Behavioral Programs for Diabetes Mellitus

There was no difference in Diabetes Distress when delivery of nonprofessional clinic staff was
compared to that by health care professionals.
Micro- and Macrovascular Complications
Authors of the LookAHEAD trial (5,145 subjects) studied outcomes of myocardial
infarctions, stroke, heart failure, diabetic nephropathy, diabetic retinopathy, and diabetic
neuropathy. Diabetic retinopathy was reduced by 14% (hazard ratio, 0.86; 95% CI, 0.75 to 0.98)
in participants receiving their intensive lifestyle program compared with an active control
(didactic education and support) over a median of 8 years. 278 A secondary analysis of
nephropathy using a post hoc outcome of very-high-risk chronic kidney disease—a combination
of the a priori outcomes albuminuria and estimated glomerular filtration rate, found a lower
incidence of nephropathy for the intensive lifestyle program at the 8 year end-of-intervention
timepoint (risk difference 0.27 cases per 100 person-years; hazard ratio, 0.69; 95% CI, 0.55 to
0.87). 293 Results for the other outcomes in this trial did not reach statistical significance—
myocardial infarction (RR, 0.86; 95% CI, 0.70 to 1.05), stroke (RR, 1.06; 95% CI, 0.79 to 1.44),
heart failure (RR, 0.83; 95% CI, 0.64 to 1.08), and diabetic neuropathy (RR, 1.13; 95% CI, 0.92
to 1.38).
All-Cause Mortality
One study examined all-cause mortality as an pre-specified outcome; 252 there were enough
data in 27 reports to calculate a difference in all-cause mortality for the associated comparisons.
There was no difference in all-cause mortality between participants receiving behavioral
programs and usual care (25 comparisons; 4,659 subjects; RR, 1.28; 95% CI, 0.84 to 1.94);
mortality between behavioral programs and active control groups (5 comparisons, 6,050
subjects) was 14 percent lower for those receiving behavioral programs (RR, 0.86; 95% CI, 0.77
to 0.96).
KQ 5. Potential Moderation of Effectiveness for T2DM:
Components, Intensity, Delivery Personnel, Method of
Communication, Degree of Tailoring, and Level of Community
Engagement
Key Points: HbA 1c
• In a network meta-analysis with usual care serving as the reference, behavioral programs
showing effect sizes above our threshold for clinical importance represented all three
major program component categories of DSME, DSME and support, and lifestyle.
• The effect sizes of all minimally intensive DSME programs (≤10 contact hours) were
lower than our threshold for clinical importance, but were all higher than that for
educational interventions not meeting our criteria for a behavioral program (e.g., didactic
education programs).
• Programs having the higher effect sizes and probabilities of being best (≥5 percent) were
more often delivered in person rather than including technology.
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