Effects of an Outpatient Diabetes Self-Management Education on Patients with Type 2 Diabetes in China: A Randomized Controlled Trial

Zheng, Fan; Liu, Suixin; Liu, Yuan; Deng, Lihua

doi:https://doi.org/10.1155/2019/1073131

Journal of Diabetes Research

On this page

Abstract Methods Results Discussion Data Availability Conflicts of Interest References Copyright Related Articles

Research Article | Open Access

Volume 2019 | Article ID 1073131 | https://doi.org/10.1155/2019/1073131

Effects of an Outpatient Diabetes Self-Management Education on Patients with Type 2 Diabetes in China: A Randomized Controlled Trial

Fan Zheng,¹Suixin Liu,¹Yuan Liu,¹and Lihua Deng¹

Academic Editor: Gianluca Iacobellis

Received05 Aug 2018

Revised07 Dec 2018

Accepted26 Dec 2018

Published17 Jan 2019

Abstract

Objective. This study is aimed at assessing the effectiveness of a simple outpatient diabetes self-management education programme. Methods. In the study, 60 patients with type 2 diabetes mellitus were randomly allocated into the control group () and intervention group (). Regular and 2-session health education programmes were provided. The summary of diabetes self-care activity measure, problem areas in the diabetes scale, fasting blood glucose, postprandial 2 h blood glucose, and HbA1c were measured before and after the intervention to assess the effects of this 2-session diabetes education programme. Results. The total mean score of the summary of diabetes self-care activities measure was points. The problem areas in the diabetes scale revealed that the total mean score was points; 27% of the patients had diabetes-related distress, while 9% suffered from severe emotional distress. Compared with the control group, scores of the summary of diabetes self-care activities measure and problem areas in the diabetes scale, fasting blood glucose, postprandial 2 h blood glucose, and HbA1c were significantly improved in the intervention group after the intervention (). Conclusion. This study showed that the 2-session diabetes education programme could effectively improve the level of self-reported self-management, psychological distress, and glycemic control in patients with type 2 diabetes mellitus.

1. Introductions

Diabetes mellitus (DM) is the world’s third-largest, chronic, noninfectious disease after cardiovascular diseases and cancer. DM and its complications threaten individual health and bring a heavy financial burden to the families and society [1–3]. Among the diabetic complications, the psychological disorders are usually neglected by the patients and their families [4, 5]. The latest Chinese study of 112 patients with type 2 diabetes mellitus (T2DM) showed that a general representation of anxiety, depression, and other psychological conditions existed among this population [6]. How to effectively improve the self-management behavior and negative mood of T2DM patients is the key goal of clinic work in China.

Diabetes self-management is considered as the cornerstone of T2DM management [7]. In reviewing the literature, the effectiveness of the didactic diabetes self-management education programmes was seemed to be rather weak when approaching T2DM and its related complications. The educational interventions that involved patient collaboration were more effective than didactic interventions in improving glycemic control [8–13]. Furthermore, a group-based diabetes self-management education programme was showed to produce improvements on clinical, lifestyle, and psychosocial outcomes in patients with T2DM [14, 15]. The researches in China also revealed that the family- and community-based diabetes self-management interventions were effective to improve the diabetes self-care behaviors in Chinese adults with type 2 diabetes [16, 17]. Indeed, the results showed that when self-management education was provided, age, education, knowledge, self-efficacy, economic factor, and social support should be considered to offer more appropriate intervention and to improve patients’ behaviors in China [18, 19]. It is, consequently, suggested to develop a more comprehensive and participatory education programme and concentrate on some significant variables, i.e., self-management behavior and psychological performances [12, 13, 20].

The purpose of this study was to develop an interactive and participatory educational programme and evaluate the effects of this programme. An outpatient diabetes self-management education was subsequently conducted to guide these subjects in an appropriate, targeted, self-management manner and to improve the self-management level.

2. Methods

2.1. Participants

A single-blinded randomized controlled study, followed by CONSORT 2010 criteria [21], was approved by the Human Ethics Committee of Xiangya Hospital at Central South University. This study was conducted at the Cardiovascular Rehabilitation Clinic, Endocrinology Clinic, and Geriatrics Clinic at Xiangya Hospital, Central South University, from 2015 to 2017. The inclusion criteria were as follows: (I) All patients with T2DM should meet the T2DM diagnostic criteria established by the American Diabetes Association in 2010 [22]: (1) ; (2) ; (3) in the oral glucose tolerance test (OGTT); and (4) typical hyperglycemia symptoms, such as polydipsia, polyuria, polyphagia, obvious weight loss, and ; if the symptoms were not evident, criteria (1)–(3) should be repeatedly measured. (II) The patients were conscious, with complete behavior and cognitive ability. (III) The patients were willing to take the follow-up tests after three months. The exclusion criteria were as follows: (1) the presence of mental disorders; (2) complications of acute diabetes or inability to take care of themselves; (3) other serious diseases, such as severe cardiovascular and cerebrovascular diseases, severe kidney disease, cancer, and visual impairment due to complications of T2DM; (4) gestational diabetes; and (5) already received systematic diabetes education.

Seventy-two potential participants were identified by the clinic physician for the study. However, 12 patients declined to take part in this study because of lack of time or inconvenient transportation. Finally, a total of 60 patients with T2DM were recruited in this study, and informed written consents were obtained from all these participants. A computer-generated randomization list with permuted, variable-size blocks was used to randomize the two groups. The allocation ratio of assignments was 1 : 1. The randomization and allocation concealment were performed by the statistician, and a therapist was in charge of enrollment and assignment of subjects to interventions. Figure 1 shows the research flow.

2.2. Two-Group Experimental Design

Two groups, a preexperimental design and a postexperimental design, were used in this study. 60 patients with T2DM were randomly allocated into 2 groups: the control group () and intervention group (). A questionnaire was distributed to the patients, and all of them were returned. This questionnaire included the general information such as gender, age, and educational background. Regular and interventional education programmes were applied to the control and intervention groups, respectively.

Regular education was given to the control group during their first clinic visit; this included general knowledge on diabetes disease process and treatment options; blood glucose monitoring; healthy lifestyle; preventing, detecting, and treating diabetes complications; and developing personalized strategies for decision-making [23]. The intervention group was given 2-session diabetes self-management education besides the regular education programme. Interventional education programme consisted of two types of courses: theory and practical. For the theory course, there were two timings for classes: the first class was given during the first clinic visit same as the control group, while the second class was given during the second clinic visit after 2 days. Each class lasted for 45 minutes. The second class consisted of group studies using an impressive PowerPoint-incorporated images and videos, presenting an overview knowledge of diabetes and additional details about self-management strategies, such as diet guidance, exercise guidance, and knowledge of hypoglycemia treatment, foot care, medication, and the blood glucose monitoring.

In the practical course, the educational tools were also culturally designed to be more appropriate and relevant for patients, including vivid models and individual practice. This course contains mainly two parts, one-on-one nutrition guidance and individualized exercise guidance. The one-on-one nutrition guidance was applied by the dietitians after the first theory class and lasted for 40 minutes. This guidance, developed for the Chinese diabetes population based on the American Diabetes Association [24], includes the definition and application of an exchangeable food portion in the diabetes diet planning assisted with the presentation of food simulation models. One piece of the “exchangeable food portion” is defined as “one serving for every 90 kcal of food produced.” The same type of the exchangeable food portion can be exchanged; the nutritional value is almost the same. The individual total energy required per day is calculated according to the individual weight and daily physical activity. Calculate the total individual servings of exchangeable food portion required per calories per day divided by 90 (kcal/serving). Distribute the three nutrients in each serving according to the total calories: 50%–60% for carbohydrates, 15%–20% for proteins, and 20%–25% for fat. The daily serving is appropriately distributed into three to six meals, and every meal is supplied on time and based on the ration. Each food simulation model is marked with weight and calories, which makes the nutrition guidance more clear and vivid.

Individualized exercise guidance [25] includes making a personalized exercise prescription for each patient, according to the outcomes of cardiopulmonary exercise testing and the Borg scale of perceived exertion (Borg scale). Generally, the exercise training is performed three times a week and 60–90 min each time. Each training programme includes (1) warm-up session: low-intensity aerobic exercise for 5–10 min; (2) exercise session: aerobic exercise for 30 min at a moderate intensity, i.e., 50%–60% of maximal oxygen uptake (VO_2max) and at a rate of 13–14 (somewhat hard of the Borg scale), and resistance exercise for 30 min at a moderate intensity, i.e., 50%–60% of 1RM; and (3) relaxation session for 10 min. The intervention group experienced a complete exercise training programme at the Cardiac Rehabilitation Center of Xiangya Hospital under therapist guidance and electrocardiogram monitoring. This individualized exercise guidance was applied after the second theory class and lasted for 60 minutes. Some instructions were mandatory: avoiding exercise on an empty stomach; knowing the identification and treatment of hypoglycemic episodes; and knowing how to adjust the insulin dose according to the exercise.

2.3. Outcomes

The SDSCA, PAIDs, FBG, postprandial 2 h blood glucose, and HbA1c tests were all performed to evaluate the effects of interventions for both groups before and after 3 months. The SDSCA scale [26] included five items: dietary behavior, exercise, medication adherence, blood glucose monitoring, and foot care. The Likert 7 rating scale was used, with scores ranging from 0 to 7, indicating “Don’t do it at all” to “Complete it all.” The ranking method was as follows: total (single ) were good, 21–28 was normal, and <21 (single ) was poor. Cronbach’s coefficients and the test-retest reliability coefficient of the SDSCA were 0.913 and 0.774 (), respectively [27].

PAID [28] was a self-administered, 20-item scale, and every item was scored from 0 to 4: problem at all, little problem, problem, problem, and problem. The total score was the sum of all item scores multiplied by 1.25, with a range of 0–100 points. The higher the score, the more serious the associated psychological distress. Scores from 0 to 33 were believed to be normal, >33 meant that DM was accompanied by a related mental pain, and >44 indicated that the mental problems were quite severe. Cronbach’s coefficients and the test-retest reliability coefficient of PAID were 0.94 and 0.65 (), respectively [29].

After fasting for 12 hours, blood samples were obtained from cubital veins of the patients in the morning. HbA1C was measured by the low-performance liquid chromatography (DiaSTAT Hemoglobin A1C analyzer, Bio-Rad Laboratories Inc., Philadelphia, USA). FBG concentration of the serum was determined by the hexokinase method (BS300 biochemistry analyzer, Mindray Inc., Shenzhen, China). After 2-hour oral administration of 75 g of anhydrous glucose, a blood sample was taken from the cubital vein again to measure the postprandial 2 h blood glucose concentration (BS300 biochemistry analyzer, Mindray Inc., Shenzhen, China).

2.4. Descriptive Statistics

Qualitative information related to the research sample was presented as frequency and percentage. The quantitative data were described as the deviation (SD). SPSS statistical software, version 17.0 Windows (SPSS Inc., Chicago, IL, USA), was used for statistical analysis. The tests were used to compare the differences between the demographics and characteristics of two groups. indicated that the difference was statistically significant.

3. Results

3.1. Baseline Information

The general information gained in this sample was as follows: the percentage of male was 55%, the average age was , the systolic blood pressure was , the diastolic blood pressure was , and the body mass index was . Most of the patients were rural residents (57%), nonsmokers (94%), physically inactive (87%), with a poorly controlled glycosylated hemoglobin level (53%), poor glucose control (52%), and a short disease course of no more than 5 years (52%) (Table 1).

The current treatments for T2DM were summarized as follows: restriction of total calorie intake combined with exercise training, oral antidiabetic agents (OADs), and insulin injection. Twelve percent of the sample undertook the restriction of total calorie intake combined with exercise training. Seventy-three percent of the sample took only OADs, which includes metformin, sulfonylureas, alpha-glucosidase inhibitors, thiazolidinediones, and meglitinides. They were used as monotherapy or in combinations to arrive at the best individualized prescription to achieve treatment goals. Last, fifteen percent of the sample took insulin injection with/without OADs (Table 1).

3.2. Self-Management Behavior and Mental Health of Patients

The present study showed that the average score of SDSCA was 17.60, and the overall score was low (<21 points is poor). The average score of PAID was 29.82 points (0~33 points are considered as normal), suggesting that the overall psychological condition of the sample was good. A further stratified analysis of the overall scores revealed that 27% of the sample had diabetes-related pain and 9% of them were severely emotionally disturbed (Table 2). These severely emotionally disturbed diabetics were all treated with insulin injection with/without OADs.

3.3. Effects of Outpatient Diabetes Self-Management Education Programme

The scores of SDSCA and PAID and blood glucose levels of the two groups were compared before and after 3 months to evaluate the effect. It was revealed that the scores of SDSCA and PAID, FBG, postprandial 2-h blood glucose, and HbA1c in the intervention group were all significantly () improved after the intervention, as compared with those in the control group (Table 3).

4. Discussion

The first finding of this study was that the overall self-management behavior score of the sample was rather low, indicating poor self-management behavior of these patients. Compared with a previous study [30], the score in this study was even lower ( points vs. points in SDSCA), which might be related to the rural population with poor education, backward economy, and an undeveloped medical health system in the study sample. The second finding of this study was that these patients performed poorly on the psychological status, showing that 27% of the patients had negative emotions, of which 9% had severe diabetes distress. This was in line with previous studies, indicating that the incidence of anxiety disorder was 14% [31] in the diabetic population, the risk of depression in T2DM was 24% more than in nondiabetics [32], and more than 33% of T2DM had depressive symptoms [33]. In fact, when those severely emotionally disturbed diabetics were interviewed, they generally responded that they had the “fear of injection.” These patients were treated with insulin and reported the “injection-related uncomfortable feelings,” such as anxiety, scarring, sensitivity, pain, and bruising. Injection was perceived as restricting and interfering with their lives. They felt embarrassed about injecting in public, particularly when injecting with meals. They were worried about the inconvenience when travelling and the increased dependence on others especially when getting older. Based on the above fears of injection, the patients would rather take more OADs than inject insulin. Thus, they showed a poor adherence to injection compared to OADs. These negative emotions, to some degree, may have affected the patient’s behavior of glycemic control, aggravated disease prognosis, and increased the patient’s mental burden, forming a “vicious circle” [34].

Diabetes is a life-long disease. As the disease progresses, acute, chronic, and serious complications develop, which greatly weaken patients’ confidence in the recovery. Patients gradually slack off in self-management behavior and reduce therapy compliance, which eventually leads to aggravation of the disease. Evidence supported the effectiveness of diabetes education and self-management programme on the self-management of T2DM, particularly in the short term. Thereinto, lifestyle advice on diet and exercise was at the core of first line. Because of the Chinese traditional view of dependence on the treatment with medication, diabetes self-management education in China is still not widely accepted and valued by the T2DM patients and their families. The current format of diabetes education in China focuses on a more didactic approach to educate patients about prescriptions and T2DM-related complications. This makes the diabetes self-management education even somehow difficult to execute and sustain by these patients. As showed in the present study, most of the patients were with lower education; thus, the diabetes self-management education should be easier to understand and follow in various forms. What is more, the cooperation between patients and providers should also be strengthened. It showed in the study that the educators could help patients relieve the fears of insulin injection and improve the injection technique to reduce physical discomfort, resulting in a better adherence to treatment and improved performance of self-management behaviors. Thus, patients should be encouraged to discuss their own problems, such as injection-related concerns, and providers should offer patients information about tools to reduce injection-related worries, preferably by directly showing to them. Patients and providers should work together to find the solutions.

On the other hand, most diabetes education studies in China are aimed at inpatients and the community population currently, with common patterns of collective instruction or individual guidance. These diabetes self-management education interventions usually involved a number of sessions over a long period and cost a lot of time and energy for the organizer. Hence, they were difficult to be promoted across the country. Patients were also reluctant to follow a long-term programme because of the transportation and the uncovered medical insurance; consequently, the rates of participation and compliance were relatively low [35]. There is currently not a unanimous diabetes self-management education developed by voluntary organizations or community groups [8]. Based on the aforementioned considerations, we employed one-to-one dietary guidance and individualized exercise instruction in the short-term outpatient education programme and investigated the effects on self-management behavior, psychological status, and glycemic control.

Dietary guidance used the “exchangeable food portion” method presented by the simulation food model. A recent study reported [36] that this type of dietary guidance applied more practical experiences and specific skills compared with the traditional Chinese education pattern. Consequently, it was easier for patients to understand and accept, resulting in improved glycemic control and lipid metabolism. This finding is in line with the results of a previous study, where the patients could make their own food services per day according to personal preferences after dietary guidance, shifting the boring and difficult-to-understand theory of dietary theories to concrete and easy-to-use individual practice. In the exercise section, a combined exercise training programme was applied, i.e., moderate intensity aerobic exercise combined with resistance exercise in the present study. Under the guidance of medical staff and continuous ECG monitoring, the patients in the intervention group took a full set of exercise training programme. This type of exercise guidance concentrated on individualized exercise education and guidance.

For the sake of economic issue, the intervention programme in the present study took place only over two turns along with the patient’s first visit and return visit to the outpatient department. This intervention programme integrated the advantages of the two education patterns, combining collective instructions with individual guidance (individualized diet guidance and exercise practice). Although taking only two sessions, the effects of the outcomes were significant, i.e., higher participation and better compliance by the patients, improved self-management behaviors and psychological conditions, and lower blood glucose levels. The spotlight of this diabetes self-management education programme was that it approached patients’ own risk factors and encouraged and educated patients to act on the risk factors of most importance to them, i.e., lifestyle, diet, and physical activity.

The strength of this study was that it provided new ideas and practical experience for diabetes health education in clinic work. As for some undeveloped districts or countries, in where patients have poor education and are under poor economic status, it is important to encapsulate a patient-centered approach to diabetes self-management to maximize the profits of these patients and greatly improve the participation and adherence to diabetes self-management education. However, there were still some limitations in this study, primarily related to the composition of the analyzed sample, that is, regionalism, resources of the patients (limited to outpatients), and so on. Additionally, the sample of this study is small. Due to the limited sample in this study, we did not compare the self-management behaviors, psychological condition, glucose control, and the effects of educational intervention in different types of antidiabetic therapy (e.g., insulin injection vs. OADs). In this sense, even the patients treated with insulin seemed to experience higher levels of emotional distress in the study, but unfortunately, we could not make such a conclusion because of the limited samples and lack of statistical analysis. Last, the intervention patterns in this study were limited, and the observation period was relatively short. Future studies will use some intelligent medical devices to track the vital signs and intervention effects of a large sample of T2DM patients for a longer time.

In conclusion, the overall level of self-management of patients with T2DM is still relatively low. Some patients have obvious negative emotions. The short-term diabetes self-management education for outpatients can effectively improve the level of self-management, psychological condition, and glycemic control in T2DM.

Data Availability

The data used to support the findings of this study are included within the article.

Conflicts of Interest

The authors declared that they have no conflicts of interest to this work.

References

W. Yang, J. Lu, J. Weng et al., “Prevalence of diabetes among men and women in China,” The New England Journal of Medicine, vol. 362, no. 25, pp. 2425-2426, 2010.
View at: Publisher Site | Google Scholar
Z. Xia, Z. Wang, Q. Cai, J. Yang, X. Zhang, and T. Yang, “Prevalence and risk factors of type 2 diabetes in the adults in Haikou city, Hainan island, China,” Iranian Journal of Public Health, vol. 42, no. 3, pp. 222–230, 2013.
View at: Google Scholar
L. Liu, Q. Lou, X. Guo et al., “Management status and its predictive factors in patients with type 2 diabetes in China: a nationwide multicenter study,” Diabetes/Metabolism Research and Reviews, vol. 31, no. 8, pp. 811–816, 2015.
View at: Publisher Site | Google Scholar
J. Guo, R. Whittemore, M. Grey, J. Wang, Z. G. Zhou, and G. P. He, “Diabetes self-management, depressive symptoms, quality of life and metabolic control in youth with type 1 diabetes in China,” Journal of Clinical Nursing, vol. 22, no. 1-2, pp. 69–79, 2013.
View at: Publisher Site | Google Scholar
J. Guo, R. Whittemore, S. Jeon et al., “Diabetes self-management, depressive symptoms, metabolic control and satisfaction with quality of life over time in Chinese youth with type 1 diabetes,” Journal of Clinical Nursing, vol. 24, no. 9-10, pp. 1258–1268, 2015.
View at: Publisher Site | Google Scholar
L. Ting and Y. Yandong, “The study of mental pain and intervention methods in 122 patients with type 2 diabetes,” Chinese Journal of Convalescent Medicine, vol. 8, p. 25, 2016.
View at: Google Scholar
D. Ausili, C. Barbaranelli, E. Rossi et al., “Development and psychometric testing of a theory-based tool to measure self-care in diabetes patients: the Self-Care of Diabetes Inventory,” BMC Endocrine Disorders, vol. 17, no. 1, p. 66, 2017.
View at: Publisher Site | Google Scholar
M. C. Portillo, A. Kennedy, E. Todorova et al., “Interventions and working relationships of voluntary organisations for diabetes self-management: a cross-national study,” International Journal of Nursing Studies, vol. 70, pp. 58–70, 2017.
View at: Publisher Site | Google Scholar
M. L. Penn, A. P. Kennedy, I. I. Vassilev et al., “Modelling self-management pathways for people with diabetes in primary care,” BMC Family Practice, vol. 16, no. 1, p. 112, 2015.
View at: Publisher Site | Google Scholar
S. L. Norris, M. M. Engelgau, and K. M. Venkat Narayan, “Effectiveness of self-management training in type 2 diabetes: a systematic review of randomized controlled trials,” Diabetes Care, vol. 24, no. 3, pp. 561–587, 2001.
View at: Publisher Site | Google Scholar
M. J. Davies, S. Heller, T. C. Skinner et al., “Effectiveness of the diabetes education and self management for ongoing and newly diagnosed (DESMOND) programme for people with newly diagnosed type 2 diabetes: cluster randomised controlled trial,” BMJ, vol. 336, no. 7642, pp. 491–495, 2008.
View at: Publisher Site | Google Scholar
E. T. Adolfsson, B. Starrin, B. Smide, and K. Wikblad, “Type 2 diabetic patients experiences of two different educational approaches-a qualitative study,” International Journal of Nursing Studies, vol. 45, no. 7, pp. 986–994, 2008.
View at: Publisher Site | Google Scholar
M. Gillett, H. M. Dallosso, S. Dixon et al., “Delivering the diabetes education and self management for ongoing and newly diagnosed (DESMOND) programme for people with newly diagnosed type 2 diabetes: cost effectiveness analysis,” BMJ, vol. 341, no. 7770, p. 439, 2010.
View at: Publisher Site | Google Scholar
A. Steinsbekk, L. Ø. Rygg, M. Lisulo, M. B. Rise, and A. Fretheim, “Group based diabetes self-management education compared to routine treatment for people with type 2 diabetes mellitus. A systematic review with meta-analysis,” BMC Health Services Research, vol. 12, no. 1, p. 213, 2012.
View at: Publisher Site | Google Scholar
Y. P. Zheng, L. F. Wu, Z. F. Su, and Q. H. Zhou, “Development of a diabetes education program based on modified AADE diabetes education curriculum,” International Journal of Clinical and Experimental Medicine, vol. 7, no. 3, pp. 758–763, 2014.
View at: Google Scholar
C. Cai and J. Hu, “Effectiveness of a family-based diabetes self-management educational intervention for Chinese adults with type 2 diabetes in Wuhan, China,” The Diabetes Educator, vol. 42, no. 6, pp. 697–711, 2016.
View at: Publisher Site | Google Scholar
M. Fu, J. Hu, and X. Cai, “Effectiveness of a community-based diabetes self-management intervention for Chinese adults with type 2 diabetes: a pilot study,” International Journal of Nursing Practice, vol. 21, Supplement 2, pp. 132–140, 2015.
View at: Publisher Site | Google Scholar
M. Huang, R. Zhao, S. Li, and X. Jiang, “Self-management behavior in patients with type 2 diabetes: a cross-sectional survey in western urban China,” PLoS One, vol. 9, no. 4, article e95138, 2014.
View at: Publisher Site | Google Scholar
C. Le, S. Rong, Y. Dingyun, and C. Wenlong, “Socioeconomic disparities in type 2 diabetes mellitus prevalence and self-management behaviors in rural Southwest China,” Diabetes Research and Clinical Practice, vol. 121, pp. 9–16, 2016.
View at: Publisher Site | Google Scholar
L. Adarmouch, A. Elyacoubi, L. Dahmash, N. El Ansari, M. Sebbani, and M. Amine, “Short-term effectiveness of a culturally tailored educational intervention on foot self-care among type 2 diabetes patients in Morocco,” Journal of Clinical & Translational Endocrinology, vol. 7, pp. 54–59, 2017.
View at: Publisher Site | Google Scholar
K. F. Schulz, D. G. Altman, D. Moher, and CONSORT Group, “CONSORT 2010 statement: updated guidelines for reporting parallel group randomised trials,” BMC Medicine, vol. 8, no. 1, p. 18, 2010.
View at: Publisher Site | Google Scholar
American Diabetes Association, “Standards of medical care in diabetes—2010,” Diabetes Care, vol. 33, Supplement 1, pp. S11–S61, 2010.
View at: Publisher Site | Google Scholar
American Diabetes Association, “Standards of medical care in diabetes—2014,” Diabetes Care, vol. 37, Supplement 1, pp. S14–S80, 2012.
View at: Publisher Site | Google Scholar
A. B. Evert, J. L. Boucher, M. Cypress et al., “Nutrition therapy recommendations for the management of adults with diabetes,” Diabetes Care, vol. 37, Supplement 1, pp. S120–S143, 2014.
View at: Publisher Site | Google Scholar
Y. Liu, S. X. Liu, Y. Cai, K. L. Xie, W. L. Zhang, and F. Zheng, “Effects of combined aerobic and resistance training on the glycolipid metabolism and inflammation levels in type 2 diabetes mellitus,” Journal of Physical Therapy Science, vol. 27, no. 7, pp. 2365–2371, 2015.
View at: Publisher Site | Google Scholar
D. J. Toobert, S. E. Hampson, and R. E. Glasgow, “The summary of diabetes self-care activities measure: results from 7 studies and a revised scale,” Diabetes Care, vol. 23, no. 7, pp. 943–950, 2000.
View at: Publisher Site | Google Scholar
L. Hua and W. Zhu, “Verification of the reliability and validity of Chinese version of diabetes self-management activities questionnaire,” Nursing Journal of Chinese People’s Liberation Army, vol. 25, no. 16, pp. 5–8, 2014.
View at: Google Scholar
K. Venkataraman, L. S. M. Tan, D. C. T. Bautista et al., “Psychometric properties of the problem areas in diabetes (PAID) instrument in Singapore,” PLoS One, vol. 10, no. 9, article e136759, 2015.
View at: Publisher Site | Google Scholar
J. Ren, X. Hong, W. Zhao et al., “Validity and reliability of the Problem Area in Diabetes Scale in patients with type 2 diabetes,” Chinese Mental Health Journal, vol. 10, no. 11, pp. 806–811, 2015.
View at: Google Scholar
X. Jie, H. Du, D. Lixue, S. Huaying, Z. Liying, and N. Lin, “Effect of community case management model in patients with type 2 diabetes mellitus,” China Modern Doctor, vol. 53, no. 25, pp. 132–136, 2015.
View at: Google Scholar
A. B. Grigsby, R. J. Anderson, K. E. Freedland, R. E. Clouse, and P. J. Lustman, “Prevalence of anxiety in adults with diabetes: a systematic review,” Journal of Psychosomatic Research, vol. 53, no. 6, pp. 1053–1060, 2002.
View at: Publisher Site | Google Scholar
A. Nouwen, K. Winkley, J. Twisk et al., “Type 2 diabetes mellitus as a risk factor for the onset of depression: a systematic review and meta-analysis,” Diabetologia, vol. 53, no. 12, pp. 2480–2486, 2010.
View at: Publisher Site | Google Scholar
R. Rajagopalan, A. Joyce, D. Ollendorf, and F. T. Murray, “PDB5: medication compliance in type 2 diabetes subjects: retrospective data analysis,” Value in Health, vol. 6, no. 3, p. 328, 2003.
View at: Publisher Site | Google Scholar
M. W. Darawad, S. Hammad, S. Mosleh et al., “Psychosocial correlates of diabetes self-management practices,” Iranian Journal of Public Health, vol. 46, no. 6, pp. 771–781, 2017.
View at: Google Scholar
X. Sun, H. Wang, X. U. Fanglei, and L. Song, “Effect of individualized health education on self-management behavior and glycemic control for patients with type 2 diabetes,” Chinese Nursing Management, vol. 2, pp. 20–23, 2015.
View at: Google Scholar
Y. H. Huang, “The application of food exchange method combined with simulated food model in the diet education in patients with diabetes mellitus,” Journal of Qiqihar University of Medicine, vol. 17, p. 10, 2016.
View at: Google Scholar

Copyright

Copyright © 2019 Fan Zheng et al. This is an open access article distributed under the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited.

PDF Download Citation

Download other formats

Order printed copies

Views

12080

Downloads

4234

Citations