications, All-Cause Mortality
Quality of Life
Outcomes for quality of life were categorized into five subcategories based on their focus
(i.e., generic vs. diabetes-specific) and the similarity between studies in measurement scales.
Groups of studies reported outcome data based on the SF-36 Health Survey (physical and mental
component scores), and the Problem Areas in Diabetes (PAID) scale (0–100; lower score
favorable) measuring diabetes distress. Accordingly, three of our subcategories represent these
tools (i.e., Quality of Life–SF36 Physical, Quality of Life–SF36 Mental, and Diabetes Distress),
for which we present results as MD. Other subcategories were created to combine other generic
(Quality of Life–Other; e.g., WHO Quality of Life Brief, W-BQ12, EuroQol 5D) and diabetesspecific
(Diabetes-specific Quality of Life; e.g., Diabetes Quality of Life, Diabetes Distress
Scale, Appraisal of Diabetes, Diabetes Symptom Checklist) quality of life questionnaires; these
results are presented as SMDs.
There was no difference in Quality of Life-SF36 (Physical) or Quality of Life-SF36 (Mental)
when measured at end of intervention for comparisons with usual care, 155,214,222,239 or up to 6-
months followup for comparisons with active controls. 169,181,252 There was no difference found
for Quality of Life–Other in comparisons (n=7) with usual care up to 6-month
followup, 195,196,206,226,249,253 or in comparisons (n=4) with active controls up to 12-months
followup. 154,192 Results favored behavioral programs compared with usual care for Diabetes
Distress (8 comparisons, 1,384 subjects) at end of intervention (MD, -1.82; 95% CI, -3.43 to -
0.21), 142,147,211,218,225,226,228,233 but not at longer followup. 146,211,234 The result at end of intervention
is not clinically important based on our prespecified threshold of a 0.5 SD using the mean SD of
the included studies. One study (167 subjects) evaluating this outcome in a comparison to active
controls found no difference at 6-month followup. 181 There was no difference in Diabetesspecific
Quality of Life at any followup timepoint to 12-month followup when comparing
behavioral programs to usual care, 146,163,175,177,189,215,253 or at end of intervention for programs
compared with active controls. 154,168,175
One trial assessed the effects on quality of life when the support phase of a DSME and
support program was delivered by peers, clinical practice staff, or health care professionals
(diabetes educators). Siminerio et al. 227 found that Diabetes Distress worsened for the group
receiving support from peers when compared to the group receiving support from the educators
(74 subjects; MD, 24.70; 95% CI, 15.02 to 34.38). This effect is considered clinically important.
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