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Davies MJ, Heller S, Skinner TC, 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 2008;336:491–5
Full paper published online on bmj.com on 14th February 2008, doi:10.1136/bmj.39474.922025.BE
Patients who attended a structured group education programme (‘DESMOND’) were significantly more likely to lose a little weight and stop smoking than those who received usual care. However, the primary outcome of the DESMOND programme trial found no statistically significant differences in glycated haemoglobin (HbA1c). There were also no benefits found in terms of cholesterol levels and blood pressure.
What is the background to this?
When guidance on the use of patient education models for patients with type 1 and 2 diabetes was developed, the National Institute for Health and Clinical Excellence (NICE) found little evidence for the effectiveness of any educational approaches. This randomised controlled trial (RCT) aimed to evaluate the effectiveness of the DESMOND programme, a six hour structured group education programme, on biomedical, psychosocial and lifestyle measures in people with newly diagnosed type 2 diabetes.
What does this study claim?
The study found that there were no statistically significant differences in the majority of the outcome measures, including the primary outcome measure of HbA1c. as well as cholesterol levels and blood pressure. In the intervention group compared with the control group there were statistically significant reductions in triglyceride levels at eight months (–0.33mmol/L, 95%CI –0.58 to –0.09; P=0.008) but not at 12 months; body weight at four months (–0.72kg, 95%CI –1.35 to –0.10; P=0.024) and 12 months (–1.01kg, 95%CI –1.91 to –0.12; P=0.027); and those reporting smoking at 12 months (odds ratio [OR] 3.56, 95%CI 1.11 to 11.45; P=0.033).
Self-reported physical activity was greater in the intervention group at four months (OR 2.17, 95%CI 1.01 to 4.66; P=0.046) but this was not sustained at 12 months. There were also significant differences between the groups in four illness belief scores (P<0.001), and at 12 months depression scores were significantly lower in the intervention group, compared with the control group (P=0.032).
So what?
The study demonstrated that a group structured education programme, focusing on changing behaviour, can help patients to make small lifestyle improvements, some of which may be sustained over 12 months without reinforcement. HbA1c was reduced in both the intervention and control groups but there was no statistically significant difference between the groups. However, as we have said in a previous blog, researchers need to demonstrate that patients live longer or better, not just that a biological parameter is improved. Significant differences were seen in some other outcomes such as weight loss and smoking cessation but again it is unclear if this had translates into an effect on patient-oriented outcomes (do people live longer or better as a result of this). A longer, larger study would be needed to demonstrate this.
It is also worth noting that participating practices in the control arm were resourced to enable them to provide contact time with healthcare professionals equivalent to that provided in the intervention group. Therefore, patients in the control group received enhanced standard care, which may mean that the benefits of the intervention are under estimated.
Action
NICE recommend that structured patient education is made available to all people with type 1 or 2 diabetes at the time of initial diagnosis and then as required on an ongoing basis, based on a formal, regular assessment of need. From the evidence available, it is still difficult to recommend a specific type of education or provide guidance on the setting for, or frequency of, sessions.
The results of the study do not change existing recommendations. As we keep saying, clinicians and patients should be aware of the importance of managing cardiovascular risk factors in patients with type 2 diabetes. This is likely to include using structured patient education to encourage smokers to stop smoking, and people who are overweight or obese to lose weight. It is also important that blood pressure is controlled, and consideration should be given to adding a statin (ideally simvastatin 40 mg/day) and aspirin (once blood pressure is controlled). Blood glucose should also be controlled to control symptoms, probably using diet and lifestyle measures along with metformin.
You can find more information on the type 2 diabetes floor of NPC.
Study details
Design: Multicentre randomised controlled trial in 207 general practices (105 control, 102 intervention) in 13 primary care sites in England and Scotland. Allocation was not concealed.
Patients: The study included 824 adults (55% men, mean age 59.5 years) with newly diagnosed type 2 diabetes.
Intervention: Within 12 weeks of diagnosis, the intervention group attended a structured group education programme for six hours, which was delivered in the community by two trained healthcare professional educators.
Comparison: Patients in the control group received enhanced standard care, which generally included some kind of diabetes education, but not a structured, evaluated education programme.
Outcomes: The main outcome measure were HbA1c, blood pressure, weight, blood lipid levels, waist circumference, smoking status, physical activity, quality of life, beliefs about illness, depression, and emotional impact of diabetes. These were measured baseline and four, eight and 12 months.
Results: There were no statistically significant differences in many outcome measures including HbA1c, cholesterol levels and blood pressure. In the intervention group there were statistically significant reductions in triglyceride levels at eight months (–0.33mmol/L, 95%CI –0.58 to –0.09; P=0.008), in body weight at four (–0.72kg, 95%CI –1.35 to –0.10; P=0.024) and 12 months (–1.01kg, 95%CI –1.91 to –0.12; P=0.027), and in those reporting smoking at 12 months (odds ratio [OR] 3.56, 95%CI 1.11 to 11.45; P=0.033), compared with the control group. Self-reported physical activity was greater in the intervention group at four months (OR 2.17, 95%CI 1.01 to 4.66; P=0.046) but this was not sustained at 12 months. There were also significant differences between the groups in four illness belief scores (P<0.001) and at twelve months depression scores were significantly lower in the intervention group, compared with the control group (P=0.032).
Sponsorship: The study was funded by Diabetes UK. Office administration was funded by an unrestricted education grant from Novo Nordisk. Researchers were independent of study funders. Study sponsor was University Hospitals of Leicester NHS Trust.
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