Behavioral Programs for Diabetes Mellitus

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When interpreting the results, we relied primarily on the relative ranking of the nodes, and looked for trends in the findings based on program variables that appeared to determine whether the effects would offer clinical benefit. Some nodes had very few studies, small sample sizes, and/or wide credibility intervals, thus we did not make any firm conclusions for a single node (or for differences in 561 potential comparisons) but rather from looking across nodes with similar features. The results of the network meta-analysis indicated that, in comparison to the reference of usual care, 14 nodes produced MDs which fell at or above our clinically important threshold (0.4) for change in percent HbA 1c. Four of these nodes represent DSME, five represent DSME and support, and five represent lifestyle programs. Six nodes represent medium-intensity programs (11–26 contact hours), six represent high-intensity programs (≥26 contact hours), and two (one DSME and support, and one lifestyle) represent low-intensity programs (≤10 contact hours). The mean contact hours for the programs represented by these effective nodes was 26.4 (range 7-40.5 hours); the mean total program duration was 8 months (range 2-12). None of the nodes representing low-intensity DSME programs showed clinically important effects; all had greater impact on HbA 1c than basic educational controls, but lower impact than a stand-alone dietary or physical activity intervention. Three of four nodes representing DSME programs with MDs showing clinically important effect were delivered by health care professionals. Eleven of the 14 nodes representing clinically important effects were delivered in person rather than incorporating some form of technology. Behavioral programs in the nodes with the highest PB (36 and 10.7 percent, respectively) were delivered in person rather than by incorporating technology. Similar observations were noted for the other four nodes having PB ≥5 percent, of which three were delivered in person and one was delivered using some form of technology; the latter group of studies provided supportive telephone calls between in-person sessions during lifestyle interventions tailored to minorities. 143,160 All effective nodes representing some use of technology were of moderate or high intensity. An outlier having an MD of 2.80 (95% CI, 1.14 to 4.48) represented a study by Brown et al. 152 which found greater HbA 1c reduction at end of intervention in a group receiving DSME compared with one receiving DSME with the addition of a care manager. Body Mass Index We created nodes using four variables for BMI (i.e., program component, program intensity, method of communication, and method of delivery). Of the 39 plausible nodes (each differing by only one level of one variable), there were studies with data to populate 26 nodes. Averaging the baseline values in the studies, BMI at baseline was similar for programs classified as DSME (32.4 kg∙m 2 ), DSME and support (33.0 kg∙m 2 ), and lifestyle (32.9 kg∙m 2 ). The effect sizes for BMI from behavioral programs relative to usual care ranged between -1.77 kg∙m 2 and 3.29 kg∙m 2 . The node with the most beneficial MD only represented one study 157 evaluating a low-intensity lifestyle program with multiple brief contacts over 6 months. Nodes with rank orders 2 and 3 were both lifestyle programs of low and medium intensity, respectively. The node having the most studies (n=12) represented a DSME program of medium intensity (11–26 hours) which was delivered in person to groups; the results indicated this program to have 0 percent PB. One difference between the programs in this node and those with higher PB is that the higher PB all offered some individual delivery, rather than relying only on group delivery. Likewise, the majority of nodes having the highest MDs (i.e., 8 of the highest 10) offered some individual delivery. 62
Table 12. Network meta-analysis for effect moderation on HbA 1c results in T2DM: description of nodes and results Rank Order of Effect, Method of Delivery Delivery MD (%HbA Arm Description Studies & Sample Size Intensity 1c), 95% Communication Method Personnel Credibility Interval of Study Arms Usual care (reference category) Active comparator (non-DSME) Active comparator (other) NA 135-137,139- 143,145,147,151,153,155,158,160,16 2,163,171,173,175-179,183,184,188- 191,193-197,203,205- 208,210,211,213-220,222- 226,228,229,231,233-236,238- 241,246,247,249,253-255,257- 262,265 N = 6,448 31 107,146,154,164,168,169,175,18 1,182,184,192,198,201,252,265 N = 3,913 15 156,161,165,166,174,186,191,20 2,230 N = 241 NA NA NA NA 0 [NA, NA] 0.0% NA NA NA NA 0.10 [-0.23, 0.43] 0.0% NA NA NA NA -0.39 [-0.89, 0.10] 0.0% Probability of Being Best 63
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Evidence Report/Technology Assessme
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This report is based on research co
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Key Informants In designing the stu
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Peer Reviewers Prior to publication
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HbA 1c reduction were more often de
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KQ 6. Subgroups for Factors Moderat
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Figure 13. Behavioral programs for
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glycemia in reducing the incidence
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together with one or more additiona
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Figure A. Analytic framework for be
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Methods Literature Search Strategy
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With input from our Technical Exper
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participants had suboptimal baselin
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duration of diabetes ranged from 2.
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Table B. Type 1 diabetes: summary o
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T2DM: Description and Risk of Bias
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Figure D. Plot of network meta-anal
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The positive findings for behaviora
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elated to the Human Development Ind
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Table D. Potential research needs b
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References 1. Renders CM, Valk GD,
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37. Chodosh J, Morton SC, Mojica W,
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Introduction Background The high bu
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Factors other than blood glucose co
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may include interventions related t
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programs. The overarching boxes (co
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Figure 2. Analytic framework for be
Page 55 and 56: American Diabetes Association, Amer
Page 57 and 58: Table 1. Inclusion criteria for typ
Page 59 and 60: S1 in the Supplementary File). The
Page 61 and 62: clinically significant); we refer t
Page 63 and 64: Synthesis for T1DM (KQs 1-4) KQ 1:
Page 65 and 66: conducted for HbA 1c and body mass
Page 67 and 68: Applicability We followed the Metho
Page 69 and 70: Type 1 Diabetes Mellitus This secti
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Page 77 and 78: Figure 6. Behavioral programs for t
Page 79 and 80: similar results were found for yout
Page 81 and 82: HbA 1c : Comparative Effectiveness
Page 83 and 84: Two trials reported on adherence to
Page 85 and 86: Table 4. Other clinical and behavio
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Page 89 and 90: Health-Related Quality of Life: Beh
Page 91 and 92: estimated effects were imprecise an
Page 93 and 94: Table 8. Type 1 diabetes: summary o
Page 95 and 96: Summary of Key Findings and Strengt
Page 97 and 98: studies 82,94,95,105,109,112 were n
Page 99 and 100: studied a DSME program in patients
Page 101 and 102: I 2 =74%), 135,137,139,141,142,145,
Page 103 and 104: Aerobic Fitness Test which estimate
Page 105: Key Points: Body Mass Index • Lif
Page 109 and 110: Table 12. Network meta-analysis for
Page 111 and 112: Table 13. Network meta-analysis for
Page 113 and 114: Figure 20. Plot of network meta-ana
Page 115 and 116: active comparator (20 trials, 7,709
Page 117 and 118: Discussion Key Findings and Discuss
Page 119 and 120: to be tempered by the findings of n
Page 121 and 122: compared with usual care. There was
Page 123 and 124: Our finding that single-topic, non-
Page 125 and 126: In their systematic review and meta
Page 127 and 128: For studies targeting adults, the m
Page 129 and 130: environmental contextual factors—
Page 131 and 132: assessors was also rarely reported,
Page 133 and 134: Tailoring programs to ethnic minori
Page 135 and 136: 17. Centers for Disease Control and
Page 137 and 138: 53. Medical Advisory Secretariat. B
Page 139 and 140: 88. Ellis DA, Templin T, Naar-King
Page 141 and 142: 122. Nansel TR, Iannotti RJ, Simons
Page 143 and 144: 158. Cooper H, Booth K, Gill G. A t
Page 145 and 146: 191. Koo BK, Han KA, Ahn HJ, et al.
Page 147 and 148: 224. Sevick MA, Korytkowski M, Ston
Page 149 and 150: 260. Yuan C, Lai CW, Chan LW, et al
Page 151 and 152: 295. Ayling K, Brierley S, Johnson
Page 153 and 154: Appendix A. Operational Definitions
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Appendix B. Literature Search Strat
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1. MeSH descriptor: [Diabetes Melli
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35. “blood glucose” N2 monitor*
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35. (behavio?r adj2 therap*).mp. 36
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52. exp animals/ not humans.sh. 53.
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57. "Follow-Up Studies"[Mesh] 58. "
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URL provided by Michelle Crain, AAD
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WHO ICTRP Trial Registry: WHO ICTRP
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Appendix D. Studies Excluded After
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Health. 2006;6:134. PMID: 16709243.
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November/December;24(9):450-6. PMID
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89. Dinneen SF, O'hara MC, Byrne M,
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119. Fitzpatrick SL, Jeffery R, Joh
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Aug;19(8):835-42. PMID: 8842601. Ex
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adherence and metabolic control. Di
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May;36(5):1297-303. PMID: 23223405.
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244. Korytkowski MT, Koerbel GL, Ko
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275. Maljanian R, Grey N, Staff I,
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306. Naccashian Z. The impact of di
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led structured program on blood glu
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Engineering. 2014;75(1-B E). PMID:
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395. Skoro-Kondza L, Tai SS, Gadelr
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426. Torbjornsen A, Jenum AK, Smast
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Americans with type 2 diabetes. J A
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patients. Diabetes Res Clin Pract.
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Table E1. Risk of bias for studies
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Weinger, 2011 L M NA M NA L NA L L
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Cramer, 2007 M M H M H L H H L M H
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Ridgeway, 1999 M M H M H L H H M L
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Appendix F. Description of Studies
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Author, Year & Country Comparison &
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Table F3. Description of studies an
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Appendix H. Strength of Evidence Ta
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Outcome # Trials (# Subjects); Tool
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Table H3. Behavioral programs compa
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16. Mayer-Davis EJ, Seid M, Crandel
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Table I1. Effectiveness of behavior
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Category Health Outcomes Outcomes A
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Table I2. Effectiveness of behavior
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Category Outcomes Timepoint Health
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Outcome Change in Body Composition
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Outcome Change in Physical Activity
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References for Appendix I 1. Adachi
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32. Rock CL, Flatt SW, Pakiz B, et
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follow-up study. Diabetes Res Clin
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98. Johnson ST, Bell GJ, Mccargar L
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Appendix J. Network Meta-Analysis R
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5 11-26h In person Group only NA -0
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9 11-26h In person Group only NA -0
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Behavioral Programs for Diabetes Mellitus

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