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Systematic Review

Navigating Diabetes: Enhancing Self-Management through Education among Diabetic People at the Early Stages of the Disease—A Systematic Review

1
Faculty of Medicine, Transylvania University, 500019 Brasov, Romania
2
Faculty of Health, University “Ismail Qemali” Vlore, 9401 Vlore, Albania
*
Author to whom correspondence should be addressed.
Int. J. Environ. Res. Public Health 2024, 21(5), 522; https://doi.org/10.3390/ijerph21050522
Submission received: 27 February 2024 / Revised: 15 April 2024 / Accepted: 17 April 2024 / Published: 23 April 2024
(This article belongs to the Special Issue 2nd Edition of Epidemiology and Global Health)

Abstract

:
Diabetes self-management education helps to improve health outcomes and qualities of life for diabetic patients. This systematic review examines the effectiveness of several types of diabetes self-management education for patients at the early stages of type 2 diabetes mellitus (T2DM). A review of studies that have researched the use and impacts of health education on diabetic patients with T2DM was conducted using the electronic databases PubMed, Elsevier, JSTORE, Walters Kluwer, and the Cochrane Library between January 2017 and November 2022. We found 789 studies, and after selecting the PRISMA flowchart, we selected 19 studies, including those of 2512 adult patients diagnosed with T2DM. Biomedical results presented the pooled effect of a glycated hemoglobin (HbA1c) of −0.64% and a fasting blood glucose (FBG) of −0.32. Emotional and social results and behavioral effects were evaluated in 10 and nine studies, respectively. The education and support of diabetic patients at the early stages of the disease impact various aspects, including the biomedical profile, lifestyle, emotional and social well-being, and anthropometric parameters. Among the factors that have been identified to enhance the effectiveness of educational interventions are the following: conducting individualized sessions (or at least in small groups of patients), extending the duration of interventions by at least 12 months, adopting a combined approach that includes both face-to-face and online components, and ensuring the involvement of a multidisciplinary healthcare team.

1. Introduction

Diabetes mellitus is mentioned as being among the major health problems in the world in terms of its widespread occurrence, the impact it has on socioeconomic development, and the severe influence it has on the quality of life of patients [1]. According to the International Diabetes Federation (IDF), in 2019, the number of diabetic adults aged 20–79 years was approximately 463 million, a number predicted to increase to 700 million individuals worldwide by 2045, with 90% of the cases being diabetes mellitus type 2 (T2DM) [2,3,4]. The IDF reported that although the incidence of T2DM is decreasing or stable in developed countries [2], a rapid increase in T2DM has been observed in developing countries [5]. An increasing number of effective treatments should be sought for diabetes, and the goal of the United Nations (UN) is to reduce premature deaths from non-communicable diseases, including diabetes [6]. Glucose control is the cornerstone of T2DM treatment, but crucial aspects of treatment are also the implementation of programs that include lifestyle modification, the careful use of oral anti-hyperglycemic medications, and the initiation of insulin when necessary [7,8,9,10]. Patients with type 2 diabetes should receive professional guidance to improve their self-care behaviors, leading to improved glucose control [11]. The four best times to provide this guidance are at the time of the diagnosis, annually or when objectives are not met, upon the emergence of factors influencing complications, and during significant life care transitions [12].
The utilization of diabetes self-management education contributes to enhanced health outcomes, the quality of care, and the overall quality of life for diabetic patients, ultimately leading to reduced expenses and bringing about positive changes in lifestyle and self-care management [12,13,14]. Implementing lifestyle interventions in newly diagnosed diabetic patients with T2DM leads to improvements in cardiometabolic parameters, offering long-term health and well-being benefits [15]. According to the American Diabetes Association (ADA), individuals diagnosed with diabetes should receive comprehensive information and guidance at the time of the diagnosis, with ongoing education and support thereafter [12]. The moment of the diagnosis serves as a critical juncture when patients actively seek information about their new health situation and must adapt to new health behaviors [16]. The support required to implement and sustain coping skills and behaviors needs to be on an ongoing basis, helped by social groups, and provided by healthcare professionals [17,18].
A previous systematic review has examined the overall impact of diabetes self-management among newly diagnosed patients with type 2 diabetes mellitus (T2DM). However, it is essential to conduct a critical appraisal to discern various educational approaches and their effects on patients with T2DM in the early stages of the disease [19].
Our systematic review aims to address this gap by evaluating the effectiveness of several types of diabetes self-management education specifically tailored to this population. We aim to identify key elements that can enhance educational interventions. By synthesizing the latest evidence, our study seeks to provide crucial insights that can assist healthcare professionals and policymakers in improving diabetes education programs for individuals at the early stages of the disease. Ultimately, our goal is to enhance health outcomes and quality of life.

2. Materials and Methods

2.1. Study Design

This is a systematic review study.

2.2. Search Methods

A literature search was conducted using the electronic databases of PubMed, Scopus, Elsevier, JSTORE, Walter Kluwer, and the Cochrane Library. This search was conducted for four months from August to November 2022, using the elements of the PICO model (P—population/patients; I—intervention; C—comparator/control; and O—outcomes). The search included the use of the following keywords:
Population-related terms: “diabetes mellitus type 2”, “diabetes mellitus II”, “type 2 diabetic patients”, “patients with T2DM”, “patients diagnosed within the last 0–5 years”;
Intervention-related terms: “educational intervention”, “diabetes self-management education program evaluation”, “diabetes self-management program effectiveness”, “diabetes self-care education”, and “lifestyle intervention”;
Comparator/control-related terms: “assessing changes in the intervention group (IG) and control group (CG)” and “evaluating changes in IG (intervention group) and CG (control group)”;
Outcome-related terms: “assessment”, “evaluation”, “examination”, “measurement”.
This study was conducted using the PRISMA guidelines for reporting systematic reviews [20].
We conducted a thorough electronic search, carefully applying filters to ensure the inclusion of articles that genuinely cater to the well-being of adults with T2DM. The focus of these articles encompasses various aspects, including educational interventions, such as multi-intervention programs, nutritional literacy or health literacy, and face-to-face or online intervention. Furthermore, we sought studies that not only assessed these educational interventions but also provided insights into measured outcomes, spanning biomedical, behavioral, emotional, and social improvements. This approach reflects our commitment to understand and address the holistic needs of individuals with T2DM.
We limited the inclusion criteria based on the participants’ ages (participants had to be older than 18 years), articles published in English between 2017 and 2022, and availability of full-text publications in peer-reviewed journals. This selection aimed to ensure a thoughtful and focused approach, considering the accessibility and language proficiency of the content while also respecting the ethical considerations associated with participants’ ages. The inclusion and exclusion criteria are presented in Table 1.
We manually searched the reference lists of pertinent publications to identify relevant articles according to our inclusion and exclusion criteria.
Following the removal of duplicate results, two researchers (E.K. and A.S.) individually reviewed the titles and abstracts to identify the most suitable articles. Collaboratively, they referred to the screening process and addressed any discrepancies and then proceeded to independently read the abstracts and select the most relevant ones.
Throughout this screening phase, any ambiguities were resolved through group discussion among the researchers, ensuring alignment with the eligibility criteria established for including or excluding articles.
Figure 1 displays the PRISMA flow diagram, depicting the systematic review process for searching for and selecting studies for inclusion.

2.3. Data Extraction

All the data were extracted by two researchers (E.K. and A.S.). The data included the details of the publications (title, authors, journal, year of publication, and country of origin), methods (the aim of the study, design, and duration of the intervention), participants (number of patients in the intervention group and in the control group, age, and sex), interventions (type of intervention, settings, descriptions of the intervention and the standard care, the duration of the intervention, timing, delivery, method of follow-up, providers), and outcomes (clinical parameters and psychological and behavioral outcomes).

2.4. Synthesis of the Results

A summary of the information from the studies included in this analysis was carried out according to the place of the study, population, duration of education, and details about the educational interventions, such as the method of delivery, the people who carried out the educational interventions, the theoretical materials offered, the frequency and duration of the educational sessions, and a summary of the outcomes of these interventions among diabetic patients. The studies included in this review had different interventions and durations. For this, we have made a narrative summary, presenting the clinical results (HbA1, FBG, postprandial blood glucose—PBG, anthropometric parameters, and blood pressure) using means ± standard deviation.
Risk of Bias: Eleven (57.89%) of the included studies had poor quality. This assessment was carried out following the revised Cochrane risk-of-bias tool [21]. Most of the studies were conducted without blinding the participants and personnel because of the nature of educational interventions (Table 2).

3. Results

Nineteen studies met the inclusion criteria established in advance for this review study.

3.1. Overview of the Studies

The evaluated participants’ characteristics and interventions are presented in Table 3 and Table 4, respectively. These studies were conducted in different countries, such as China [22,23,24,25,26,27], India [28,29,30,31], and the Netherlands [32,33] and one study each in Spain [34], Mexico [35] Italy [36], USA [37], the United Kingdom [38], Germany [39], and Lebanon [40].
This study encompassed 2512 newly diagnosed diabetic patients with a sample size ranging from 17 to 358 patients. The mean age range of the participants was from 25 to 74 years, with 75% of the studies involving a population of over 50 years old. The mean duration of the diabetes ranged from 3 months to 5 years (Table 3).
While analyzing the studies, various interventions were identified, each characterized by distinct features, durations, and assessment methods. The purpose of the included studies was to evaluate the impacts of various educational interventions within a period from 1.4 to 30 months. We included 19 studies, of which 16 used methods for comparing interventions with a control group, while three of them did not use any control group. Among the 19 studies, nine were randomized controlled trials (RCTs) [22,26,28,29,31,32,33,38], one was an experimental study [23], four were intervention studies [24,36,37,39], two were program evaluation studies [35,40], two were prospective studies [27,34], and one was a non-randomized controlled study [25].
The interventions assessed in these studies include a multi-intervention program (73.68%) [22,23,24,25,26,27,28,29,32,33,34,35,37,38], physical activity intervention (10.5%) [30,31], nutritional intervention (10.5%) [39,40], and a single study that evaluated psychological interventions [36]. Educational interventions included groups of participants in 47.36% of the studies, individual interventions in 47.36%, and a combination of the two in only one study (Table 4).
In terms of intervention methods, 26.3% of the studies utilized telephone applications, and one study used text messages directed to the participants. Face-to-face interventions were implemented in most studies (68.4%). Educational interventions for newly diagnosed diabetic patients with T2DM were conducted by different healthcare professionals (physicians, nurses, dieticians, pharmacists, and diabetes educators). Twenty-one percent of the studies [22,25,34,35] included educational interventions delivered by a team of more than one member, including a nurse. Meanwhile, nurses delivered educational interventions in 26.3% of the studies [23,24,26] (Table 4).
The evaluation included five programs that were evaluated as the AADE 7 Self-Care Behaviors program [22] PAET-Debut DM2 program [34] Omaha System-based integrated nursing management model [25], CAIPadi model [35], and nurse-led integrative-medicine-based structured education program–multi intervention program [26] (Table 4).
Biomedical outcomes were reported in 16 studies; psychosocial outcomes, in 12 studies; behavioral outcomes, in 10 studies. Six studies included elements in all the outcome categories [26,28,32,34,35,37].

3.2. Impacts of Educational Interventions on Biomedical Results

3.2.1. The Impacts of Educational Interventions on HbA1c Levels (Table 5)

The effects of educational interventions on HbA1c levels were evaluated in 12 studies (60%) [22,23,26,27,28,30,32,34,35,36,37,40]. A comparison of the results between the intervention and control groups is presented in nine studies, where we evaluated the absolute effect. Improvement in HbA1c values was significant in the intervention group in 10 (83.3% of the) studies and in the control group in three studies. Six studies showed significant differences in the effects on HbA1c values between the two study groups (IG and CG). Notably, in a study conducted in the Netherlands, there was no evident change in HbA1c levels after the intervention; in fact, there was a very slight increase (0.1%) in HBa1c values [32]. The differences in the intervention and control groups were 1.18% and 0.277%, respectively. The absolute effect of the educational intervention on HbA1c was −0.64.
Table 5. The effects of educational interventions on HbA1c, FBG, and PGB.
Table 5. The effects of educational interventions on HbA1c, FBG, and PGB.
Studies’ General
Information
Pre-InterventionPost-InterventionChangeAbsolute Effect
IGCGIGCGIGCG
Effect of educational intervention on HbA1c
[22] 8.44 ± 2.288.95 ± 2.346.92 ± 1.27 *7.82 ± 12.98 *#−1.52 $−1.13−0.39
[23]7.20 (6.40, 9.10)7.90 (6.80, 10.30)6.20 (5.80, 6.60) *6.70 (6.40, 7.30) *−1 **−1.2+0.2
[26]6.66 ± 1.096.86 ± 1.345.85 ± 0.37 *6.97 ± 1.18−0.81 **+0.11−0.70
[27]9.82 ± 2.479.05 ± 2.326.76 ± 0.50 *7.25 ± 0.98 *−3.03 **−1.8−1.23
[28]9.5 ± 2.19.5 ± 2.07.4 ± 1.5 *9.5 ± 2.1−2.1 **0−2.1
[30]5.95 ± 0.475.95 ± 0.475.14 ± 0.36 *5.85 ± 0.37 *−0.81 **−0.1−0.71
[32]6.5 (6.2–7.0)6.6 (6.3–7.1)6.6 (6.3–7.1)6.7 (6.3–7.1)+0.1 *#+0.10
[34]7.2 (6.6–9.2)6.7 (6.4–7.5)6.2 (5.8–6.7) *6.4 (5.8–6.8)−1 $−0.3−0.7
[35]7.77 ± 2.22No control group7.16 ± 1.62No control group−0.61 *#−0.61
[36]7.85 ± 1.197.32 ± 1.236.66 ± 0.84 *6.95 ± 1.31−1.19 **−0.37−0.82
[37]8.0 (1.6)-6.2 (1.1) *-−1.8 *#−1.6 ± 0.5
[40] 9.1 ± 2.3-7.4 ± 1.3 *-−1.7 ± 2.5 *−1.7 ± 1
Mean ± SD−1.18 ± 0.21−0.277 ± 0.13−0.64 ± 0.08
Effect of educational intervention on FBG
[23]8.008.006.78 *7.70 *−1.22 $−0.3−0.92
[24]8.43 ± 1.258.51 ± 1.177.03 ± 1.01 *7.68 ± 1.12−1.4 **−0.83−0.57
[25]9.964 ± 2.70710.490 ± 2.7817.792 ± 0.925 *9.042 ± 1.561−2.172 **−1.448−0.72
[28]10.9 ± 3.611.5 ± 3.97.5 ± 2.3 *8.4 ± 2.8 *−3.4 **−3.1−0.3
[32]7.47.37.97.5+0.5 *#+0.2 *#+0.3
[38]5.75 ± 1.016.55 ± 1.765.66 ± 1.206.73 ± 2.66−0.09 *#+0.180.27
Mean ± SD−1.656 ± 2.11−2.839 ± 2.31−0.32 ± 1.16
Effect of educational intervention on PBG
[23]13.2912.677.90 *10.58 *−5.39 $−2.09−3.3
[24]11.21 ± 1.6511.34 ± 1.739.52 ± 1.05 *10.43 ± 1.24−1.69 **−0.91−0.78
[25]14.612 ± 4.68514.692 ± 4.4009.980 ± 1.446 *12.275 ± 2.120−4.632 **−2.417−2.215
[28]17.1 ± 4.617.2 ± 4.912.5 ± 3.3 *12.7 ± 3.6 *−4.6 *#−4.5−0.1
Mean ± SD−4.078 ± 2.35−2.479 ± 2.41−1.598 ± 0.23
Notes: * Significant difference between pre- and post-intervention in the same group. *# Non-significant difference between pre- and post-intervention in the same group. ** Significantly different effects between IG and CG. $ No statistical comparison or no data about significance. Studies without control group are not included in the calculation of absolute effects on HbA1c, FBG, and PBG levels.
Educational interventions demonstrate visible effects in reducing HbA1c levels, particularly in cases with fewer patients attending educational sessions and interventions lasting 12 months [34,36,40]. Additionally, a combination of face-to-face and online educational methods [22,28,40] has proven to be effective.
Concerning the personnel involved in the educational interventions, cases with only one type of professional yielded more satisfactory results (The absolute effect on the level of HbA1c was −0.87 ± 0.67). When interventions were conducted by nurses, the absolute effect was −0.50 ± 0.15. Conversely, when interventions were carried out by a team, the absolute effect was −0.56 ± 0.78.
Individual interventions emerged as the most efficient in 55% of the studies assessing HbA1c levels. These individual interventions demonstrated a notable improvement in the HbA1 level by 1.12% [22,27,28,30,35,40], while group-based education resulted in a less pronounced effect of 0.50%.

3.2.2. The impacts of Educational Interventions on FBG and PBG Values

Seven studies (35%) assessed the impacts of educational interventions on FBG levels [23,24,25,28,32,38]. In one study, very slight increases in FBG values were observed in both the intervention and control groups [32]. Significant changes in FBG values within the intervention group were reported in four studies [23,24,25,28], whereas this difference was significant in the control group in one of these studies [28]. Notably, significantly different effects between intervention and control groups were observed in three studies [24,25,28].
Four studies (20%) investigated the effects of educational interventions on PBG levels [23,24,25,28]. All these studies demonstrated a significant difference between pre- and post-intervention levels in the intervention group, with significant differences observed between the intervention and control groups in only two studies [24,25]. Collectively, the mean change (improvement) in FBG levels after the intervention was 0.32% and in PBG levels was 1.59%. The absolute effect of the educational intervention on FBG was −0.32 ± 1.16 and on PBG was −1.598 ± 0.23 (Table 5).

3.2.3. The Impacts of Educational Interventions on Lipid Profiles

Five studies examined the impacts of educational interventions on lipid profiles (total cholesterol (T-Chol), low-density lipoprotein cholesterol (LDL-C), high-density lipoprotein cholesterol (HDLC), and triglycerides (TGs)) [23,32,34,39,40]. These studies used different units of measurement to assess lipid levels, making it impossible to statistically evaluate the mean ± SD.
Significant differences in T-Chol between pre- and post-intervention in the intervention group were observed in two studies [34,39] and for LDL-C in two studies [32,39]. Changes in HDL-C and triglyceride levels were not statistically significant.

3.2.4. The impacts of Educational Interventions on Anthropometric Parameters

The impacts of educational interventions on the bodyweights of diabetic patients with T2DM were assessed in five studies [22,31,32,38,39] and on body mass indices (BMIs) in 11 studies [22,23,27,31,32,34,35,37,38,39,40].
Four studies revealed a decrease in bodyweight, but only one study reported a significant change in body weight [22]. The absolute effect of educational interventions, among studies with two groups (intervention and control groups), on weight was 2.94%.
Of the 11 studies evaluating the effects of educational interventions on the BMIs of diabetic patients, five studies did not compare the results with a control group [34,35,37,39,40]. BMI decreased in both groups without a significant intervention effect, except for one study in which the effect size was insignificant or small [38]. The absolute effect of educational interventions among studies with two groups (intervention group and control group) on BMI was 0.39% (Table 6).

3.2.5. The Impacts of Educational Interventions on Blood Pressures

Eight studies [22,23,31,32,34,35,38,40] evaluated the impacts of educational interventions on arterial pressures among newly diagnosed patients with T2DM, and six compared arterial pressure values between the two study groups (intervention and control groups) [22,23,31,32,38]. Only one study reported a statistically significant difference in systolic blood pressure (SBP) and diastolic blood pressure (DBP) [40].
The mean changes in the SBP and DBP of the intervention group were −2.3 ± 6.5 mmHg and −0.87 ± 4.5 mmHg, respectively. The absolute effect of educational interventions on the SBP was −0.34 ± 7.9 mmHg and on the DBP was −0.36 ± 5.5 mmHg (Table 7).

3.3. The impacts of Educational Interventions on Emotional and Social Results

To assess the emotional and social impacts of educational interventions among newly diagnosed diabetics, we collected information on improvements in knowledge, illness perception, anxiety and depression, diabetes distress, empowerment, diabetes self-efficacy, diabetes self-management, and quality of life.
Five studies evaluated the impacts of educational interventions on the knowledge of patients with diabetes, using different assessment tools [22,25,29]. All five studies reported improvements in knowledge at the end of the interventions, with a noticeable significant difference in knowledge between the intervention group (IG) and the control group (CG) stated in three particular studies [22,25,29].
Among these studies, only one assessed illness perception using the “Illness Perceptions Questionnaire” (IPQ-R). Immediately after the education program, the intervention group showed a significantly higher belief in having diabetes than did the control group [33].
Depression and anxiety were evaluated in three studies; anxiety, in two studies [23,35]; depression, in three studies [23,35,37]. All these studies revealed that educational interventions positively reduced anxiety, depression, and other symptoms in patients with T2DM.
Two studies showed significant improvements in diabetes distress as a result of educational interventions [35,37], whereas another study did not show any improvement in this aspect [33].
Diabetic patient empowerment was assessed in three studies using different assessment methods, such as the Diabetes Empowerment Scale-Short Form [DESSF] [35] and the Diabetes Empowerment Scale (DES) [33,37]. All three of these studies reported significant improvements in the intervention groups.
Quality of life was evaluated in six studies [24,25,28,32,34,35], with two of them lacking a data comparison between the intervention and control groups. The instruments used to evaluate interventions in the quality of life were SF-36, EuroQol-5d, Diabetes-Specific Quality-of-Life scale (DSQL), Diabetes Quality-of-Life Measure (DQoL), and Diabetes-Dependent Quality-of-Life (ADDQoL). In four studies [24,25,34,35], significant improvements were observed in the quality of life of patients with T2DM, whereas in the other two studies, patients presented negative effects that did not change over time [28,32].

3.4. The Impacts of Educational Interventions on Behavioral Results

The studies included in this analysis employed diverse assessment methods.
Three studies assessed the changes in tobacco use. In one study, there were moderate but significant reductions in smoking and alcohol consumption [34]. In two other studies, a moderate reduction in tobacco use was observed, although the difference was not statistically significant [26,33].
Eight studies reported physical activity, assessed in six studies through standardized questionnaires [26,28,31,32,33,35], the use of a mobile application [38], or through subjective measures [40]. Hernandez et al., reported an improvement in physical activity [35], while in other studies, these changes were not significant between the intervention and control groups.
Changes in dietary behavior were reported in five studies. In four of them, the impact of educational interventions was evaluated through the use of validated methods [26,32,33,34] and the self-reporting of patients regarding the use of high- and low-carbohydrate foods [37]. Initially, changes in two of these studies were not significant [32,34]. Participants in the intervention group exhibited significantly better self-management behaviors related to the intakes of fruits and vegetables at both the immediate post-intervention and 12th-week follow-ups [32]. Meanwhile, in another study, although immediately after the program was used [33], the results showed an increase in the consumption of fruits and vegetables, these effects were no longer present six months after the interventions. Oser et al. reported satisfactory results in terms of reducing the use of high-carbohydrate foods, even three months after the interventions [37].
The self-care activity has been evaluated in five studies, all of which presented a positive impact of educational interventions, thereby increasing patients’ awareness [26,32,33,34,35].

4. Discussion

The results of this study reveal the effectiveness of educational interventions implemented for newly diagnosed patients with T2DM to promote the importance of healthcare education since the beginning of the diagnosis.
In this systematic review, we uncovered compelling evidence supporting the effectiveness of diabetes self-management education during the early stages of type 2 diabetes mellitus (T2DM). Our analysis delineated the variances among several types of educational approaches: individual versus team training, personalized versus group counseling, short-term versus ongoing support, and online versus face-to-face interaction. We observed how these factors contributed to enhanced glucose control and improved health outcomes among this population.
Early educational interventions possess the potential to empower patients to embrace healthy behaviors and self-care practices, thereby mitigating the risk of complications associated with T2DM.
Based on the overall analysis of the impacts of various educational interventions for diabetic patients regarding their clinical or other parameters, significant results were found.
According to the American Diabetes Association (ADA), educational interventions can cause a reduction by 1% in HbA1c levels among diabetic patients [17].
Our results showed that there was a significant improvement in HbA1c levels in the intervention group in most of the included studies, with an absolute effect size of −0.64%, a lower result compared to another study conducted in 2020 [41] but slightly higher compared to two other reviews, one in 2020, with an absolute effect of 0.21% [32,33,34,35]. The factors, mentioned in these studies, that improve the control of glycemia are the implementation periods of educational interventions; use of various techniques, such as the combination of face-to-face with online methods; use of different intervention strategies; and use of means to help to achieve expected results, such as online applications or providing supportive materials for patients to improve their knowledge of diabetes and glycemic control.
Regarding clinical parameters, four studies assessed changes in an FBG of 0.32 and changes in a PBG of 1.59. However, the results for lipid profile changes were inconclusive because of variations in the measurement units.
Anthropometric parameters, specifically the BMI, showed a difference of 0.87% in 11 studies and a 0.39% difference in the intervention group. The changes in the arterial pressure were not statistically significant.
Nine studies evaluated changes in HbA1c compared to a control group, revealing that better changes were achieved when the interventions lasted for more than one year [34,36], were conducted face-to-face, and were implemented by one healthcare professional. When we compared the absolute effect on HbA1c levels for different approaches of educational interventions, the model of face-to-face combined with online interventions, such as a text message or a mobile application, offered better results in glycemic control.
Support from healthcare teams is crucial for diabetes management [42]. The most interesting result in our review was that better results were achieved when the intervention was conducted by one healthcare professional compared with the interventions offered by a team of healthcare professionals. This result is similar to that in another review that concluded that the healthcare education offered by pharmacists improved the clinical results of newly diagnosed diabetic patients [43]. The factors that may have impacted the improvement could have been the consistent approach, expertise of the professionals, clear and easy communication, and instructions only with one individual, and personalized attention.
Our systematic review presented the need to implement educational interventions individually, as they improved the control of the hyperglycemia. Additionally, Odgers-Jewelle et al. suggested that group-based diabetes self-management education is related to improved clinical and psychosocial results in people with type 2 diabetes [44]. However other studies have concluded that individual and group interventions show positive clinical results [45].
Our study found that there were more significant improvements in HbA1c levels in studies in which educational interventions were provided by one healthcare specialist. This result is consistent with a study that showed that individual-based education can achieve greater glycemic improvement than team-based education [41].
Educational interventions demonstrated modest effects on the BMIs and bodyweights of diabetic patients, exhibiting noticeable reductions in both parameters, especially in studies associated with individual interventions. These parameters, especially the body mass index (BMI), showed a difference of 0.87% in 11 studies and a 0.39% difference in the intervention group.
The duration of the education is important to obtain better results in glycemic control in diabetes management. According to the ADA, from 6 to 12 months is the best time duration for educational sessions among diabetes patients [46]. Our study found that we had significant improvement in HbA1c levels in those cases where patients’ education was followed for 12 months.
Regarding emotional and social findings, six studies assessed knowledge levels, showing significant improvements in the intervention groups. Similar results were reported in a previous study [41]. Furthermore, 50% of the studies focused on emotional and social aspects, with noticeable changes in anxiety, illness perception, empowerment, depression, diabetes distress, diabetes self-efficacy, and quality of life.
Patients recently diagnosed with T2DM have a better tendency to engage in positive behavioral changes [44]. In our systematic review, behavioral results indicated positive changes, including lifestyle changes, such as reductions in smoking and alcohol use. Physical activity was found in eight studies, while adherence to healthy diets was evaluated in five studies. Significant changes were reported immediately after the intervention, but these effects were not sustained over time. A result similar to ours was presented by Tanaka et al. [15].
This systematic review provides valuable information regarding the effectiveness of educational interventions among diagnosed diabetes patients at the early stages of the disease, treating various aspects, contents of education, and factors that impact the achievement of better results. This study has both strengths and weaknesses. This study followed the Preferred Reporting Items for Systematic Reviews guidelines to collect and evaluate the collected studies, but we only used some electronic databases. A meta-analysis could not be performed because of the heterogenicity of the data and methods that were used. Populations included in the study were from different parts of the world and countries with significant changes in their economic development, which could be a reason for the heterogeneous results.

5. Conclusions

In conclusion, our research highlights the profound influence that educational interventions by healthcare professionals can have on the management of type 2 diabetes mellitus (T2DM) in the early stages of diabetes. These interventions impact various aspects, including biomedical profiles, lifestyles, emotional and social well-beings, as well as anthropometric parameters.
Among the factors that have been identified to enhance the effectiveness of educational interventions are the following: conducting individualized sessions (or at least in small groups of patients), extending the duration of interventions to at least 12 months, adopting a combined approach that includes both face-to-face and online components, and ensuring the involvement of a multidisciplinary healthcare team.
Researchers should assess the sustainability of educational interventions, thus evaluating the long-term effects and preservation of knowledge in the long run, behavioral changes, and improvement in clinical results longer than the period of the healthcare education.

Author Contributions

Conceptualization, E.K. and L.R.; data curation, E.K.; formal analysis, E.K.; investigation, E.K. and A.S.; methodology, E.K., A.S., R.Ç. and V.P.; project administration, E.K., A.S. and L.R.; resources, E.K. and A.S.; supervision, L.R.; validation, A.S. and L.R.; visualization, E.K. and S.Q.; writing—original draft preparation, E.K. and V.P.; writing—review and editing, R.Ç., V.P. and S.Q. All authors have read and agreed to the published version of the manuscript.

Funding

This research received no external funding.

Data Availability Statement

Data sharing does not apply to this article as no datasets were generated or analysed during the current study.

Conflicts of Interest

The authors declare no conflicts of interest.

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Figure 1. The PRISMA flowchart of included and excluded studies.
Figure 1. The PRISMA flowchart of included and excluded studies.
Ijerph 21 00522 g001
Table 1. Inclusion and exclusion criteria.
Table 1. Inclusion and exclusion criteria.
Inclusion CriteriaExclusion Criteria
Publication DateJanuary 2017–November 2022<2017
Study DesignRCTs 1 and non-randomized controlled studies, intervention studies, and cohort studiesNonintervention studies 2
Population Adults ≥ 18 years old, diabetic patients
Patients at the early stages of the disease 3 ≤5 years from diagnosis with an oral hypoglycemic agent and lifestyle intervention
Children, not newly diagnosed T2DM patients ≥5 years from diagnosis with type 2 diabetes
Intervention Different interventions are used for health education.
Face-to-face intervention
-Online intervention
No changes in medication treatment during the study
Drug-based intervention with changes in medication treatment
Control GroupStandard care, routine care if it is present
Effectiveness
Assessment
Biomedical results
Behavioral results
Emotional and social results
1 RCTs—randomized controlled studies; 2 nonintervention studies—qualitative studies, case control studies, review studies, and observational studies. 3 Early stages of disease include recent diagnoses (0–1 year after diagnosis) and short-term diagnoses (1–5 years after diagnosis).
Table 2. Assessment of bias risk in the included studies.
Table 2. Assessment of bias risk in the included studies.
Studies’
General
Information
Random
Sequence
Generation
Allocation
Concealment
Blinding of
Participants
and
Personnel
Blinding of
Outcome
Assessment
Incomplete
Outcome
Data
Selective
Reporting
Other
Biases
Study
Quality
[22]
(2019) China
++?+?+Fair
[23]
(2018) China
???+++Poor
[24]
(2018) China
+???+?+Poor
[25]
(2019) China
??+++Poor
[26]
(2022) China
++++++?Fair
[27]
(2018) China
??+++?Poor
[28]
(2019) India
+++++++Fair
[29]
(2018) India
?+?++Poor
[30]
(2020) India
++??++?Fair
[31]
(2022) India
++??+++Fair
[32]
(2019) Netherlands
++?+++Fair
[33]
(2019) Netherlands
++?+++Fair
[34]
(2018) Spain
??++Poor
[35]
(2019) Mexico
?++No control groupPoor
[36]
(2018) Italy
????++?Poor
[37]
(2022) USA
????++No control groupPoor
[38]
(2020) UK
+++?++?Fair
[39]
(2021) Germany
???++No control groupPoor
[40]
(2017) Lebanon
???++No control groupPoor
Note: (+) shows low risk of bias; (−) shows high risk of bias; (?) shows unclear risk of bias.
Table 3. Characteristics of study participants.
Table 3. Characteristics of study participants.
Studies’
General
Information
Total Number of
Participants/Numbers of Participants in
Intervention Group/Control Group
Demographic
Characteristics
Significant Baseline
Differences between Groups
Duration of Diabetes
Diagnosis
Setting(s)
[22] (2019)
China
97 participants
IG: 49
CG: 48
Average age: 63.71 yearsNo significant differences between groupsDiagnosis received within the prior 3 monthsOutpatient ward
[23] (2018)
China
118 participants
IG: 63
CG: 55
Mean age: 54 ± 11.5No significant differences between groups Newly diagnosed T2DM Outpatients and inpatients
[24] (2018)
China
106 patients
IG: 53
CG: 53
Mean age: 58.62 ± 15.74 years oldNo significant difference between groups1.24 years ± 0.35 yearsHospitalized patients
[25] (2019)
China
358 participants
IG: 179
CG: 179
Mean age of 50.1 ± 9.1 yearsNo significant difference between the two groups (p > 0.05)Newly diagnosed T2DM Outpatient ward
[26] (2022)
China
128 participants
IG: 64
CG: 64
Average age: 57.43 years, and
41.4% were female
No significant differences between groups Newly diagnosed T2DM
(Diagnosed in the preceding 3 to 9 months)
Primary healthcare services
[27] (2018)
China
126 participants
IG: 66
CG: 60
Mean age: 32.71 ± 5.69No significant differences between groups Newly diagnosed T2DM
(Duration < 6 months)
Outpatients
[28] (2019)
India
248 participants
IG: 126
CG: 122
The mean age was 43 ± 8.7 years, and
32.3% were women.
No significant differences between groupsNewly diagnosed T2DM Outpatient ward
[29] (2018)
India
96 participants
IG: 48
CG: 48
The age group was from 25 to 65 years.Not clearNewly diagnosed T2DM Medical outpatient ward
[30] (2020)
India
136 participants
IG: 66
CG: 70
Mean ages (IG: 37.2 ± 4.09 and
CG: 37.55 ± 4.29);
41.89% were female
Not clear Newly diagnosed T2DM Medical outpatient ward
[31] (2022)
India
66 participants
IG = 33
CG = 33
Mean age: 42.29 ± 9.5;
66.66% Male
No significant differences between groups Newly diagnosed T2DM
(Within 3 months of diagnosis)
Endocrinology outpatient ward
[32] (2019)
Netherlands
108 participants
IG: 56
CG: 52
Mean age: 62.3 ± 7.8There were some differences between groups in the prevalence of diabetes-related complications. Newly diagnosed T2DM
(Diabetes duration from 3 months to 5 years)
Outpatient ward
[33] (2019)
Netherlands
137 participants
IG: 62
CG: 75
Mean age: 63.6 (10.2)No significant differences between groups Newly diagnosed T2DM
(Diabetes duration 1–3 years)
Outpatients
[34](2018)
Spain
271 participants
IG: 134
CG: 137
IG 65.6 ± 10.6
CG 67.5 ± 13.5
Not clearNewly diagnosed T2DM, 1 year after diagnosisPrimary health centers
[35] (2019)
Mexico
288 patients who had followed the program
No control group
The mean age was 51.1 ± 10.3 years, and 56.2% were women.Not clear≤5 years after diagnosis with T2DMOutpatient ward
[36] (2018)
Italy
95 participants
IG: 47
CG: 48
Mean age: 58.43 ± 7.34No significant differences between groups Newly diagnosed T2DM
(Diagnosed within the previous 12 months)
Outpatient ward
[37] (2022)
USA
17 participants
No control group
Mean age: 52 yearsNot clearNewly diagnosed T2DM
(Diagnosed within the past 12 months)
Outpatients
[38] (2020)
UK
18 participants
IG: 9
CG: 9
Mean age: 56 (6.5); F/M: 50%/50%No significant differences between groups Newly diagnosed T2DM
(Diagnosed within the past 4 years
Outpatients
[39] (2021)
Germany
24 participants
No control group
Mean age: 56 (6.5); F 58%-Newly diagnosed T2DM
(Diabetes duration < 4 years)
Outpatients
[40] (2017)
Lebanon
75 participants
No control group
Mean age: 55 ± 10.7;
552% Female
-Newly diagnosed T2DMDiabetes outpatient clinics
Table 4. Characteristics of the educational interventions evaluated in the studies included in the review.
Table 4. Characteristics of the educational interventions evaluated in the studies included in the review.
Studies’
General
Information
Type of StudyType of
Intervention
Follow-up PeriodCharacteristics of Educational InterventionsTheoretical BasisAssessed Outcomes
Educational Sessions,
Duration
DeliveryProviderCovered Self-Care TopicsSupporting Strategy
[22]
(2019)
China
Experimental design/RCTsHealth promotion–multi-intervention program
Individual intervention
18 monthsDifferent return visit times for each patient
Mobile application
Face-to-face and online TeamGeneral information for diabetes
Self-care
Mobile and tabletsAADE 7 Self-Care Behaviors programBiomedical outcomes Psychosocial outcomes
[23] (2018)
China
Experimental design Education program–multi-intervention program
Group education
6 months 2 lecture sessions and interactive sessions Face-to-faceNursesGeneral information for diabetes
Self-care
Lecturing, audio-visual, and discussion approach Problem-based learningBiomedical outcomes Psychosocial outcomes
[24] (2018)
China
Intervention study Education program–multi-intervention program
Group education
“One-to-one” health education
3 monthsNot clearFace-to- faceNurses General information for diabetes
Self-care
noneOrem’s self-care theory Biomedical outcomes Psychosocial outcomes
[25] (2019)
China
Non-randomized controlled studyImplementation of a model
Group education
6 monthsThe first education was outpatient education. Follow-up telephone visits Face-to-face and phone call visitsTeamGeneral information for diabetes
Self-care
Learning manual,
video tutorials, phone calls,
diabetes clubs, meetings
Omaha System-based integrated nursing management modelBiomedical outcomes Psychosocial outcomes
[26] (2022)
China
RTCsMulti-intervention program
Group education
12 weeks8 interactive educational sessionsFace-to-faceNurses General information for diabetes
Self-care
Handbook and PowerPoint slidesHealth belief model and Self-efficacy theoryBiomedical outcomes Psychosocial outcomes
Behavioral outcomes
[27] (2018)
China
Prospective cohort studyEducation program–multi-intervention program
Individual intervention
Mobile application
24 weeksUse of the medical app to assist in doctor–patient communication, Online Physician General information for diabetes
Self-care
Use of other functions of the app software None Biomedical outcomes
[28] (2019)
India
RCTsEducation program–multi-intervention program
Individual intervention
24 monthsAdvice from 2–3 educatory text messages per weekText message Face-to-facePhysicians General information for diabetes
Self-care
None NoneBiomedical outcomes Psychosocial outcomes
Behavioral outcomes
[29] (2018)
India
RCTsEducation program–multi-intervention program
Group intervention
4 months1 session for 7–15 minFace-to-faceNot clearGeneral information for diabetes
Self-care
Video
leaflets
NonePsychosocial outcomes
[30]
(2020)
India
RCTsStructured exercise therapy
Individual intervention
6 monthsAerobic exercise Face-to-face PhysiciansRole of specific exerciseBookletsNone Biomedical outcomes
[31] (2022)
India
RCTsPhysical promotion
Individual intervention
12 months Contacted by phone at 3-month intervals Calls and face-to-faceNot clearRole of physical activityNo informationNone Biomedical outcomes
Behavioral outcomes
[32]
(2019)
Netherlands
RCTsEducation program–multi-intervention program
Individual and group intervention
30 monthstwo individual and five group sessionsFace-to-faceNurses General information for diabetes
Self-care
Telephone consultation, None Biomedical outcomes Psychosocial outcomes
Behavioral outcomes
[33] (2019)
Netherlands
RCTsEducation program–multi-intervention program
Group intervention
8 monthsThree monthly 2-h interactive sessions and one booster session Face-to-faceNurses Illness perceptions Workbook for both patients and partners.None Psychosocial outcomes
Behavioral outcomes
[34] (2018)
Spain
Prospective studyPAET-Debut DM2
Standardized group education
Group education
12 monthsThree phases Face-to-faceTeamGeneral information for diabetes
Self-care
Standardized materialsAISBE group for chronic diabetes diseaseBiomedical outcomes Psychosocial outcomes
Behavioral outcomes
[35] (2019)
Mexico
Program evaluation studyImplementation of the CAIPadi model
Individual intervention
24 months Intervention visits and two follow-up visits (12 and 24 months)Face-to-face TeamGeneral information for diabetes
Self-care
Support in distance system webpageCAIPaDi program Biomedical outcomes Psychosocial outcomes
Behavioral outcomes
[36] (2018)
Italy
Intervention study Psychological intervention
Group intervention
12 months90 min biweekly group sessions over 3 monthsFace-to-faceClinical psychologistGeneral information for diabetes
Self-care
None No Biomedical outcomes
[37] (2022)
USA
Intervention studyEducation program–multi-intervention program
Individual intervention
6-week intervention and 3-month follow-upFour sessionsFace-to-face Not clearRole of foods and physical activity The GEM pocket guide;
Text messages
None Biomedical outcomes Psychosocial outcomes
Behavioral outcomes
[38] (2020)
UK
RCTsEducation program–multi-intervention program
Individual intervention
8 weeks Participants received two text messages per week Online Not clearBehavioral change Use of a mobile applicationTheory of planned behaviorBehavioral outcomes
[39] (2021)
Germany
Intervention studyFood-based digital education
Individual intervention
Mobile application
12 weeksDuring the weekly coaching callsOnline Trained nutritionistStructured behavioral change
Role of a healthy diet
Recipe bookNone Biomedical outcomes
[40] (2017)
Lebanon
Descriptive pre-/poststudyFood education
Individual intervention
Mobile platform
12 months 5 visitsFace-to-face and onlineSix Lebanese dietitiansGeneral information for diabetes
Self-care
No informationAcademy of Nutrition and Dietetics EBNPGsBiomedical outcome
Behavioral outcomes
Table 6. The effects of educational interventions on anthropometric parameters.
Table 6. The effects of educational interventions on anthropometric parameters.
Studies’ General
Information
Pre-InterventionPost-InterventionChangeAbsolute
Effect
IGCGIGCGIGCG
Effect of educational intervention on weight
[22]67.86 ± 16.8466.67 ± 17.2857.5 ± 15.33 *65.65 ± 16.98−10.36 **−1.02−9.34
[31]71.47 ± 11.4371.47 ± 11.4369.27 ± 13.8871.20 ± 12.76−2.2−0.27−1.93
[32]88.2 ± 16.287.7 ± 15.486.6 ± 16.186.7 ± 14.1−1.6−1−0.6
[38]89.60 ± 20.390.2 ± 19.990 ± 21.790.5 ± 19.2+0.4+0.3+0.1
[39]97.0 ± 13.9-87.7 ± 12.1 *-−9.3 −9.3
Mean ± SD −4.6−0.49−2.94
Effect of educational intervention on BMI
[22]25.47 (3.31)25.29 (3.25)25.28 (2.93)24.94 (2.89)−0.19−0.35−0.16
[23]25.70 ± 3.3825.06 ± 3.3825.16 ± 3.3825.28 ± 3.47−0.54+0.02−0.56
[27]26.27 ± 4.6425.52 ± 4.7625.68 ± 4.2125.48 ± 4.65−0.59−0.04−0.55
[31]27.73 ± 5.1426.80 ± 2.7626.97 ± 5.0426.66 ± 3.18−0.76−0.14−0.62
[32]29.6 (4.9)30.1 (4.5)29.2 (4.8) *29.6 (4.5)−0.4−0.5−0.1
[34]29.6 (27.2–34.2)-28.8 (25.9–32.6) *-−0.8 * −0.8
[35]29.19 ± 4.27-28.8 ± 4.2-−0.39 −0.39
[37]36.5 (8.1)-34.4 (8.2)-−2.1 −2.1
[38]31.1 ± 6.429.9 ± 4.731.2 ± 6.931.2 ± 4.6+0.1+1.3
[39]32.6 ± 4.6-29.4 ± 3.9 *-−3.2 −3.2
[40] 31.7 ± 4.9-30.6 ± 4.9 *-−1.1 ± 2.7 * −1.1
Mean ± SD −0.900.29−0.398
Notes: * Significant difference between pre- and post-intervention in the same group. ** Significantly different effect between IG and CG. Studies without a control group are not included in the calculation of the absolute effect on anthropometric parameters.
Table 7. The effects of educational interventions on blood pressures.
Table 7. The effects of educational interventions on blood pressures.
Blood Pressure/Studies’ General Information[22][23][31][32][34][35][38][40]Mean ± SD
SBPPre-intervention IG130.24 ± 18.92130.00128.09 ± 10.78132 ± 13130.64 ± 13.5128.9 ± 16.4136.3 ± 17.2131.3 ± 20.4
CG128.09 ± 17.36120.00129.48 ± 10.71133 ± 14--134.0 ± 18.1
Post-interventionIG131.37 ± 19.12130.00119.15 ± 7.75135 ± 17129.4 ± 14.4120.86 ± 11.83138.2 ± 20.7124.9 ± 9.9 *
CG131.15 ± 18.24130.00119.88 ± 7.31135 ± 15--135.6 ± 20.3
Change IG1.130−8.943.01.24−8.041.9−6.4 *−2.3 ± 6.5
CG3.0610.00−9.63 1.6 1.61 ± 8.10
Absolute Effect -−0.660-−8.04-−6.4 *−0.34 ± 7.9
DBPPre-interventionIG74.99 ± 13.1280.0079.33 ± 8.14-77.8 ± 978.4 ± 7.8783.8 ± 9.581.3 ± 12.5
CG76.22 ± 12.1180.0081.24 ± 8.03-- 83.3 ± 10.7
Post-interventionIG75.58 ± 11.0480.0078.15 ± 4.83-76.4 ± 8.474.06 ± 6.8682.4 ± 9.878.1 ± 9.5
CG78.61 ± 12.9885.0078.73 ± 5.78---84.3 ± 13.2
Change IG−0.5901.18 ± 6.48-−1.44.34−1.3−3.1 *−0.87 ± 4.5
CG2.390.52.51 ± 6.90- 1.0 1.6 ± 5.1
Absolute Effect3.980.51.33--4.342.3-3.10.36 ± 5.5
Notes: * Significant difference between pre- and post-intervention in the same group.
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Kiçaj, E.; Saliaj, A.; Çerçizaj, R.; Prifti, V.; Qirko, S.; Rogozea, L. Navigating Diabetes: Enhancing Self-Management through Education among Diabetic People at the Early Stages of the Disease—A Systematic Review. Int. J. Environ. Res. Public Health 2024, 21, 522. https://doi.org/10.3390/ijerph21050522

AMA Style

Kiçaj E, Saliaj A, Çerçizaj R, Prifti V, Qirko S, Rogozea L. Navigating Diabetes: Enhancing Self-Management through Education among Diabetic People at the Early Stages of the Disease—A Systematic Review. International Journal of Environmental Research and Public Health. 2024; 21(5):522. https://doi.org/10.3390/ijerph21050522

Chicago/Turabian Style

Kiçaj, Emirjona, Aurela Saliaj, Rudina Çerçizaj, Vasilika Prifti, Sonila Qirko, and Liliana Rogozea. 2024. "Navigating Diabetes: Enhancing Self-Management through Education among Diabetic People at the Early Stages of the Disease—A Systematic Review" International Journal of Environmental Research and Public Health 21, no. 5: 522. https://doi.org/10.3390/ijerph21050522

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