DIABETICMedicine

DOI: 10.1111/dme.14256

PSAD Special Issue Paper

Trends in diabetes self-management education: where
are we coming from and where are we going? A narrative
review

N. Hermanns1,2,3 , D. Ehrmann1,2 , K. Finke-Groene1 and B. Kulzer1,2,3

1
Research Institute Diabetes Academy Mergentheim (FIDAM), Bad Mergentheim, Germany, 2Department of Clinical Psychology and Psychotherapy, University of
Bamberg, Bamberg and 3Diabetes Clinic Mergentheim, Bad Mergentheim, Germany

Accepted 23 January 2020

Abstract
Aims To summarize the history, development and efficacy of diabetes self-management education on glycaemic control
and mental health in adults and children or adolescents with type 1 diabetes and people with type 2 diabetes. A further
aim was to review the status of implementation of diabetes self-management education into routine care and outline
current gaps in implementation and research.
Methods We searched PubMed and Google scholar for German- and English-language articles regarding diabetes self-
management education, glycaemic control and mental health, and restricted this search to meta-analyses.
Results Diabetes education has evolved from a compliance- and knowledge-oriented approach to an empowerment-
and self-management-oriented approach. Diabetes self-management education seems to have a greater impact on
glycaemic outcomes than on mental health outcomes, but the latter are rarely assessed. Technological development and
digitalization can provide chances and challenges for diabetes self-management education. Digital solutions show
promising results and great potential for improving the efficacy of diabetes self-management education further and
providing ongoing support. The implementation of diabetes self-management education into routine clinical care
frequently remains a challenge.
Conclusion Diabetes self-management education has been acknowledged as an essential part of diabetes therapy;
however, current gaps regarding the efficacy of diabetes self-management education on mental health, and the need for
education on the use of diabetes technology, are future avenues for research.
Diabet. Med. 37, 436–447 (2020)

psychosocial outcome variables. This is largely attributable

Introduction
to the increase in the amount of psychosocial research in the
Diabetes mellitus is a chronic condition whose long-term past 25 years, initiated in part by study groups such as the
prognosis is highly dependent on the self-care behaviour of Psychosocial Aspects in Diabetes (PSAD) study group within
the affected people. Diabetes self-management education the European Association for the Study of Diabetes (EASD)
(DSME) has thus become an essential part of diabetes care. A and the Behavioural Research In Diabetes Group Exchange
joint position statement of the American Diabetes Associa- (BRIDGE) in the USA. This psychosocial research identi-
tion, the American Association of Diabetes Educators and fied mental health as an important determinant of self-
the Academy of Nutrition and Dietetics defined DSME as the management [2,3] that should be addressed with DSME; it is
process of facilitating the knowledge, skills and ability also an important outcome of DSME [4,5].
necessary for diabetes self-care [1]. The concept of DSME In the present narrative review, building on the review by
has changed in recent decades, from a rather didactical, Chatterjee et al. [6], we aimed to examine the development
knowledge- and skill-centred approach to a more self- and establishment of DSME as an evidenced-based interven-
management- and empowerment-centred approach. This tion in diabetes. We summarize the updated evidence of
shift has also been mirrored in an increasing interest in DSME on glycaemic control and psychosocial outcomes in
people with type 1 and type 2 diabetes. We expand on
Correspondence to: Norbert Hermanns. E-mail: [email protected] previous reviews [6,7] by providing an update on the impact

436 ª 2020 Diabetes UK

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PSAD Special Issue Paper DIABETICMedicine

enough knowledge to engage in intensified insulin therapy

What’s new? [9]. Within the EASD, in 1977, a new study group, the
• Diabetes education is an established intervention which Diabetes Education Study Group was founded, indicating
has changed from a knowledge- and compliance- the high level of interest of the EASD in the establishment
centred approach to an empowerment- and self-man- of diabetes education at that time. A first structured
agement-centred approach. diabetes education programme for groups was developed
by Michael Berger and his group [10], and it focused on
• Diabetes self-management education (DSME) is effec- the transfer of knowledge and skills regarding strategies for
tive in reducing HbA1c levels in type 1 and type 2 glucose self-control, counting carbohydrates, adapting
diabetes, although its impact in children and adoles- doses of prandial insulin, and preventing acute complica-
cents is smaller. tions such as hypoglycaemia and diabetic ketoacidosis. This
• There is increased interest in the potential impact of education programme was highly structured and delivered
DSME on mental health. The impact of DSME on by a diabetes nurse or diabetes educator to groups of
mental health and psychological outcomes is inconsis- people with type 1 diabetes. As a consequence, diabetes
tent. educators were established as a new profession in many
countries in Europe. This programme was adopted in
• A major challenge is the implementation of DSME in modified forms in many countries, for example, Bulgaria,
routine clinical practice. Austria, and later the UK and Australia [10–13]. An
essential part of this movement towards structured diabetes
education was the evaluation of its efficacy by controlled
of the rapid development of diabetes technology and studies to establish DSME as an evidence-based treatment.
digitalization on DSME. Real-world data on the implemen- This proved to be beneficial for convincing clinicians as
tation reveals gaps in the adoption of DSME in routine care well as decision-makers in the healthcare system of the
by comparing DSME in different healthcare systems. This relevance of diabetes education, and it facilitated the
and other gaps in research and clinical practice are addressed reimbursement of structured education.
in the final part of the present review.
For this narrative review we searched PubMed for articles
What has the past 25 years of research told
regarding DSME, glycaemic control and mental health, and
us?
restricted this search to meta-analyses and systematic reviews
(details of the search strategy are described in Box 1 in the Over the past 25 years there have been several developments
Supporting Information). No criteria on publication date that have had significant implications for DSME. These
were set, and all articles in English or German were included include changes in the concept of diabetes education and a
if published before 1 October 2019. We also checked sharpened awareness of the importance of mental health,
reference lists within relevant articles as well as Google both as an outcome of DSME and as a determinant of
Scholar for additional references. successful diabetes self-management. There was also growing
evidence regarding the efficacy of DSME in type 1 and type 2
diabetes. The last 25 years have also seen a rapid develop-
What we knew in 1995
ment of diabetes technology and digitization that can both
Elliot Joslin’s famous 1923 statement that ’insulin is a benefit from DSME.
remedy primarily for the wise and not for the foolish,
whether they be patients or doctors’ [8] indicates that the
Self-management and empowerment
introduction of insulin into diabetes care was accompanied
by the recognition that the use of insulin requires specific In 1995, a task force to revise the National Standards for
knowledge and skills. On the basis that ’teaching is cheaper Diabetes Treatment of the American Diabetes Association
than nursing’, as early as the 1930s, Joslin developed recommended that diabetes education be renamed, and
teaching materials containing individualized diet plans and created the technical term ’diabetes self-management educa-
insulin dosing schemes, as well as instructions for diabetic tion’. Consequently, the overall objectives of DSME switched
foot care and treatment of early acidosis and hypoglycaemia to an emphasis on informed decision-making, self-care
(then called ’insulin reactions’) [8]. behaviour, problem-solving, and active collaboration and
The next evolution of diabetes education came with the participation with the healthcare team to improve not only
availability of blood glucose self-monitoring in the late clinical outcomes but also health status, coping with the
1970s, enabling intensive insulin therapy which allowed chronic condition, and quality of life [14]. This approach is
greater flexibility in lifestyle. Philipp Assal and Michael designed to provide people with the tools to manage diabetes
Berger proposed that structured education programmes autonomously, increasing their feeling of control over the
were necessary to equip people with type 1 diabetes with chronic condition and its treatment, and, most importantly,

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DIABETICMedicine Trends in diabetes self-management education  N. Hermanns et al.

introduces shared decision-making between the healthcare emotional aspects of living with diabetes, motivational issues
team and those affected [6]. and social support, were now incorporated into structured
Diabetes education for type 1 diabetes also paved the way DSME programmes [18].
for structured diabetes education in type 2 diabetes. In
addition to the management of glycaemic control, the
Efficacy of DSME in type 1 diabetes
treatment of type 2 diabetes requires the management of
metabolic risk factors such as weight, lipid levels and Glycaemic control is a central and prognostically relevant
hypertension to reduce the risk of cardiovascular complica- outcome of all diabetes therapies. As DSME is an integral
tions [5]. In more behaviourally oriented concepts of lifestyle part of diabetes management, it should also be evaluated
modification, simple advice and recommendations for life- by the central outcome used for diabetes therapies: HbA1c
style changes were replaced by an analysis of the function- level. As DSME increases the competence and skills of
ality of certain behaviours. For example, if eating behaviour people with diabetes in their treatment, it would also be
frequently occurred in response to stressful or boring expected to reduce disease burden and improve psychoso-
situations, problem-solving strategies for these specific situ- cial outcomes. For the evaluation of the efficacy of DSME
ations might be more effective than the advice to eat less. A on HbA1c and psychosocial outcomes, we concentrated on
review and meta-analysis by Norris et al. [5] concluded that meta-analytical findings during the last 25 years (for the
the shift towards empowerment with a self-management- literature research strategy, see Supporting Information). In
centred approach was more effective in people with type 2 type 1 diabetes, we identified two meta-analyses [23,24] on
diabetes regarding glycaemic and metabolic measurements the effects of DSME on different outcomes. The meta-
than the primarily knowledge- and didactic-oriented analysis by Pillay et al. [24] included 36 randomized
approach [5]. controlled trials (RCTs) and found an overall significant
impact on HbA1c with a mean reduction of 0.29
percentage points (95% CI 0.45 to 0.13) at the 6-month
Mental health
follow up. The efficacy of DSME in adults [ 0.38 (95% CI
Another remarkable result of the early review from Norris 0.82 to 0.06)] was higher than that in adolescents or
et al. was the finding that psychological aspects were rarely children [ 0.26 (95% CI 0.47 to 0.05)]. The impact of
explicitly addressed, since only six out of 72 studies (8.3%) DSME on HbA1c tended to become smaller with longer
reported the psychological outcomes of DSME [5]. In the follow-up periods. In addition, efficacy with regard to
following years, however, there was growing interest in HbA1c also differed with the choice of the control group
mental health issues in diabetes. In 1994, a working group of (usual care vs active control), with fewer studies having an
the WHO/International Diabetes Federation St Vincent active control group (Table 1).
declaration stressed that diabetes treatment should not only The second meta-analysis was limited to children and
improve metabolic measurements, but also encourage psy- young people with type 1 diabetes and included 10 RCTs.
chological well-being in people with diabetes [15]. As The studies had mixed follow-up periods that ranged from
epidemiological evidence demonstrates, quality of life in 2.3 to 24 months. Overall, a non-significant HbA1c reduction
people with diabetes is reduced [16,17], and evidence of 0.1% (95% CI 0.4 to 0.2) was observed (Table 1). This
emerged that having diabetes could be a precipitating factor represents a small effect size of 0.06 (95% CI 0.21 to 0.09)
for poor mental health [18]. At the turn of the millennium, [23]. Both meta-analyses thus indicate that DSME has lower
depression in diabetes became an important issue as it was efficacy with regard to glycaemic control in children and
evident that rates of depression in diabetes were doubled adolescents than in adults.
compared to the general population [19]. Depression also Effects of DSME on psychosocial outcomes were
emerged as an independent risk factor for diabetes outcomes reported significantly less frequently than effects on gly-
such as quality of life, self-management behaviour, morbidity caemic control. Pillay et al. [24] did not find a significant
and mortality [18]. This also led to a heightened interest in impact of DSME on diabetes-specific and general quality of
the effects of DSME on psychosocial outcomes and mental life, depression, or diabetes distress (Table 2). The meta-
health. Since depression is a rather general concept, with a analysis by Charalampopoulos et al. [23] surveyed a
symptomatology independent from diabetes, a more proxi- broader spectrum of psychosocial outcomes, such as self-
mal marker of mental health in diabetes was introduced: efficacy, general and diabetes-specific quality of life,
diabetes distress [20,21]. Diabetes distress is viewed as an diabetes distress and family functioning. No significant
emotional response to the fact of having diabetes and is effects of DSME on these psychosocial domains was
caused by an imbalance in diabetes-related stressors and observed. The impact of DSME on psychosocial outcomes
individual coping abilities [18]. Diabetes distress has there- appears to be lower than its impact on glycaemic control
fore also become a key target for interventions [18,22]. This (Table 1); however, the fact that DSME studies are usually
heightened interest in mental health also led to an adjustment not powered for proving effects on psychosocial outcomes
in DSME [6], whereby the psychosocial aspects, such as the as the primary outcome should be taken into account. Lack

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PSAD Special Issue Paper DIABETICMedicine

Table 1 Meta-analytical findings on the efficacy of diabetes self-management education on HbA1c in type 1 diabetes

Control Included Number

Meta-analysis Population group studies (participants) MD (95% CI) I2 statistic, % of RCTs

Short-term follow-up (end of intervention)

Pillay et al. 2015 [24] Youths Usual care 14 (975) 0.12 ( 0.43 to 0.19) 53 13/14
Youths Active control 3 (419) 0.33 ( 1.65 to 0.99) 69 3/3
Adults Usual care 5 (502) 0.28 ( 0.57 to 0.01) 0 4/5
Adults Active control 1 (110) 0.35 ( 0.81 to 0.11) – 1/1
Medium-term follow-up (6-month follow-up)
Pillay et al. 2015 [24] Youths Usual care 12 (1418) 0.26 ( 0.47 to 0.05) 35 11/12
Youths Active control 2 (208) 0.60 ( 2.56 to 1.36) 0 2/2
Adults Usual care 2 (250) 0.38 ( 0.82 to 0.06) 0 2/2
Adults Active control 2 (259) 0.38 ( 0.93 to 0.17) 0 2/2
Long-term follow-up (≥12-month follow-up)
Pillay et al. 2015 [24] Youths Usual care 8 (1402) 0.29 ( 0.60 to 0.02) 59 7/8
Youths Active control 2 (195) 0.52 ( 1.04 to 0.00) 0 2/2
Adults Active control 1 (110) 0.14 ( 0.61 to 0.33) – 1/1
Charalampopoulos Youths Usual care 9 (1838) 0.1 ( 0.4 to 0.2) 59.9 9/9
et al. 2017 [23]

MD, mean difference in % HbA1c; RCT, randomized controlled trial.

I2 statistic = measure of heterogeneity of included trials in the meta-analysis.

of statistical power might therefore partially explain this The results regarding empowerment and self-efficacy were
finding [25]. more positive, with effect sizes of up to 1.21 standard
More recent DSME programmes that also incorporate deviations. The impact of DSME on quality of life outcomes
coaching and cognitive behavioural therapeutic elements are therefore mixed (Table 4).
had a larger impact on the reduction of diabetes distress,
which ranged from 0.47 [26] to 1.13 [13,27] standard
New diabetes technologies
deviations. This might indicate that newer DSME might be
better at addressing the negative emotional impact of type 1 The last 25 years have seen a rapid development of diabetes
diabetes. technologies. Insulin pumps with more functions, improved
continuous glucose monitoring (CGM) systems, automated
or semi-automated closed-loop systems and digital glucose
Efficacy of DSME on type 2 diabetes
analysis have provided great opportunities for diabetes care
Much more evidence is available regarding the efficacy of and hold great potential to improve life with diabetes [50,
DSME in type 2 than in type 1 diabetes. We identified 21 S1]. However, these new diabetes technologies require new
meta-analyses on the efficacy of DSME in type 2 diabetes, expertise, knowledge and skills because they must all still be
which included more than 450 primary studies with a effectively used by the person with diabetes and carefully
combined total of >74 000 participants [28–48]. The meta- monitored or supervised. For example, real-time CGM and
analytical studies reported results on different follow-up intermittently scanned CGM also require skills to process the
periods (Table 3), which ranged from 1 to 24 months. The magnitude of glucose information provided by the systems.
reduction in HbA1c within different follow-up periods This amount of information must be integrated into mean-
showed an expected decreasing effect of DSME on HbA1c ingful treatment decisions while avoiding overreaction in
with longer follow-up periods in type 2 diabetes as well. response to single glucose readings. New glycaemic outcome
Perrin et al. [48] recently published a meta-analysis of the measures such as time in range, time in hypo- or hypergly-
impact of DSME on diabetes distress as a key mental health caemic range, and glycaemic variability were established and
outcome [48]. A mean reduction in diabetes distress scores of now stand alongside more traditional outcomes such as
0.13 standard deviations (95% CI 0.25 to 0.01) was HbA1c [S2].
observed, an impact of DSME on diabetes distress in type 2 Data from the type 1 registry of the USA showed that the
diabetes which was smaller than that in type 1 diabetes. The adoption of new technologies is rapidly rising [49]. The use
differences in the efficacy of DSME on reducing diabetes of CGM increased from 6% of people with diabetes in 2012
distress between type 1 and type 2 diabetes could be to 38% in 2017. In children, the use of insulin pump therapy
attributable to several factors, such as the higher rate of rose to 63% [49]; however, despite the wide adoption of new
comorbidities in type 2 diabetes, the overall deteriorating technologies, longitudinal real-world data from the type 1
progression of type 2 diabetes necessitating intensification of registry showed that HbA1c values rose from 61.7 mmol/mol
therapy, and circumstances of life due to age differences. to 68.3 mmol/mol during this period. This might indicate

ª 2020 Diabetes UK 439

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DIABETICMedicine

Table 2 Meta-analytical findings on the efficacy of diabetes self-management education on mental-health outcomes in type 1 diabetes

Included
studies I2 Number
Meta-analysis Population Outcome Follow-up period (participants) SMD (95% CI) statistic, % of RCTs

Depression
Pillay et al. 2015 [24] Adults Depression (HADS) Short-term (end of intervention) 1 (74) 0.51 ( 0.97 to 0.05) – 1/1
Pillay et al. 2015 [24] Adults Depression (PHQ-9) Medium-term (6-month follow-up) 1 (235) 0.20 ( 0.05 to 0.46) – 1/1
Pillay et al. 2015 [24] Adults Depression (CES-D) Medium-term (6-month follow-up) 1 (149) 0.30 ( 0.63 to 0.02) – 1/1
Distress
Pillay et al. 2015 [24] All ages Diabetes distress Short-term (end of intervention) 4 (209) 0.31 ( 0.83 to 0.21) NR 4/4
Pillay et al. 2015 [24] All ages Diabetes distress Medium-term (6-month follow-up) 4 (236) 0.28 ( 0.94 to 0.38) NR 4/4
Charalampopoulos Youths Psychological distress Mixed (2.3 to 24-month follow-up) 5 (1357) 0.28 ( 0.59 to 0.02) 87.3 5/5
et al. 2017 [23]
Quality of Life
Pillay et al. 2015 [24] All ages Diabetes quality of life Short-term (end of intervention) 3 (212) 0.08 ( 1.44 to 1.60) NR 2/3
Charalampopoulos Youths Diabetes Quality of Life Long-term (12 to 24 months) 6 (1677) 0.06 ( 0.13 to 0.02) 0 6/6
et al. 2017 [23]
Pillay et al. 2015 [24] All ages General quality of life Short-term (end of intervention) 7 (474) 0.15 ( 0.16 to 0.46) NR 7/7
Pillay et al. 2015 [24] All ages General quality of life Medium-term (6-month follow-up) 1 (53) 0.29 ( 0.83 to 0.26) – 1/1
Charalampopoulos Youths General quality of life Long-term (24 months) 2 (619) 0.02 ( 0.14 to 0.18) 0.0 2/2
et al. 2017 [23]
Pillay et al. 2015 [24] All ages General quality of life Long-term (12 months) 2 (405) 0.02 ( 0.11 to 0.15) NR 2/2
Other
Charalampopoulos Youths Self-efficacy Long-term (12 to 24 months) 4 (511) 0.30 ( 0.16 to 0.76) 70.6 4/4
et al. 2017 [23]
Charalampopoulos Youths Family functioning Mixed (2.3 to 24-month follow-up) 4 (700) 0.02 ( 0.26 to 0.23) 50.8 4/4
et al. 2017 [23]

CES-D, Center for Epidemiologic Studies Depression Scale; HADS, Hospital Anxiety and Depression Scale; NR, not reported; PHQ-9, Patient Health Questionnaire; RCT, randomized controlled
trial; SMD, standardized mean difference.
I2 statistic = measure of heterogeneity of included trials in the meta-analysis.
Trends in diabetes self-management education  N. Hermanns et al.

ª 2020 Diabetes UK
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 Table 3 Meta-analytical findings on the efficacy of diabetes self-management education on HbA1c in type 2 diabetes

ª 2020 Diabetes UK
Included studies Number
Meta-analysis Follow-up period (participants) MD (95% CI) I2 statistic, % of RCTs

Short-term follow-up
PSAD Special Issue Paper

Deakin et al. 2005 [31] Short-term (4 to 6-month follow-up) 3 (395) 1.4 ( 1.9 to 0.8) 36.7 2/3
Cheng et al. 2017 [44] Short-term (3 to 6-month follow-up) 11 (1947) 0.49 ( 0.77 to 0.2) 85 11/11
Jiang et al. 2019 [47] Short-term (3 to 6-month follow-up) 4 (508) 0.61 ( 0.87 to 0.35) 21 3/4
Ricci-Cabello et al. 2014 [36] Short-term (1-month follow-up) 20 (3149) 0.31 ( 0.48 to 0.14) 0.0 Mixed
Azami et al. 2018 [45] Short-term (1 to 6-month follow-up) 12 (1102) 0.96 ( 1.23 to 0.68) 61 12/12
Norris et al. 2002 [29] Short-term (≥ 4-month follow-up) 8 (1361) 0.26 ( 0.48 to 0.05) Q sig. level > 0.10 8/8
Sherifali et al. 2016 [40] Short-term (≤6-month follow-up) 6 (500) 0.23 ( 0.37 to 0.09) 2 6/6
Medium-term follow-up
Hawthorne et al. 2010 [33] Medium-term (6-month follow-up) 6 (729) 0.6 ( 0.85 to 0.35) 31.7 6/6
Steinsbekk et al. 2012 [28] Medium-term (6-month follow-up) 13 (1827) 0.44 ( 0.69 to 0.19) 55.8 13/13
Pillay et al. 2015 [38] Medium-term (6-month follow-up) 23 (4138) 0.16 ( 0.36 to 0.04) 61 23/23
Creamer et al. 2016 [41] Medium-term (6-month follow-up) 13 (2271) 0.53 ( 0.72 to 0.35) NR 13/13
Duke et al. 2009 [32] Medium-term (6 to 9-month follow-up) 3 (295) 0.23 ( 0.49 to 0.03) 16 3/3
Zhao et al. 2017 [42] Medium-term (6 to 12-month follow-up) 16 (4642)† 0.38 ( 0.51 to 0.26) 16.9 16/16
Cheng et al. 2017 [44] Medium-term (6 to 12-month follow-up) 6 (1224) 0.44 ( 0.63 to 0.25) 0 6/6
Odgers-Jewell et al. 2017 [43] Medium-term (6 to 10-month follow-up) 30 (4107) 0.31 ( 0.48 to 0.15) 65 Mixed
Minet et al. 2010 [34] Medium-term (≤ 12-month follow-up) 23 (3757)† 0.43 ( 0.65 to 0.21) NR‡ 23/23
Sherifali et al. 2016 [40] Medium-term (>6-month follow-up) 2 (224) 0.57 ( 0.76 to 0.38) 0 2/2
Long-term follow-up
Hawthorne et al. 2010 [33] Long-term (12-month follow-up) 3 (660) 0.14 ( 0.42 to 0.15) NR 3/3
Steinsbekk et al. 2012 [28] Long-term (12-month follow-up) 11 (1503) 0.46 ( 0.74 to -0.18) 64.6 11/11
Pillay et al. 2015 [38] Long-term (12-month follow-up) 9 (1494) 0.14 ( 0.4 to 0.12) 59 9/9
Creamer et al. 2016 [41] Long-term (12-month follow-up) 9 (1966) 0.19 ( 0.34 to 0.04) 17 9/9
Duke et al. 2009 [32] Long-term (12 to 18-month follow-up) 4 (632) 0.08 ( 0.25 to 0.08) 31 4/4
Deakin et al. 2005 [31] Long-term (12 to 14-month follow-up) 7 (1044) 0.8 ( 1.0 to 0.7) 18.0 6/7
Odgers-Jewell et al. 2017 [43] Long-term (12 to 14-month follow-up) 27 (4384) 0.33 ( 0.49 to 0.17) 64 Mixed
Minet et al. 2010 [34] Long-term (>12-month follow-up) 10 (1633)† 0.06 (-0.39 to 0.28) NR‡ 10/10
Cheng et al. 2017 [44] Long-term (>12-month follow-up) 2 (649) 0.07 ( 0.06 to 0.19) 34 2/2
Unclear or mixed follow-up periods
Sherifali et al. 2015 [37] unclear 17 (4517) 0.2 ( 0.31 to 0.1) 71 17/17
Ellis et al. 2004* [30] Mixed (3 to 15-month follow-up) 20 (1768) 0.32 ( 0.57 to –0.07) Q = 14 20/20
Ferguson et al. 2015 [39] Mixed (6 to 12-month follow-up) 11 (2616) 0.33 ( 0.57 to -0.08) 78.2 11/11
Cunningham et al. 2018 [46] Mixed (1 to 24-month follow-up) 8 (1630) 0.08 ( 0.4 to 0.23) 92 8/8
Perrin et al. 2019 [48] Mixed (1 to 24-month follow-up) 23 (3818) 0.28 ( 0.48 to 0.08) 70.6 23/23
Tshiananga et al. 2012* [35] Mixed (1 to >12-month follow-up) 34 (5993) 0.48 ( 0.71 to 0.18) 88.2 34/34

MD, mean difference in % HbA1c; NR, not reported; RCT, randomized controlled trial.
I2 statistic = measure of heterogeneity of included trials in the meta-analysis; Mixed = inclusion of non-RCTs.
*Studies included type 2 + type 1 diabetes; †Estimated sample size; ‡Significant heterogeneity mentioned but no statistic reported.

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DIABETICMedicine Trends in diabetes self-management education  N. Hermanns et al.

that technology alone is not a remedy for poor glycaemic

Translation into routine care:
control. Exaggerated expectations or perceived barriers to
implementation
diabetes technologies are important determinants of the long-
term implementation, attrition and outcomes of these tech- For the translation of DSME into routine care, it is important
nologies [S3–S5]. This also poses new challenges for DSME, that DSME has the same effect size on study outcomes in
which should thus also address the psychosocial aspects of real-world settings as it does in more restricted study
using these diabetes technologies. conditions. In a series of real-world studies, the Dose
Adjustment for Normal Eating (DAFNE) study group
showed that the magnitude of education effects observed in
Digitalization
the original DAFNE RCT [12] can also be replicated under
Digital solutions have become increasingly available in conditions of routine care [13,S9,S10]. The DAFNE study
diabetes care and have the ability to support empowerment group also showed the stability of study effects over 1 year in
and self-management. Diabetes apps have the potential to real-world settings. In two comparative effectiveness trials,
simplify daily diabetes care by providing either feedback to Ehrmann et al. [S11] and Bergis et al. [S5] showed that the
improve self-management or summary reports on glucose RCT results of two DSME programmes for people with type
data or lifestyle characteristics [S6]. Results of a meta- 1 diabetes and for insulin pump users could also be replicated
analysis based on 14 RCTs showed that mobile apps can in routine care settings. This indicates for type 1 diabetes that
reduce HbA1c by 0.36 percentage points (95% CI 0.87 to the DSME effects found in RCTs can be translated into
0.14) in type 1 diabetes and by 0.49 percentage points routine care.
(95% CI 0.68 to 0.30) in type 2 diabetes. It is noteworthy Another important question regarding the translation of
that a sub-analysis including only high-quality studies DSME into routine care is the extent to which DSME is
showed a reduction of only 0.1 and 0.41 percentage adopted into such care. The adoption rates of DSME
points, respectively, indicating that such mobile apps might differ among countries. For example, in the UK, the
be more effective in type 2 diabetes than in type 1 diabetes National Diabetes Audit showed somewhat sobering
[S6]. results regarding participation in DSME. Fewer than
Web-based interventions can allow consultations between 10% of people with type 1 or type 2 diabetes had
people with diabetes and healthcare professionals via the attended DSME, despite DSME being offered to 40% of
internet. Many web-based programmes also allow people people with type 1 diabetes and 90% of people with type
with diabetes to submit diabetes data (e.g. glucose data), 2 diabetes. Coates et al. [S12] showed that the reasons for
which can then be discussed online with the healthcare not participating in DSME were heterogeneous and highly
provider. A meta-analysis including 19 studies of type 2 individual.
diabetes from Zhai et al. [S7] demonstrated a rather large In North Rhine Westphalia, the most populous region in
reduction in HbA1c of 0.62 percentage points (95% CI Germany, 580 000 people with diabetes are registered in a
0.82 to 0.42) in these web-based interventions. In addi- disease management programme for diabetes which defines
tion, 12 studies that provided telephone- or SMS-based treatment targets, timing and frequency of medical check-
feedback saw a similar mean reduction in HbA1c of 0.53 ups, and regulates participation in DSME [S13]. Overall,
(95% CI 0.81 to 0.25) percentage points. 72.7% of registered people with type 2 diabetes and 90% of
The latest developments involve real-time glucose data- registered people with type 1 diabetes participated in
sharing with healthcare professionals and people from the structured DSME, showing a much higher participation rate
personal social support system. Thus, new options for than in the UK.
diabetes care are constantly evolving to include social media Explanations for the different uptake of DSME in the UK
and online communities that facilitate peer-to-peer contact and Germany are, of course, difficult, since the healthcare
among people with diabetes. This can enhance the experience systems of these countries differ considerably. Contextual
of social support, knowledge and empowerment of people factors such as the availability of diabetes educators on a
with diabetes. Online communities are available around the large scale, a widespread system of secondary care practices
clock, in contrast to traditional DSME group sessions or offering DSME free of charge for people with diabetes, the
face-to-face peer support, which rely on appointments. integration of DSME in a structured disease management
Certainly, the reach of digital solutions is greater than that programme, and reimbursement of DSME for healthcare
of traditional DSME and can therefore supplement struc- professionals might contribute to the greater adoption of
tured face-to-face DSME in certain groups of people with DSME in Germany.
diabetes with limited access to healthcare. Blended pro- Results from the disease management programme report in
grammes such as the HypoAWARE or REDEEM studies, Germany, however, showed that 58% of people with type 1
consisting of a combination of face-to-face and digital diabetes still fail to attain the glycaemic target established by
solutions, could enrich classic DSME and provide better the German Diabetes Association, despite the relatively high
ongoing support to maintain the benefits of DSME [28,S8]. adoption rate of DSME [S13]. This might indicate that the

442 ª 2020 Diabetes UK

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Table 4 Meta-analytical findings on the efficacy of diabetes self-management education on mental-health outcomes in type 2 diabetes
PSAD Special Issue Paper

Included studies Number

Meta-analysis Outcome Follow-up period (participants) SMD or MD (95% CI) I2 statistic, % of RCTs

Diabetes Distress / Depression

Perrin et al. 2019 [48] Diabetes distress Mixed (0.25 to 24-month follow-up) 32 (5213) SMD: 0.13 ( 0.25 to 0.01) 77.4 32/32
Pillay et al. 2015 [38] Diabetes distress Medium-term (6-month follow-up) 4 (1382) MD: -1.89 ( 4.37 to 0.59) 0 4/4
Pillay et al. 2015 [38] Diabetes distress Long-term (12-month follow-up) 3 (757) MD: 1.30 ( 5.84 to 3.24) 0 3/3
Cheng et al. 2017 [44] Psychologial distress Mixed 2 (506) SMD: 0.21 ( 0.39 to 0.04) NR 2/2
Pillay et al. 2015 [38] Depression symptoms Medium-term (6-month follow-up) 5 (1189) SMD: 0.09 ( 0.57 to 0.39) 80 5/5
Empowerment / Self-efficacy
Deakin et al. 2005 [31] Empowerment/self-efficacy Short-term (4-month follow-up) 1 (314) MD: 0.3 (0 to 0.6) – 1/1
Deakin et al. 2005 [31] Empowerment/self-efficacy Long-term (14-month follow-up) 1 (314) MD: 0.3 (0.04 to 0.6) – 1/1
Jiang et al. 2019 [47] Self-efficacy Short-term (3 to 6-month follow-up) 4 (499) SMD: 1.17 (0.61 to 1.73) 88 2/4
Jiang et al. 2019 [47] Self-efficacy Short-term (<3-month follow-up) 4 (554) SMD: 0.61 (0.23 to 0.98) 75 3/4
Odgers-Jewell et al. 2017 [43] Self-efficacy Long-term (12-month follow-up) 3 (528) SMD: 0.15 ( 0.02 to 0.33) 0 Mixed
Zhao et al. 2017 [42] Self-efficacy Mixed (3 to 12-month follow-up) 7 (1830) SMD: 1.21 (0.50 to 1.92) 97.5 7/7
Cheng et al. 2017 [44] Self-efficacy Mixed 3 (533) SMD: 0.29 (0.14 to 0.44) NR 3/3
Quality of Life
Deakin et al. 2005 [31] Quality of life Short-term (4 to 6-month follow-up) 2 (406) No pooling possible – no significant – 2/2
effect in both studies
Jiang et al. 2019 [47] Quality of life Short-term (3 to 6-month follow-up) 3 (342) SMD: 0.29 (0.08 to 0.50) 41 2/3
Steinsbekk et al. 2012 [28] Quality of life Medium-term (6-month follow-up) 3 (473) SMD: 0.31 ( 0.15 to 0.78) 77.1 3/3
Pillay et al. 2015 [38] Quality of life Medium-term (6-month follow-up) 3 (789) SMD: 0.08 ( 0.11 to 0.27) 0 3/3
Zhao et al. 2017 [42] Quality of life Mixed (3 to 12-month follow-up) 5 (738) SMD: 0.30 (0.04 to 0.56) 61.9 5/5
Deakin et al. 2005 [31] Quality of life Long-term (12 to 14-month follow-up) 2 (426) No pooling possible - no significant – 2/2
effect in both studies
Cheng et al. 2017 [44] Quality of life Mixed 5 (972) SMD: 0.31 ( 0.30 to 0.92) NR 5/5
Cunningham et al. 2018 [46] Quality of life Mixed (1 to 24-month follow-up) 5 (596) No pooling possible – significant – 5/5
effects in four studies
Pillay et al. 2015 [38] Diabetes-specific quality of life Medium-term (6-month follow-up) 3 (366) SMD: 0.04 ( 0.38 to 0.3) 0 3/3
Pillay et al. 2015 [38] Diabetes-specific quality of life Long-term (12-month follow-up) 2 (325) SMD 0.09 ( 1.15 to 0.97) 0 2/2

MD, mean difference; NR, not reported; RCT, randomized controlled trial; SMD, standardized mean difference.
I2 statistic = measure of heterogeneity of included trials in the meta-analysis; Mixed = inclusion of non-RCTs.

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DIABETICMedicine Trends in diabetes self-management education  N. Hermanns et al.

translation of DSME into action in the type 1 diabetes comparability of the psychosocial outcomes of different
population has room for improvement and that high partic- DSME programmes [S16,S17].
ipation rates in current DSME programmes do not guarantee Another key problem is the rather slow implementation of
that glycaemic targets will be attained. DSME into clinical routine [S18]. Aside from the availability
of DSME programmes, several contextual and individual
factors might be associated with the slow uptake of DSME in
What are the current gaps?
clinical practice. The integration of DSME in structured
The present review revealed several gaps in the efficacy, disease management programmes associated with reimburse-
adoption in routine care, and concept of DSME, and these ment and the availability of trained personnel with expertise
should be addressed by further researchers and the key in diabetes education and patient-centred care has been
stakeholders of the healthcare system. found to be helpful for the implementation of DSME in
The reviewed evidence regarding the efficacy of DSME in Germany. Healthcare service research may help by examin-
type 1 and type 2 diabetes has indeed shown that DSME has ing which elements are useful for the implementation of
a significant impact on glycaemic control, but the observed DSME in routine care.
improvements were small to medium-sized. For better Large heterogeneity was also apparent among the reviewed
prevention of long-term diabetes complications, ways to studies regarding aspects of DSME programmes such as type
improve the impact of DSME on glycaemic control need to of intervention, concepts of DSME, duration and format.
be explored further. This is especially relevant because the The interventions which were included in the studies differed
effect of DSME on HbA1c tends to decline with longer as to whether they emphasized knowledge and skills or self-
follow-up periods; therefore, an ongoing support measure management and psychological aspects. The lengths of the
after the completion of DSME might be helpful to prevent a programmes as well as their format also differed (e.g. one-to-
decline in the treatment effect after the completion of DSME. one interventions, group education, or mixed interventions).
More research is needed to examine whether digital solutions Given this plethora of possible differences between DSME
such as apps or online communities might be an important programmes, it is not clear what elements of DSME are most
element for this ongoing support. effective. The meta-analysis of Fan et al. [S19] provides
The reviewed studies clearly indicate lower efficacy of initial results, indicating that interactive delivery methods of
DSME in children and adolescents in terms of glycaemic longer duration and with more sessions, as well as the
control and psychosocial outcomes. This represents a clear incorporation of booster sessions, appear to be more effective
gap in current research and care. Sources of diabetes in improving metabolic control and self-management beha-
distress may vary considerably between adults and children viour [S19]; however, more research is necessary to clarify
or adolescents because they face very different developmen- the potential mechanisms of action in different populations
tal tasks. This might have consequences for the assessment of people with diabetes. While the meta-analysis by Fan et al.
of diabetes-related distress, as well as for concepts of provides some indication what intervention elements can
DSME. In addition, type 1 diabetes in children/adolescents improve metabolic control, a clear gap in this regard remains
also leads to considerable distress for parents and care- in studies analysing which elements and components are
givers, who are in part responsible for diabetes therapy. necessary to improve mental health outcomes such as
New DSME concepts might therefore also be necessary to diabetes distress.
target the parents and caregivers of young children [S14, Currently, there is a lack of evaluated DSME for diabetes
S15]. technologies. Only two evaluated DSME programmes exist
The high comorbidity between diabetes and mental health for insulin pump therapy (a modified DAFNE course [S20]
issues and the less pronounced impact of DSME on and the INPUT programme [26]) that demonstrated a similar
psychosocial outcomes clearly shows the need to develop effect on the reduction of HbA1c ( 0.27 and 0.24
effective strategies to improve the impact of DSME on these percentage points, respectively). In addition, positive effects
issues for adults and children. More research is clearly on the number of severe hypoglycaemia events, diabetes
needed to examine whether the integration of psychothera- treatment satisfaction, and some domains of quality of life
peutic techniques such as motivational interviewing, cogni- were reported [27,S20]. For the use of CGM systems, there is
tive behavioural elements or coaching into DSME currently just one DSME programme (named FLASH) which
programmes might be helpful to increase its efficacy in has demonstrated efficacy regarding improved glycaemic
improving diabetes distress or other psychosocial outcomes. control and reduced diabetes distress in an RCT [S21]. In
The psychosocial outcomes of DSME are being assessed summary, DSME that addresses the technological and
with increasing frequency in newer DSME programmes. psychosocial aspects of diabetes technologies can unfold
Currently, a plethora of psychosocial outcomes are being the full potential of these technologies.
examined, and many different instruments are used. An The evaluation of digital solutions is another gap as digital
agreement about a set of mandatory core psychosocial solutions do not necessarily represent a new intervention per
outcome variables assessed in DSME would facilitate the se. In many cases, they are simply a new delivery method

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PSAD Special Issue Paper DIABETICMedicine

(telephone, internet or diabetes apps instead of face-to-face smaller effects of DSME on glycaemic control than in adults
delivery methods) for already established interventions. Some were observed. Improving the efficacy of DSME especially in
studies may therefore overestimate the efficacy of digital children and adolescents remains a challenge for the future.
solutions because the effects of delivery method (digital vs A major change of DSME to a self-management- and
face-to-face) and content cannot be clearly distinguished. empowerment-oriented approach has broadened the scope
Head-to-head comparisons of interventions with similar of DSME outcomes beyond metabolic and diabetes knowl-
content and context but different delivery methods could edge to psychological and mental health outcomes. Techno-
thus provide more clarity in this regard. logical innovations are currently far from rendering DSME
The integration of digital solutions into DSME is also a obsolete, since their use in daily routines usually involves a
current gap. It remains an open question as to which groups certain amount of skills and knowledge and is associated
of people with diabetes profit more from face-to-face with a number of psychological aspects, all of which can
intervention than from digital interventions. The results of frequently be addressed by DSME. Digitalization can
the cited meta-analyses [S6,S7] on digital solutions showed improve the self-management of people with diabetes and
relatively high efficacy; however, it is not clear if the samples provides the possibility of increasing the reach and efficacy of
in the studies were representative of the general population DSME. One major challenge remains the implementation of
of people with diabetes or if the participants were the so- DSME in routine care. These key findings confirm the key
called ’early adopters’ of a new technology, a group which is conclusions of the excellent review by Chatterjee et al. [6]
more likely to profit than people with a more sceptical view that DSME is efficacious in improving glycaemic and mental
of digital solutions. health outcomes by informing, training and motivating
people with diabetes to manage their disease and treatment
requirement on their own. This review additionally identified
Review limitations
DSME in children, adolescents and young adults as a target
The present review has several limitations which should be for improvement. We also identified DSME regarding
kept in mind when interpreting its results. The terms diabetes technology as a current gap but found evidence
’diabetes education’ or ’DSME’ may be used differently in that DSME can improve effective use and acceptance of
the various studies included in this review. The content of diabetes technology. Efforts to implement DSME on a large
DSME and the definitions of the term can also vary across scale might be aided by performing comparisons between
the included studies. The summary of meta-analytical find- countries or healthcare systems with low vs high adoption of
ings is subject to the same bias as the individual meta- DSME into routine care.
analyses with regard to the comparability of the included The studies included in this review were mainly conducted
studies. It is also possible that a single study was included in in western countries with a reasonable healthcare system,
more than one meta-analysis; this is especially true for the therefore, the results are valid primarily for developed
meta-analyses of type 2 diabetes; however, a quality assess- countries, and their transferability to less developed countries
ment of all studies included in these meta-analyses would might be limited. However, since DSME is a cost-effective
have been beyond the framework of a narrative review. intervention [6] and can also be performed in countries with
Based on the I2 statistics as a measure of heterogeneity and lower technological standards, the adoption of DSME in
number of included RCTs (Tables 1–4), the effect estimates developing countries might also be possible.
appear to reliably indicate the effectiveness of DSME. In With diabetes numbers rising worldwide and the conse-
addition, most studies do not report fidelity measures; quent risk of diabetes complications and diabetes-related
therefore, it remains unclear to what extent the theoretical stress that can affect quality of life and mental health, DSME
concept of the examined DSME programmes are actually can be an important pillar in the management of diabetes.
realized and the conduct of the programme was in line with Addressing the identified gaps in research and implementa-
its curriculum. A specific challenge here is that the claim to tion in clinical routine has promising implications for self-
personalize DSME to the individual needs and problems can management in people with diabetes.
challenge the curricular conduct of the DSME programme.

Competing interests
Conclusions
N.H. is an advisory board member of Novo Nordisk,
In the last 25 years, DSME has become an established Abbott, Lilly, Roche Diabetes Care and Ypsomed, has
evidence-based intervention which should be an integral part received speakers’ honoraria from Novo Nordisk, Abbott,
of diabetes treatment in type 1 and type 2 diabetes. The Berlin Chemie, Lilly and Ypsomed, and has received grants in
analysis of the current gaps showed small to medium effect support of investigator trials from Dexcom, Berlin Chemie,
sizes of DSME on glycaemic control in adults. These findings Ypsomed, Abbott and Roche Diabetes Care. D.E. has
are in line with those of Chatterjee et al. [6]. The present received speakers’ honoraria from Berlin Chemie, Sanofi
review further showed that in children and adolescents even and Roche Diabetes Care. K.F.G. has no conflict of interest.

ª 2020 Diabetes UK 445

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DIABETICMedicine Trends in diabetes self-management education  N. Hermanns et al.

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