Basics of education
A person living with type 2 diabetes may see a healthcare professional for a few hours per year, but for the rest of the time they need to manage their condition themselves. There are many daily decisions to be made about diet, physical activity, taking medication and monitoring that will impact on diabetes control. Education to help support people in making these decisions is therefore vital. As well as improving knowledge and skills, self management education can encourage and motivate people to make and sustain lifestyle change. People with diabetes consider that structured education is a priority, and this has been reflected in national policy in many countries including the UK, where offering structured education to all people newly diagnosed with diabetes is mandatory.
Structured self management education is usually delivered to groups of people with diabetes, and has several key elements including, a structured written curriculum delivered by trained educators, with quality assurance and audit of the programmes. A number of RCT’s of such programmes have been published and reviews of the evidence have demonstrated benefit. In the UK the most well known group education programmes are the DAFNE programme for people with type 1 diabetes and the X-Pert and DESMOND programmes for people with type 2 diabetes. Education can be delivered by one to one programmes but this has been less well described and evaluated.
WHAT IS DIABETES PATIENT EDUCATION
A person living with type 2 diabetes may see a healthcare professional for a few hours per year, but for the rest of the time they need to manage their condition themselves. There are many daily decisions to be made about diet, physical activity, taking medication and monitoring that will impact on diabetes control. Education to help support people in making these decisions is therefore vital. As well as improving knowledge and skills, self management education can encourage and motivate people to make and sustain lifestyle change.
PROVISION OF DIABETES PATIENT EDUCATION & NATIONAL POLICY
People with diabetes themselves feel that the provision of structured education should be a priority  and this is becoming reflected in national and international policy. For example in the UK the first of the Diabetes Quality Standards published in 2011 says “People with diabetes and/or their carers receive a structured educational programme that fulfils the nationally agreed criteria from the time of diagnosis, with annual review and access to ongoing education”  The Quality Standards state that A patient educational programme should meet five key criteria laid down by the Department of Health and the Diabetes UK Patient Education Working Group:
- Any programme should be evidence-based, and suit the needs of the individual. The programme should have specific aims and learning objectives. It should support the learner plus his or her family and carers in developing attitudes, beliefs, knowledge and skills to self-manage diabetes.
- The programme should have a structured curriculum that is theory-driven, evidence-based and resource-effective, has supporting materials, and is written down.
- The programme should be delivered by trained educators who have an understanding of educational theory appropriate to the age and needs of the learners, and who are trained and competent to deliver the principles and content of the programme.
- The programme should be quality assured, and be reviewed by trained, competent, independent assessors who measure it against criteria that ensure consistency.
- The outcomes from the programme should be regularly audited.
It also states that data on the numbers of people who are offered, who start, and who complete such programmes should be collected and audited.
The UK Quality and Outcomes framework has a clinical indicator relating to diabetes patient education which helps general practice to incentivise referral. It is ”Percentage of patients newly diagnosed with diabetes, on the practice register, in the preceding 1 April to 31 March who have a record of being referred to a structured education programme within 9 months after entry on to the diabetes register “ .
Information on the numbers of people being referred are now being audited by the National Diabetes Audit in the UK. In the latest report for 2012/2013 the national figure is only 3.9% for those with type 1 diabetes and 16.7% for those with type 2 .
EVIDENCE BASE FOR DIABETES EDUCATION
Evidence on the effectiveness of diabetes self management education prior to 2005 was published in a Cochrane review  It reviewed 11 studies with 1532 participants and concluded that the education reduced HBA1c, fasting glucose and weight. Following this, a trial of the X-pert programme in 314 participants with type 2 diabetes showed reductions in HBA1c, weight and cholesterol at 14 months. The programme consisted of 6 two hourly weekly group sessions .
The Diabetes Education and Self Management for Ongoing and newly diagnosed (DESMOND) programme consisting of a 6 hour programme delivered as two half days or a full day was evaluated in a trial of 824 participants newly diagnosed with type 2 diabetes. At 12 months there was a non statistically significant reduction in HBA1c, with statistically significant weight loss and reduced smoking levels in the intervention group .
An Italian study in 815 people with type 2 diabetes, where the intervention was 40-50 min of group education every 3 to 4 months reported its findings in 2008  This was a roll out of a successful pilot study done in Turin. Compared to a control group who received usual care after 4 years follow up there were significant improvements in the biomedical outcomesHBA1c, weight, blood pressure and lipids and in psychosocial measures of quality of life, improved knowledge and better health behaviours.
For people with type 1 diabetes a team in Germany had developed a 5 day structured inpatient training programme in intensive insulin management that had produced sustained improvements in glycaemic control without increasing severe hypoglycaemia  This was developed in the UK into a 5 day outpatient programme called DAFNE (Dose Adjustment For Normal Eating) In a trial of 169 adults this resulted at 6 months in a 1% reduction in HBA1c, improved quality of life and general well being in the intervention group as compared with controls. There was no difference in weight or severe hypoglycaemia between the groups .
Evaluating educational interventions in people with diabetes is difficult and complex. Some evaluations have shown improvement in biomedical targets. All show improvements in many psychological outcomes. They are therefore likely to be having a significant impact on how an individual manages their diabetes on a day to day basis. There are still research questions about the sustainability of the interventions and challenges around implementation and training. Despite this structured self management education for people with both type 1 and type 2 diabetes is now recognised as vitally important in the management of diabetes. This is reflected in national and international policies and guidelines which state that it should be available for all from diagnosis. The numbers of people being referred to structured self management education however are still low in the UK. There is as yet little real world data on how many of those who are referred actually complete the programme.
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^ Healthcare Commission. Managing Diabetes: Improving services for people with Diabetes. Healthcare Commission. London 2007
^ NICE Diabetes Quality Standards 2011 NICE London http://www.nice.org.uk/guidance/qs6/chapter/quality-statement-1-structured-education last accessed 12 Nov 2014
^ QoF Clinical Indicators 2014/15 http://www.patient.co.uk/doctor/quality-and-outcomes-framework-qof-2014-2015 last accessed 12 Nov 2014
^ NDA report 1 2012/13 http://www.hscic.gov.uk/catalogue/PUB14970/nati-diab-audi-12-13-care-proc-rep.pdf
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^ Muhlhauser I, JorgensV, Berger M et al Bicentric evaluation of a teaching and treatment programme for type 1 diabetic patients: improvement of metabolic control and otherv measures of diabetes care for up to 22 months. Diabetologia 1983 25:476-452
^ DAFNE Group Training in flexible, intensive insulin management to enable dietary freedom in people with type 1 diabetes: dose adjustment for normal eating (DAFNE) randomised controlled trial BMJ 2002 325:746-749