Structured therapeutic education in diabetes: is it time to re-write the chapter on the prevention of diabetic complications? (original) (raw)
Diabetes mellitus is an epidemic, chronic condition characterized by increased morbidity, disability, and mortality because of frequent complications [[1](/article/10.1007/s12020-016-0947-0#ref-CR1 "A. Coppola, L. Sasso, A. Bagnasco, A. Giustina, C. Gazzaruso, The role of patient education in the prevention and management of type 2 diabetes: an overview. Endocrine (2015). doi: 10.1007/s12020-015-0775-7
")\]. Complications mainly affect the heart, brain, limbs, eyes, nerves, and kidneys; in addition, most of the diabetic patients die from cardiovascular events \[[1](/article/10.1007/s12020-016-0947-0#ref-CR1 "A. Coppola, L. Sasso, A. Bagnasco, A. Giustina, C. Gazzaruso, The role of patient education in the prevention and management of type 2 diabetes: an overview. Endocrine (2015). doi:
10.1007/s12020-015-0775-7
")\]. A strict glycemic control, together with the appropriate management of any associated risk factor, such as hypertension, dyslipidemia, obesity, and thrombotic risk, can significantly decrease the complications of diabetes \[[2](/article/10.1007/s12020-016-0947-0#ref-CR2 "P. Gaede, P. Vedel, N. Larsen, G.V. Jensen, H.H. Parving, O. Pedersen, Multifactorial intervention and cardiovascular disease in patients with type 2 diabetes. New Engl. J. Med. 348(5), 383–393 (2003)")–[4](/article/10.1007/s12020-016-0947-0#ref-CR4 "J.J. Chamberlain, A.S. Rhinehart, C.F. Shaefer Jr, A. Neuman, Diagnosis and management of diabetes: synopsis of the 2016 American Diabetes Association Standards of Medical Care in Diabetes. Ann. Intern. Med. (2016). doi:
10.7326/M15-3016
")\]. The tight control of diabetes and other risk factors is usually obtained by treatments with specific medications \[[2](/article/10.1007/s12020-016-0947-0#ref-CR2 "P. Gaede, P. Vedel, N. Larsen, G.V. Jensen, H.H. Parving, O. Pedersen, Multifactorial intervention and cardiovascular disease in patients with type 2 diabetes. New Engl. J. Med. 348(5), 383–393 (2003)")–[4](/article/10.1007/s12020-016-0947-0#ref-CR4 "J.J. Chamberlain, A.S. Rhinehart, C.F. Shaefer Jr, A. Neuman, Diagnosis and management of diabetes: synopsis of the 2016 American Diabetes Association Standards of Medical Care in Diabetes. Ann. Intern. Med. (2016). doi:
10.7326/M15-3016
")\]. Therapeutic patient education (TPE) is considered a central element of the management of diabetes \[[1](/article/10.1007/s12020-016-0947-0#ref-CR1 "A. Coppola, L. Sasso, A. Bagnasco, A. Giustina, C. Gazzaruso, The role of patient education in the prevention and management of type 2 diabetes: an overview. Endocrine (2015). doi:
10.1007/s12020-015-0775-7
")\]. Many studies have shown that a structured TPE is able to determine a significant improvement in several clinical, lifestyle, and psycho-social outcomes in people suffering from diabetes \[[1](/article/10.1007/s12020-016-0947-0#ref-CR1 "A. Coppola, L. Sasso, A. Bagnasco, A. Giustina, C. Gazzaruso, The role of patient education in the prevention and management of type 2 diabetes: an overview. Endocrine (2015). doi:
10.1007/s12020-015-0775-7
")\]. However, there are a few data regarding the potential direct and indirect role that a structured TPE may have in the prevention of diabetic complications. An early study suggested that complications can occur about 4 times more frequently in diabetic people with no education \[[5](/article/10.1007/s12020-016-0947-0#ref-CR5 "A. Nicolucci, D. Cavaliere, N. Scorpiglione, F. Carinci, F. Capani, G. Tognoni, M.M. Benedetti, A comprehensive assessment of the avoidability of long-term complications of diabetes: a case-control study. SID-AMD Italian Study Group for the Implementation of the St. Vincent declaration. Diabetes Care 19(9), 927–933 (1996)")\]. In the present issue of Endocrine, Wong and colleagues have shown that a structured TPE, called patient empowerment programme (PEP), can determine a lower incidence rate of all-cause mortality and first macrovascular and microvascular events \[[6](/article/10.1007/s12020-016-0947-0#ref-CR6 "C.K. Wong, W.C. Wong, E.Y. Wan, A.K. Chan, F.W. Chan, C.L. Lam, Macrovascular and microvascular disease in obese patients with type 2 diabetes attending structured diabetes education program: a population-based propensity-matched cohort analysis of Patient Empowerment Programme (PEP). Endocrine (2016). doi:
10.1007/s12020-015-0843-z
")\]. Nevertheless, an additional benefit was not observed in obese diabetic subjects who participated in a specific weight management program \[[6](/article/10.1007/s12020-016-0947-0#ref-CR6 "C.K. Wong, W.C. Wong, E.Y. Wan, A.K. Chan, F.W. Chan, C.L. Lam, Macrovascular and microvascular disease in obese patients with type 2 diabetes attending structured diabetes education program: a population-based propensity-matched cohort analysis of Patient Empowerment Programme (PEP). Endocrine (2016). doi:
10.1007/s12020-015-0843-z
")\]. However, the present study has confirmed previous data on the effectiveness of PEP in decreasing complications and mortality in people with diabetes \[[7](/article/10.1007/s12020-016-0947-0#ref-CR7 "C.K. Wong, W.C. Wong, A.K. Chan, K.L. Chung, F.W. Chan, C.L.K. Lam, Patient Empowerment programme in primary care reduced all-cause mortality and cardiovascular diseases in patients with type 2 diabetes mellitus: a population-based propensity-matched cohort study. Diabetes Obes. Metab. 17(2), 128–135 (2015)"), [8](/article/10.1007/s12020-016-0947-0#ref-CR8 "C.K. Wong, W.C. Wong, Y.F. Wan, A.K. Chan, F.W. Chan, C.L. Lam, Patient empowerment programme (PEP) and risk of microvascular diseases among patients with type 2 diabetes in primary care: a population-based propensity-matched cohort study. Diabetes Care 38(8), e116–e117 (2015)")\]. In the recent long-term study with a follow-up of about 13 years, a structured personal care delivered by general practitioners to 1381 newly diagnosed type 2 diabetic patients was able to reduce mortality and morbidity in women but not in men \[[9](/article/10.1007/s12020-016-0947-0#ref-CR9 "M.O. Krag, L. Hasselbalch, V. Siersma, A.B.S. Nielsen, S. Reventlow, K. Malterud, N. de Fine Olivarius, The impact of gender on long-term morbidity and mortality of patients with type 2 diabetes receiving structured personal care: a 13 year follow-up study. Diabetologia 59, 275–285 (2016)")\]. These findings should open an active debate and stimulate new research on the decisive role that TPE can play in the prevention of diabetic complications and in the reduction of mortality. On the other hand, the American Association of Diabetes Educators has suggested that diabetes self-management education and support should be an essential tool to reduce the risks of complications and death \[[10](/article/10.1007/s12020-016-0947-0#ref-CR10 "D. Kent, G. D’EramoMelkus, P.M. Stuart, J.M. McKoy, P. Urbanski, S.A. Boren, L. Coke, J.E. Winters, N.L. Horsley, D. Sherr, R. Lipman, Reducing the risks of diabetes complications through diabetes self-management education and support. Popul. Health Manag. 16(2), 74–81 (2013)")\]. In other words, a structured TPE should be always added to medications not only to better manage the disease but also to reduce its risks. The new findings suggest some questions: Could TPE improve the impressive results obtained with medications in the prevention of complications and reduction of mortality \[[2](/article/10.1007/s12020-016-0947-0#ref-CR2 "P. Gaede, P. Vedel, N. Larsen, G.V. Jensen, H.H. Parving, O. Pedersen, Multifactorial intervention and cardiovascular disease in patients with type 2 diabetes. New Engl. J. Med. 348(5), 383–393 (2003)"), [11](/article/10.1007/s12020-016-0947-0#ref-CR11 "B. Zinman, C. Wanner, J.M. Lachin, D. Fitchett, E. Bluhmki, S. Hantel, M. Mattheus, T. Devins, O.E. Johansen, H.J. Woerle, U.C. Broedl, S.E. Inzucchi, EMPA-REG Outcome Investigators, Empagliflozin, cardiovascular outcomes, and mortality in type 2 diabetes. New Engl. J. Med. 373(22), 2117–2128 (2015)")–[13](/article/10.1007/s12020-016-0947-0#ref-CR13 "H.M. Colhoun, D.J. Betteridge, P.N. Durrington, G.A. Hitman, H.A. Neil, S.J. Livingstone, M.J. Thomason, M.I. Mackness, V. Charlton-Menys, J.H. Fuller, CARDS investigators, Primary prevention of cardiovascular disease with atorvastatin in type 2 diabetes in the Collaborative Atorvastatin Diabetes Study (CARDS): multicentre randomised placebo-controlled trial. Lancet 364(9435), 685–696 (2004)")\]? Could TPE modify the results of the trials which failed to show significant differences in the outcomes between intervention and control group \[[14](/article/10.1007/s12020-016-0947-0#ref-CR14 "M. Meier, M. Hummel, Cardiovascular disease and intensive glucose control in type 2 diabetes mellitus: moving practice toward evidence-based strategies. Vasc. Health Risk Manag. 5, 859–871 (2009)"), [15](/article/10.1007/s12020-016-0947-0#ref-CR15 "J.B. Green, M.A. Bethel, P.W. Armstrong, J.B. Buse, S.S. Engel, J. Garg, R. Josse, K.D. Kaufman, J. Koglin, S. Korn, J.M. Lachin, D.K. McGuire, M.J. Pencina, E. Standl, P.P. Stein, S. Suryawanshi, F. Van de Werf, E.D. Peterson, R.R. Holman, TECOS Study Group, Effect of sitagliptin on cardiovascular outcomes in type 2 diabetes. New Engl. J. Med. 373(3), 232–242 (2015)")\]? A sure answer does not exist, but we cannot exclude that TPE could give an additional benefit. Indeed, a synergic effect between medications and TPE on the reduction of complications and death can be hypothesized for at least two reasons: (1) both can improve outcomes in an independent manner and therefore the positive effect may be additive; (2) TPE can optimize effects of medications because of an improvement in adherence \[[16](/article/10.1007/s12020-016-0947-0#ref-CR16 "S. Sapkota, J.A. Brien, J. Greenfield, P. Aslani, A systematic review of interventions addressing adherence to anti-diabetic medications in patients with type 2 diabetes: impact on adherence. PLoS One 10(2), e0118296 (2015)")\]. However, if we assume that TPE can prevent the complications, other investigations should explain whether the effectiveness of TPE reported in the published studies \[[1](/article/10.1007/s12020-016-0947-0#ref-CR1 "A. Coppola, L. Sasso, A. Bagnasco, A. Giustina, C. Gazzaruso, The role of patient education in the prevention and management of type 2 diabetes: an overview. Endocrine (2015). doi:
10.1007/s12020-015-0775-7
"), [6](/article/10.1007/s12020-016-0947-0#ref-CR6 "C.K. Wong, W.C. Wong, E.Y. Wan, A.K. Chan, F.W. Chan, C.L. Lam, Macrovascular and microvascular disease in obese patients with type 2 diabetes attending structured diabetes education program: a population-based propensity-matched cohort analysis of Patient Empowerment Programme (PEP). Endocrine (2016). doi:
10.1007/s12020-015-0843-z
")–[9](/article/10.1007/s12020-016-0947-0#ref-CR9 "M.O. Krag, L. Hasselbalch, V. Siersma, A.B.S. Nielsen, S. Reventlow, K. Malterud, N. de Fine Olivarius, The impact of gender on long-term morbidity and mortality of patients with type 2 diabetes receiving structured personal care: a 13 year follow-up study. Diabetologia 59, 275–285 (2016)")\] can be further increased. At the moment, the ideal characteristics of TPE to give the best results in the management of diabetes and in the prevention of its complications are not defined \[[1](/article/10.1007/s12020-016-0947-0#ref-CR1 "A. Coppola, L. Sasso, A. Bagnasco, A. Giustina, C. Gazzaruso, The role of patient education in the prevention and management of type 2 diabetes: an overview. Endocrine (2015). doi:
10.1007/s12020-015-0775-7
"), [10](/article/10.1007/s12020-016-0947-0#ref-CR10 "D. Kent, G. D’EramoMelkus, P.M. Stuart, J.M. McKoy, P. Urbanski, S.A. Boren, L. Coke, J.E. Winters, N.L. Horsley, D. Sherr, R. Lipman, Reducing the risks of diabetes complications through diabetes self-management education and support. Popul. Health Manag. 16(2), 74–81 (2013)")\]. Therefore, other works are needed to definitively clarify these ideal characteristics: type of PTE (individual or group education, or both), themes, frequency and number of education sessions, contact time between educator and patient, background of educators, use of new technologies \[[1](/article/10.1007/s12020-016-0947-0#ref-CR1 "A. Coppola, L. Sasso, A. Bagnasco, A. Giustina, C. Gazzaruso, The role of patient education in the prevention and management of type 2 diabetes: an overview. Endocrine (2015). doi:
10.1007/s12020-015-0775-7
")\]. Another intriguing consideration regards the fact that TPE was able to significantly reduce the risks due to diabetes, even if in the above-mentioned studies the program included some of the potential themes of education \[[6](/article/10.1007/s12020-016-0947-0#ref-CR6 "C.K. Wong, W.C. Wong, E.Y. Wan, A.K. Chan, F.W. Chan, C.L. Lam, Macrovascular and microvascular disease in obese patients with type 2 diabetes attending structured diabetes education program: a population-based propensity-matched cohort analysis of Patient Empowerment Programme (PEP). Endocrine (2016). doi:
10.1007/s12020-015-0843-z
")–[9](/article/10.1007/s12020-016-0947-0#ref-CR9 "M.O. Krag, L. Hasselbalch, V. Siersma, A.B.S. Nielsen, S. Reventlow, K. Malterud, N. de Fine Olivarius, The impact of gender on long-term morbidity and mortality of patients with type 2 diabetes receiving structured personal care: a 13 year follow-up study. Diabetologia 59, 275–285 (2016)")\]. So, it is likely that a global, comprehensive education could give better results. Therefore, other investigations should clarify whether the positive impact of TPE on the prevention of diabetic complications can be further increased by including additional themes, such as diabetic foot, sexual health, and peripheral artery disease \[[1](/article/10.1007/s12020-016-0947-0#ref-CR1 "A. Coppola, L. Sasso, A. Bagnasco, A. Giustina, C. Gazzaruso, The role of patient education in the prevention and management of type 2 diabetes: an overview. Endocrine (2015). doi:
10.1007/s12020-015-0775-7
"), [17](/article/10.1007/s12020-016-0947-0#ref-CR17 "C. Gazzaruso, A. Coppola, T. Montalcini, E. Baffero, A. Garzaniti, G. Pelissero, S. Collaviti, A. Grugnetti, P. Gallotti, A. Pujia, S.B. Solerte, A. Giustina, Lipoprotein(a) and homocysteine as genetic risk factors for vascular and neuropathic diabetic foot in type 2 diabetes mellitus. Endocrine 41(1), 89–95 (2012)")–[19](/article/10.1007/s12020-016-0947-0#ref-CR19 "C. Gazzaruso, A. Coppola, C. Falcone, C. Luppi, T. Montalcini, E. Baffero, P. Gallotti, A. Pujia, S.B. Solerte, G. Pelissero, A. Giustina, Transcutaneous oxygen tension as a potential predictor of cardiovascular events in type 2 diabetes: comparison with ankle-brachial index. Diabetes Care 36(6), 1720–1725 (2013)")\].The positive effects of a structured TPE on several metabolic, lifestyle, and psycho-social outcomes are well known and all guidelines regarding diabetes recommend delivering an adequate education [[1](/article/10.1007/s12020-016-0947-0#ref-CR1 "A. Coppola, L. Sasso, A. Bagnasco, A. Giustina, C. Gazzaruso, The role of patient education in the prevention and management of type 2 diabetes: an overview. Endocrine (2015). doi: 10.1007/s12020-015-0775-7
")\]. As reported, recent data suggest that TPE may even have a positive impact on the prevention of the complications of diabetes \[[6](/article/10.1007/s12020-016-0947-0#ref-CR6 "C.K. Wong, W.C. Wong, E.Y. Wan, A.K. Chan, F.W. Chan, C.L. Lam, Macrovascular and microvascular disease in obese patients with type 2 diabetes attending structured diabetes education program: a population-based propensity-matched cohort analysis of Patient Empowerment Programme (PEP). Endocrine (2016). doi:
10.1007/s12020-015-0843-z
")–[9](/article/10.1007/s12020-016-0947-0#ref-CR9 "M.O. Krag, L. Hasselbalch, V. Siersma, A.B.S. Nielsen, S. Reventlow, K. Malterud, N. de Fine Olivarius, The impact of gender on long-term morbidity and mortality of patients with type 2 diabetes receiving structured personal care: a 13 year follow-up study. Diabetologia 59, 275–285 (2016)")\]. Nonetheless, in clinical practice, a structured TPE is not delivered to all people with diabetes. Some data are dismaying: <50 % (about 35–40 %) of diabetic people ever attend a diabetes education/behavioral intervention program and about 50 % complete the program \[[20](/article/10.1007/s12020-016-0947-0#ref-CR20 "L. Fisher, R.E. Glasgow, A call for more effectively integrating behavioral and social science principles into comprehensive diabetes care. Diabetes Care 30(10), 2746–2749 (2007)")\]. This is a serious problem that should be avoided. On the other hand, the omission to deliver TPE may explain at least partially why there is the so-called “residual risk” of developing complications, when an adequate control of all risk factors is obtained with medications.In conclusion, it may be the time to re-write the chapter on the prevention of the complications of diabetes. In this new chapter, the structured TPE should have an important role, as it may be pivotal in reducing morbidity, mortality, and disability, if it is delivered to all the patients both in primary care and in diabetes clinics.
References
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