G Model

PEC 5922 No. of Pages 6

Patient Education and Counseling xxx (2018) xxx–xxx

Contents lists available at ScienceDirect

Patient Education and Counseling

journal homepage: www.elsevier.com/locate/pateducou

The effect of diabetes self-management education on psychological

status and blood glucose in newly diagnosed patients with diabetes
type 2
Sanbao Chaia , Baoting Yaob , Lin Xub , Danyang Wangb , Jianbin Suna , Ning Yuana ,
Xiaomei Zhanga,* , Linong Jia,c
a
Department of Endocrinology and Metabolism, Peking University International Hospital, Beijing, 102206, China
b
Department of Endocrinology and Metabolism, First Hospital of Dandong, Dandong, 118000, China
c
Department of Endocrinology and Metabolism, Peking University People's Hospital, Beijing, 100044, China

A R T I C L E I N F O A B S T R A C T

Article history: Objective: The purpose of this study was to evaluate the efficacy of self-management education on
Received 6 October 2017 psychological outcomes and glycemic control in type 2 diabetes mellitus.
Received in revised form 13 March 2018 Methods: Patients were randomly assigned to education group and control group. Education group
Accepted 24 March 2018
received professional education and control group received routine outpatient education.
Results: A total of 118 patients were randomly assigned to two groups (education group, n = 63; control
Keywords: group, n = 55). Compared with control group, the anxiety score (36.00 vs. 42.50, P < 0.05) and depression
Type 2 diabetes mellitus
score (35.50 vs. 44.00, P < 0.05) significantly decreased at the sixth month in education group,
Self-management education
Anxiety
respectively. Compared with control group, fasting blood glucose (6.78 mmol/L vs. 7.70 mmol/L,
Depression P < 0.00), postprandial blood glucose (7.90 mmol/L vs. 10.58 mmol/L, P < 0.00) and glycosylated
Blood glucose haemoglobin A1C level [6.20 (5.80, 6.60)% vs. 6.70 (6.40, 7.30)%, P < 0.01] significantly decreased after
the sixth month in education group.
Conclusion: The psychological status and blood glucose of patients with diabetes receiving self-
management education were significantly improved. Practice Implications: Type 2 diabetes mellitus has
been usually linked to increased prevalence and risk of depression and anxiety, which can affect blood
glucose levels. Through education, the mood of newly diagnosed patients with diabetes improved,
resulting in better blood glucose control.
© 2018 Published by Elsevier B.V.

1. Introduction achieve successful health related outcomes [3]. Diabetes self-

Type 2 diabetes mellitus (T2DM) is a worldwide epidemic, and
its prevalence is growing, creating a global healthcare burden. It is
linked to increased risk of severe cardiovascular complications,
morbidity and mortality which can be reduced by optimal glycemic
control [1]. According to the International Diabetes Federation, in
2015 it was estimated that there were 415 million people with
diabetes aged 20–79 years, and this figure was predicted to rise to
642 million by 2040 [2]. To effectively manage individuals with
diabetes, appropriate education, lifestyle modification, medication
treatment and blood glucose monitoring are all required. Educa-
tion is the foundation of care for all diabetes patients who want to
* Corresponding author at: Life Park Road No.1, Zhongguancun Life Science Park,
Changping District, Beijing, China. 102206.
E-mail address: z.x.mei@163.com (X. Zhang).
management training, the process of teaching individuals to
manage their diabetes, has been considered as an important part of
clinical management since the 1930s. 50–80% individuals with
diabetes lack of knowledge about diabetes education, and ideal
glycosylated haemoglobin A1C (HbA1C) 7.0% target is achieved in
less than half of type 2 diabetes [4,5,6]. Extensive self-management
related to diet, exercise and medication are regarded as critical
treatment for all patients with diabetes [7]. As such, diabetes self-
management education (DSME) is widely recommended and
carried out. However, despite the great variety of DSME programs
that are currently available internationally, there is a lack of
knowledge about the importance of diabetes education in the
treatment of diabetes and in prevention of diabetes complications
in developing countries [8,9]. Also patients with diabetes have an
increased risk of developing mental disorders and psychological
disturbances. Previous studies suggested that compared to the
general population, individuals with diabetes have a higher

https://doi.org/10.1016/j.pec.2018.03.020
0738-3991/© 2018 Published by Elsevier B.V.

Please cite this article in press as: S. Chai, et al., The effect of diabetes self-management education on psychological status and blood glucose in
newly diagnosed patients with diabetes type 2, Patient Educ Couns (2018), https://doi.org/10.1016/j.pec.2018.03.020
G Model
PEC 5922 No. of Pages 6
2 S. Chai et al. / Patient Education and Counseling xxx (2018) xxx–xxx
prevalence of depression and anxiety [10,11]. Therefore, the
primary objective of the present study was to evaluate the efficacy
of self-management education on psychological outcomes and
glycemic control in newly diagnosed T2DM.
2. Methods
2.1. Study design
The study was approved by the Ethics Committee in the First
Hospital of Dandong. The patients involved in the study were recruited
from both outpatients and inpatients of the First Hospital of Dandong.
The physician in charge of this research first introduced the program to
patients eligible. With patients’ consent, the Informed Consent Forms
were signed hereafter. Based on the statistical analysis, there was
about 5% patient eligible but failing to participate in this study. Patients
had the right to refuse to participate in or withdraw from the study at
any time. From May 12016 to July 12016, a total of 118 newly diagnosed
T2DM were recruited into our study. The inclusion criteria were newly
diagnosed type 2 diabetes (18 years) treated with oral hypoglycemic
agents combined with or without insulin. Nursing mothers, pregnant
woman, hepatorenal disease, or psychotic disorders were excluded.
Eligible participants were divided into two groups according to
completely randomized design: education group and control group.
The program duration was six months. The education of the patients
was accomplished by professional education nurses. All nurses were
well-trained. The education courses in this study were delivered under
the guidance of Problem Based Learning (PBL). Lecturing approach,
audio-visual approach, discussion approach and demonstration
approaches were adopted. Lecturing approach was targeted at all
patients and helped them to receive knowledge systematically. Audio-
visual approach was implemented with the assistance of PowerPoint
and video projector etc. Discussion approach was used to encourage
patients to proactively ask questions and express their own feelings.
Through discussion, patients were able to learn from each other and
communicate on knowledge and experience of diabetes. In demon-
stration approach, further explanation was given to patients with the
help of specific models and teaching aids. As for the content of
education courses, we designed a detailed curriculum in advance. We
offered a two-hour course each week, comprising of two sessions of
lectures (40 minutes each), two breaks (10 min each) and interactive
session (20 min). In the interactive session, patients could communi-
cate with each other in groups or raise any questions to the lecturers. In
control group, doctors make more health education with patients.
Patients in the education group were given daily record sheets to track
the diet, physical activities, medications and blood glucose. Patients
should fill in the sheets based on their own conditions and return them
by week. Based on the real-time information, we would assess the
patient conditions and offer corresponding suggestions for better self-
management. The Self-rating Anxiety Scale (SAS) and Self-rating
Depression Scale (SDS) are the scales for assessing anxiety and
depression, which includes 20 problems respectively, using a 4-point
scale ranging from 1 (none, or a little of the time) to 4 (most, or all of the
time) [12,13]. The statistical score of all questions were calculated after
completion of the answers.
2.2. Education group
Patients in the education group were delivered 2-h diabetes
education course by professional educational nurses every week.
Patients in education group were divided into different groups by
their most remarkable feature: overweight group (BMI  24 kg/m2,
30 patients); smoking group (10 cigarettes per day, 10 patients);
sedentary group (7 hours per day, 12 patients); low education
group (high school degree and less, 5 patients); drinking group
(50 g per day, 6 patients). The content of education included
Please cite this article in press as: S. Chai, et al., The effect of diabetes self-management education on psychological status and blood glucose in
newly diagnosed patients with diabetes type 2, Patient Educ Couns (2018), https://doi.org/10.1016/j.pec.2018.03.020
healthy diet, exercise, self-monitoring of blood glucose, complication
prevention and understanding the risk factors of diabetes. Mean-
while, the patients were provided with medical history assessment,
physical examination and laboratory evaluation. The anxiety and
depression scale was used to assess the psychological status of the
patients at the beginning and end of the study.
2.3. Control group
Patients in the control group did not receive diabetes education
provided by professional education nurses. Diabetes education was
usually provided upon routine outpatient visits. The length of
education varied from 5 to 10 min. The content of education
included healthy diet, exercise, self-monitoring of blood glucose,
complication prevention and understanding the risk factors of
diabetes. In addition, they were provided with medical history
assessment, physical examination and laboratory evaluation. The
anxiety and depression scale was used to assess the psychological
status of the patients at the beginning and end of the study.
2.4. Statistical analysis
SPSS 16 was used for statistical analysis. Data were expressed as
mean  standard deviation or median (p25, p75). Statistical
analysis included independent t-test, paired t-test and Mann-
Whitney U test. P < 0.05 was considered statistically significant.
3. Results
3.1. Baseline data
A total of 118 patients were assigned to the education group
(n = 63) and control group (n = 55). No significant differences
between groups were detected with respect to baseline clinical
data and laboratory findings between the two groups. (Table 1)
3.2. Six months outcomes
In education group, anxiety score decreased from 40.00 (38.00,
47.00) at baseline to 36.00 (30.75, 40.50) at the sixth month
(P < 0.05), and depression score decreased from 41.00 (38.00, 47.75)
at baseline to 35.50 (30.75, 42.25) at the sixth month (P < 0.05),
respectively. In control group, anxiety score [42.00 (40.00, 44.50) vs.
42.50 (36.50, 47.50), P = 0.73] and depression score [42.00 (40.00,
42.00) vs. 44.00 (41.00, 47.50), P = 0.10] were not significantly lower
at the sixth month, respectively. As compared with baseline,
education group showed reduced fasting blood glucose (FBG)
(8.00 mmol/L vs. 6.78 mmol/L, P < 0.00) and showed reduced
postprandial blood glucose (PBG) (13.29 mmol/L vs. 7.90 mmol/L,
P < 0.00) at the sixth month. In education group, HbA1C significant-
ly decreased at the sixth month compared with baseline [7.20%
(6.40%, 9.10%) at baseline and 6.20% (5.80%, 6.60%) at the sixth
month, P < 0.00]. FBG (8.00 mmol/L vs 7.70 mmol/L, P < 0.00) and
PBG (12.67 mmol/L vs 10.58 mmol/L, P < 0.00) were significantly
lower at the sixth month in control group than baseline. HbA1C
decreased from 7.90% (6.80%, 10.30%) at baseline to 6.70% (6.40%,
7.30%) (P < 0.00) at the sixth month in control group. (Table 2)
3.3. Group comparisons
The education group showed significantly reduced anxiety
score [36.00 (30.75, 40.50) vs. 42.50 (38.00, 47.00), P < 0.05] and
depression score [35.50 (30.75, 42.25) vs. 44.00 (41.00, 47.50),
P < 0.05] at the sixth month, compared with control group
(Fig. 1A). Compared with control group, FBG [6.78 (6.43, 7.18)
mmol/L vs. 7.70 (7.22, 8.23)mmol/L, P < 0.00] and PBG [7.90 (6.93,
G Model
PEC 5922 No. of Pages 6

S. Chai et al. / Patient Education and Counseling xxx (2018) xxx–xxx 3

Table 1
Baseline characteristics of patients in the education group and control group

parameter control group education group p value

N(F/M) 55.00 (26.00/29.00) 63.00 (33.00/30.00) 0.58
Age* 53.00  9.00 55.00  7 0.00 0.10
Duration# 0.20(0.10, 0.50) 0.30  0.30 0.30
BMI(kg/m2)* 25.06  3.38 25.70  3.35 0.30
WHR* 0.89  0.06 0.88  0.06 0.59
SBP(mmHg)# 120.00(120.00, 140.00) 130.00(120.00, 140.00) 0.94
DBP(mmHg)# 80.00(80.00, 90.00) 80.00(80.00, 90.00) 0.91
FBG(mmol/L)# 8.00(7.00, 13.00) 8.00(7.00, 10.00) 0.22
PBG(mmol/L)# 12.67(10.05, 17.10) 13.29(9.70, 16.08) 0.89
HbAlc(%)# 7.90(6.80, 10.30) 7.20(6.40, 9.10) 0.07
UAER(mg/g)* 21.41  14.75 20.92  14.38 0.93
ALT(U/L)# 23.00(18.00, 29.00) 21.00(16.00, 33.00) 0.88
AST(U/L)# 21.00(17.00, 25.00) 19.00(17.00, 25.00) 0.67
Cholesterol(mmol/L)* 5.30  1.17 5.35  1.06 0.78
Triglyceride(mmol/L)# 1.80(1.30, 2.40) 1.60(1.00, 2.40) 0.37
HDL-C(mmol/L)# 1.26(1.07, 1.42) 1.37(1.08, 1.70) 0.12
LDL-C(mmol/L)* 3.29  0.93 3.18  0.75 0.47
anxiety score# 42.00(34.00, 42.50) 41.00(38.00,52.00) 0.25
depression score# 40.00(34.00, 45.50) 42.50(36.00, 51.00) 0.37

Abbreviations;: BMI, body mass index; WHR, waist hip ratio; SBP, systolic blood pressure; DBP, diastolic blood pressure; FBG, fasting blood glucose; PBG, postprandial blood
glucose; HbA1c, glycated haemoglobin A1C; UAER, urinary albumin to creatinine ratio; ALT, alanine aminotransferase; AST, aspartate aminotransferase; HDL-C, high-density
lipoprotein cholesterol; LDL-C, low-density lipoprotein cholesterol.
*data expressed as mean  standard deviation and tested by independent t-test.
# data expressed as median (p25, p75) and tested by Mann-Whitney U test.

10.00)mmol/L vs. 10.58 (8.70, 13.10)mmol/L, P < 0.00] significantly
decreased at the sixth month in education group, respectively
(Fig. 1B). HbA1C significantly decreased in education group
compared to control group at the sixth month [6.20 (5.80,
6.60)% vs. 6.70 (6.40, 7.30)%, P < 0.01] (Fig. 1C). There was no
difference in blood pressure (SBP), diastolic blood pressure (DBP),
body mass index (BMI), waist hip ratio (WHR), the ratio of urinary
albumin to creatinine (UAER), blood lipids and depression scores
between education group and control group.
4. Discussion and conclusion
4.1. Discussion
Diabetes mellitus is a chronic and progressive disease and
characterized by insulin resistance and relative insulin deficiency.
Poorly controlled blood glucose leads to serious complications,
which will impose a large economic burden on the individual and
healthcare system. Hence, caring of patients with diabetes is of
growing importance to public health. For proper control of
diabetes mellitus, it is essential for patients to actively participate
in their own management such as appropriate diet, physical
activity, blood glucose monitoring and adherence to medication.
The basic targets in the treatment of T2DM are the normalization of
blood glucose, blood pressure control and lipid management.
Studies have shown that good glycemic control is associated with
significant reduction in the risk of many complications. Control of
diabetes is affected by both lifestyle factors and by pharmacologi-
cal treatments, and the management of diabetes is largely the
responsibility of those affected. Several clinical practice guidelines
recommend a stepwise treatment pathway for T2DM. Diet control
and lifestyle intervention are considered as the cornerstones for

Table 2
Comparison of pre- and post-intervention parameters each group

parameter control group education group p-value

Pre Post p-value Pre Post

BMI(kg/m2)* 25.06  3.38 25.28  3.47 0.15 25.70  3.38 25.16  3.38 0.85
WHR* 0.89  0.06 0.88  0.06 0.07 0.88  0.06 0.87  0.05 0.23
SBP(mmHg)# 120.00(120.00, 140.00) 130.00(125.00, 140.00) 0.60 130.00(120.00, 140.00) 130.00(120.00, 140.00) 0.94
DBP(mmHg)# 80.00(80.00, 90.00) 85.00(80.00, 95.00) 0.01 80.00(80.00, 90.00) 80.00(80.00, 90.00) 0.45
FBG(mmol/L)# 8.00(7.00, 13.00) 7.70(7.22, 8.23) <0.00 8.00(7.00, 10.00) 6.78(6.43, 7.18) <0.00
PBG(mmol/L)# 12.67(10.05, 17.10) 10.58(8.70, 13.10) <0.00 13.29(9.70, 16.08) 7.90(6.93, 10.00) <0.00
HbAlc(%)# 7.90(6.80, 10.30) 6.70(6.40, 7.30) <0.00 7.20(6.40, 9.10) 6.20(5.80, 6.60) <0.00
UAER(mg/g)* 21.41  14.75 23.00  12.30 0.22 20.22  11.61 20.48  14.43 0.20
ALT(U/L)# 23.00(18.00, 29.00) 25.00(19.00, 31.00) 0.18 21.00(16.00, 33.00) 23.00(18.00, 30.00) 0.67
AST(U/L)# 21.00(17.00, 25.00) 21.00(18.00, 27.00) 0.41 19.00(17.00, 25.00) 19.00(16.00, 23.00) 0.11
CHO(mmol/L)* 5.30  1.17 5.25  0.93 0.65 5.35  1.06 5.14 0.95 0.04
TG(mmol/L)# 1.80(1.30, 2.40) 1.95(1.42, 2.75) 0.09 1.60(1.00, 2.40) 1.49(1.16, 2.35) 0.47
HDL-C(mmol/L)# 1.26(1.07, 1.42) 1.24(1.10, 1.44) 0.85 1.37(1.08, 1.70) 1.36(1.11, 1.60) 0.50
LDL-C(mmol/L)* 3.29  0.93 3.28  0.80 0.90 3.18  0.75 3.12  0.77 0.47
anxiety score# 42.00(40.00, 44.50) 42.50(36.50,47.50) 0.73 40.00(38.00, 47.00) 36.00(30.75, 40.50) <0.05
depression score# 42.00(40.00, 42.00) 44.00(41.00, 47.50) 0.10 41.00(38.00, 47.75) 35.50(30.75, 42.25) <0.05

Abbreviations: BMI, body mass index; WHR, waist hip ratio; SBP, systolic blood pressure; DBP, diastolic blood pressure; FBG, fasting blood glucose; PBG, postprandial blood
glucose; HbA1c, glycated haemoglobin A1C; UAER, urinary albumin to creatinine ratio; ALT, alanine aminotransferase; AST, aspartate aminotransferase; HDL-C, high-density
lipoprotein cholesterol; LDL-C, low-density lipoprotein cholesterol.
*data expressed as mean  standard deviation and tested by independent t-test.
# data expressed as median (p25, p75) and tested by Mann-Whitney U test.

Please cite this article in press as: S. Chai, et al., The effect of diabetes self-management education on psychological status and blood glucose in
newly diagnosed patients with diabetes type 2, Patient Educ Couns (2018), https://doi.org/10.1016/j.pec.2018.03.020
G Model
PEC 5922 No. of Pages 6
4 S. Chai et al. / Patient Education and Counseling xxx (2018) xxx–xxx
Fig. 1. Changes in anxiety scores, depression scores, FBG, PBG and HbA1C between
the education group and control group at the sixth month.
Abbreviations;: A: anxiety and depression scores; B: FBG and PBG; C: HbA1C; CG:
control group; EG: education group; FBG: fasting blood glucose; PBG: postprandial
blood glucose; HbA1c: glycated haemoglobin A1C. *p < 0.05, #p < 0.01 vs. CG (6m).
treatment of T2DM according to these guidelines. Comprehensive
lifestyle interventions effectively decrease the incidence of
diabetes in high-risk patients, but its effect in patients who
already have T2DM are variable among trials [14,15]. So the role of
education is to improve patients’ understanding of diabetes
mellitus and enhance self-management practices. Meanwhile,
active collaboration with care givers can improve clinical outcomes
and quality of life.
Similarly, mental health of patients with diabetes can not be
ignored. Some studies have shown that both depressive disorders
and anxiety disorders have a close relationship with type 2
diabetes [16,17]. Studies of adults suggest that psychological states,
particularly depressive symptoms, may independently predict
increased risk for type 2 diabetes [18,19]. Depressive symptoms
have both been associated with increases in fasting insulin, insulin
resistance, the onset of type 2 diabetes, and future risk for poorer
glycemic control in T2DM [20,21]. Baumeister et al. [22] conducted
a systematic review to evaluate the effectiveness of psychological
and pharmacological interventions for depression in patients with
both diabetes and depression. The results indicated that short-
term glycemic control improved in pharmacological trials with
depression remission. Xie et al. [23] reported that the psychosocial
intervention was effective for depression symptoms and anxiety
symptoms. Meanwhile, the additional effects indicated a better
improvement of FBG, PBG, and HbA1c. These results demonstrated
Please cite this article in press as: S. Chai, et al., The effect of diabetes self-management education on psychological status and blood glucose in
newly diagnosed patients with diabetes type 2, Patient Educ Couns (2018), https://doi.org/10.1016/j.pec.2018.03.020
that the psychosocial intervention was very effective in treatment
of T2DM patients with depression and anxiety. In addition, the
improvement of anxiety and depression can also indirectly affect
blood glucose. A recent study [24] focusing on psychological
intervention for T2DM indicated that the patients turned to be
more proactive in self-management, such as diet, along with the
improvement of anxiety and depression. Therefore, the blood
glucose was strictly controlled. In our study, the patients’
depression and anxiety scores have significantly decreased after
6 months’ self-management education, as compared with baseline
data. Meanwhile, the blood glucose of patients have also been
better controlled. Combining with the results of above listed
studies, we believe that the improvement of depression and
anxiety does play an active role in the control of blood glucose. As
it’s known, there are many factors influencing the level of blood
glucose. There is no denying that the improvement of blood
glucose has been impacted by the professional education. Through
systematic learning of diet, physical activities, diabetic medica-
tions and complications, patients have gained a better under-
standing of diabetes before enrollment. They have become capable
of tackling with diabetes and also confident for proper self-
management of diabetes. Therefore, the improvement of the
psychological status of patients with diabetes promoted the
outcome of education in turn. There are several possible
pathophysiological mechanisms that may explain the possible
relationship between depression and blood glucose level. Depres-
sion is associated with disruption to the hypothalamic-pituitary-
adrenal axis, causing an increase in cortisol and catecholamine,
hormones responsible for antagonizing the hypoglycemic effects of
insulin and resulting in IR [25]. People with diagnostic depression
have increased levels of inflammation [26], and psychological
stresses have been shown to activate the innate inflammatory
response leading to IR in the early stage of T2DM [27]. Depression
can also have influence on lifestyle associated with diabetes risk
factors such as dietary intake, sleep disturbance and exercise
[28,29].
Our study indicated both anxiety scores and depression scores
were decreased at the sixth month as compared with baseline level
in education group. Moreover, anxiety scores and depression
scores of patients in the education group showed significant
improvement as compared to the control group at the sixth month.
The incidence of depression in patients with diabetes seems to be
associated with family status, obesity, smoking habits, physical
activity and sedentary lifestyle [30]. Therefore, in the education
group, the content of education was mainly focused on these
aspects. Patients were divided into different groups based on their
actual situation. For example, there were an overweight group, a
smoking group and a sedentary group. According to the assess-
ment results of the patients, professional educators would define
one pacesetter in each group every month. This approach was
intended to stimulate the patients' motivation. With weight loss,
quitting smoking and other lifestyle changes, the patients’ mental
state and self-confidence had been significantly improved. The role
of education professionals is to enable patients to acquire
knowledge, while making active choices about their diseases.
Subjective initiative cannot be given or taught, it is a spontaneous
process that people must engage in for themselves. With the
improvement of mental health, the control of blood glucose,
quality of life and treatment adherence will be in a good direction.
The present study found that there were significant improve-
ments in blood glucose control at the sixth month in control group,
compared with the baseline level. In control group, FBG, PBG and
HbA1c reduced in different degrees by usual care compared with
the baseline levels. In education group, FBG, PBG, HbA1C and
psychological scores improved significantly at the sixth month
compared with the baseline levels. These results indicated that
G Model
PEC 5922 No. of Pages 6
S. Chai et al. / Patient Education and Counseling xxx (2018) xxx–xxx
both usual care and intensive education can improve glycemic
control in some degree. But comparisons were made between the
two groups. In the education group, FBG, PBG, and HbA1C have
improved significantly. Content of education in both the education
and control groups involved diet, exercise, self-monitoring of blood
glucose and prevention of complications. But in the education
group, the content of education was more specific and detailed. On
the basis of the patients’ ideal body weight and daily activity, the
daily needs of calories were calculated. Individualized plan of daily
or weekly exercises was formulated. Pictures and teaching aids
were used to explain the complications of diabetes. Patients in the
education group were delivered a 2-h diabetes education course by
professional education nurses every week. While diabetes educa-
tion was usually provided upon routine outpatient visits in control
group. The length of course was usually from 5 to 10 min. The
patients were merely provided with a brief principle of diet and
exercise by doctors. The distinction of education can lead to
difference in disease awareness. With the patients’ understanding
of diabetes and the improvement of disease self-management, the
mental state of the patients in the education group was improved.
They became more active in self-management of blood glucose.
The present findings were consistent with those of similar studies
investigating the efficacy of structured group education compared
with usual care [31,32]. Yang et al. [31] reported that there was
significant improvement in glycemic outcomes from baseline to 3,
6 and 12 months in the structured education group, as compared
with the usual care group. Research evidence [33] shown that
intensified monthly self-monitoring of blood glucose combined
with education was effective in improving postprandial glucose
and HbA1C in diabetes. The intervention group also showed higher
improvements in knowledge, attitude and behavior than the
control group. A recent study [34] reported that group education
intervention may improve clinical outcomes, such as fasting
glucose, systolic blood pressure (SBP) and diastolic blood pressure
(DBP). However, our study indicated that education did not have
any effect on other risk factors, including BMI, SBP, DBP, UAER, low-
density lipoprotein cholesterol (LDL-C), and high-density lipopro-
tein cholesterol (HDL-C), compared with control group. Studies of
focused educational intervention did not yield consistent results.
Some effects were shown on measures of glycemic control in
studies that focused on diet or exercise alone. Recently, Huang and
his colleagues [35] reported that diet modifications showed a
significant improvement in all major cardiovascular risk factors
associated with diabetes, such as the HbA1C, SBP, DBP, and HDL-C,
except for LDL-C and BMI. The physical activity intervention
showed a significant improvement on HbA1C and DBP, but not on
the other risk factors (BMI, SBP, LDL-C, and HDL-C). The patient
education program, however, did not show any difference in all the
risk factors assessed in the study. There are many factors involved
in the complexity of the education, including the variety of
education programs and group size as well as the difference in
education background. These factors need to be taken into account
in interpretation of the results.
The study was conducted in China. As it’s known, there are lots
of differences between the Western and Eastern food. Carbohy-
drate is the main type of diet in China, while the Western diet is
dominated by meat, eggs and milk. Food difference plays an
important role in the content of education. Carbohydrate should be
appropriately controlled in Asia and high-fat food should be
appropriately reduced in Europe and America. As mentioned
earlier, a diagnosis of T2DM increases the risk of incidence of
depression and may result in severe depression. Diabetes self-
management is directly related to the prognosis of patients with
diabetes. Therefore, in any case, self-management of blood glucose
is suitable for all patients with diabetes in Asia, Europe and
America.
Please cite this article in press as: S. Chai, et al., The effect of diabetes self-management education on psychological status and blood glucose in
newly diagnosed patients with diabetes type 2, Patient Educ Couns (2018), https://doi.org/10.1016/j.pec.2018.03.020
5
There is also limitation to the present study. One shortcoming is
that self-management education simply gives the patients the
principle of diet and exercise, so the intensity of the exercise and
variety of dietary regimen might also affect the clinical outcomes.
Secondly, mental health is also affected by economic conditions,
but we did not evaluate the patients’ incomes. Thirdly, we did not
have a subgroup analysis of whether blood glucose levels were
related to the severity of anxiety or depression.
4.2. Conclusion
In summary, this paper indicated that self-management
education was effective in improving psychological status and
glycemic control. Intensive education did not lead to significant
improvements in BMI, SBP, DBP, UAER, LDL-C, and HDL-C,
compared to control group.
4.3. Practice implications
Diabetes education plays a very important role in newly
diagnosed patients with diabetes. Patients with newly diagnosed
diabetes have mood swings, such as anxiety or depression, which
can affect blood glucose levels. Through education, the mood of
newly diagnosed patients with diabetes has been improved.
Meanwhile, the blood glucose is better controlled.
I confirm all patient/personal identifiers have been removed or
disguised so the patient/person(s) described are not identifiable
and cannot be identified through the details of the story.
Funding: This research did not receive any specific grant from
funding agencies in the public, commercial, or not-for-profit sectors.
Conflicts of interest
None.
Appendix A. Supplementary data
Supplementary data associated with this article can be found, in
the online version, at https://doi.org/10.1016/j.pec.2018.03.020.
References
[1] E.S. Schellenberg, D.M. Dryden, B. Vandermeer, C. Ha, C. Korownyk, Lifestyle
interventions for patients with and at risk for type 2 diabetes: a systematic
review and meta-analysis, Ann. Intern. Med. 159 (2013) 543–551.
[2] K. Ogurtsova, J.D. da Rocha Fernandes, Y. Huang, U. Linnenkamp, L. Guariguata,
N.H. Cho, D. Cavan, J.E. Shaw, L.E. Makaroff, IDF Diabetes Atlas: global estimates
for the prevalence of diabetes for 2015 and 2040, Diabetes Res. Clin. Pract. 128
(2017) 40–50.
[3] L. Haas, M. Maryniuk, J. Beck, C.E. Cox, P. Duker, L. Edwards, E.B. Fisher, L.
Hanson, D. Kent, L. Kolb, S. McLaughlin, E. Orzeck, J.D. Piette, A.S. Rhinehart, R.
Rothman, S. Sklaroff, D. Tomky, G. Youssef, Standards revision task force.
national standards for diabetes self-management education and support,
Diabetes Care 37 (2014) S144–53.
[4] American Diabetes Association, Standards in medical care in diabetes-2017,
Diabetes Care 39 (Suppl. 1) (2017) S1–107.
[5] M.A. Powers, J. Bardsley, M. Cypress, P. Duker, M.M. Funnell, A.H. Fischl, M.D.
Maryniuk, L. Siminerio, E. Vivian, Diabetes self-management education and
support in type 2 diabetes: a joint position statement of the American Diabetes
Association, the American Association of Diabetes Educators and the Academy
of Nutrition and Dietetics, Diabetes Care 38 (2015) 1372–1382.
[6] J. Beck, D.A. Greenwood, L. Blanton, S.T. Bollinger, M.K. Butcher, J.E. Condon, M.
Cypress, P. Faulkner, A.H. Fischl, T. Francis, L.E. Kolb, J.M. Lavin-Tompkins, J.
MacLeod, M. Maryniuk, C. Mensing, E.A. Orzeck, D.D. Pope, J.L. Pulizzi, A.A.
Reed, A.S. Rhinehart, L. Siminerio, J. Wang, Standards Revision Task Force, 2017
National standards for diabetes self-management education and support,
Diabetes Care 40 (2017) 1409–1419.
[7] L. Schinckus, S. Van den Broucke, M. Housiaux, Assessment of implementation
fidelity in diabetes self-management education programs: a systematic
review, Patient Educ. Couns. 96 (2014) 13–21.
[8] L. Dube, S. Van den Broucke, M. Housiaux, W. Dhoore, K. Rendall-Mkosi, Type 2
diabetes self-management education programs in high and low mortality
developing countries: a systematic review, Diabetes Educ. 41 (2015) 69–85.
G Model
PEC 5922 No. of Pages 6
6 S. Chai et al. / Patient Education and Counseling xxx (2018) xxx–xxx
[9] C. Ezenwaka, J. Eckel, Prevention of diabetes complications in developing
countries: time to intensify self-management education, Arch. Physiol.
Biochem. 117 (2011) 251–253.
[10] M. Meurs, A.M. Roest, B.H. Wolffenbuttel, R.P. Stolk, P. de Jonge, J.G. Rosmalen,
Association of depressive and anxiety disorders with diagnosed versus
undiagnosed diabetes: an epidemiological study of 90,686 participants,
Psychosom. Med. 78 (2016) 233–241.
[11] M.M. Collins, P. Corcoran, I.J. Perry, Anxiety and depression symptoms in
patients with diabetes, Diabetes Med. 26 (2009) 153–161.
[12] W.W.K. Zung, A self-rating depression scale, Arch. Gen. Psychiatry 12 (1965)
63–70.
[13] W.W.K. Zung, A rating instrument for anxiety disorders, Psychosomatics 12
(1971) 371–379.
[14] L. Angermayr, D. Melchart, K. Linde, Multifactorial lifestyle interventions in the
primary and secondary prevention of cardiovascular disease and type 2
diabetes mellitus-a systematic review of randomized controlled trials, Ann.
Behav. Med. 40 (2010) 49–64.
[15] H. Sone, S. Tanaka, S. Iimuro, S. Tanaka, K. Oida, Y. Yamasaki, S. Oikawa, S.
Ishibashi, S. Katayama, H. Yamashita, H. Ito, Y. Yoshimura, Y. Ohashi, Y.
Akanuma, N. Yamada, Japan Diabetes Complications Study Group, long-term
lifestyle intervention lowers the incidence of stroke in Japanese patients with
type 2 diabetes: a nationwide multicentre randomised controlled trial (the
Japan Diabetes Complications Study), Diabetologia 53 (2010) 419–428.
[16] K.G. Kahl, U. Schweiger, C. Cowell, C. Müller, M.L. Busch, M. Bauer, P. Schwarz,
Depression, anxiety disorders, and metabolic syndrome in a population at risk
for type 2 diabetes mellitus, Brain Behav. 5 (2015) e00306.
[17] A. Mikaliukštienë, K. Žagminas, A. Juozulynas, L. Narkauskaite, _ J. Sa˛lyga, K.
Jankauskiene, _ R. Stukas, G. Šurkiene,
_ Prevelence and determinants of anxiety
and depression symptoms in patients with type 2 diabetes in Lithuania, Med.
Sci. Monit. 20 (2014) 182–190.
[18] F. Rotella, E. Mannucci, Depression as a risk factor for diabetes: a meta-analysis
of longitudinal studies, J. Clin. Psychiatry 74 (2013) 31–37.
[19] A. Campayo, C.H. Gomez-Biel, A. Lobo, Diabetes and depression, Curr.
Psychiatry Rep. 13 (2011) 26–30.
[20] T. Khambaty, J.C. Stewart, M.F. Muldoon, T.W. Kamarck, Depressive symptom
clusters as predictors of 6-year increases in insulin resistance: data from the
Pittsburgh Healthy Heart Project, Psychosom. Med. 76 (2014) 363–369.
[21] K. Semenkovich, M.E. Brown, D.M. Svrakic, P.J. Lustman, Depression in type 2
diabetes mellitus: prevalence, impact, and treatment, Drugs 75 (2015) 577–587.
[22] H. Baumeister, N. Hutter, J. Bengel, Psychological and pharmacological
interventions for depression in patients with diabetes mellitus: an abridged
Cochrane review, Diabetes Med. 31 (2014) 773–786.
[23] J. Xie, W. Deng, Psychosocial intervention for patients with type 2 diabetes
mellitus and comorbid depression: a meta-analysis of randomized controlled
trials, Neuropsychiatr. Dis. Treat. 13 (2017) 2681–2690.
Please cite this article in press as: S. Chai, et al., The effect of diabetes self-management education on psychological status and blood glucose in
newly diagnosed patients with diabetes type 2, Patient Educ Couns (2018), https://doi.org/10.1016/j.pec.2018.03.020
[24] A.L. Wroe, E.W. Rennie, S. Sollesse, J. Chapman, A. Hassy, Is cognitive
behavioural therapy focusing on depression and anxiety effective for
people with long-term physical health conditions? A controlled trial in the
context of type 2 diabetes mellitus, Behav. Cogn. Psychother. 46 (2018)
129–147.
[25] D.L. Musselman, E. Betan, H. Larsen, L.S. Phillips, Relationship of depression to
diabetes types 1 and 2: epidemiology, biology, and treatment, Biol. Psychiatry
54 (2003) 317–329.
[26] M. Webb, M. Davies, N. Ashra, D. Bodicoat, E. Brady, D. Webb, C. Moulton, K.
Ismail, K. Khunti, The association between depressive symptoms and insulin
resistance, inflammation and adiposity in men and women, PLoS One 12
(2017) e0187448.
[27] L.B. Shomaker, N.R. Kelly, R.M. Radin, O.L. Cassidy, L.M. Shank, S.M. Brady, A.P.
Demidowich, C.H. Olsen, K.Y. Chen, E. Stice, M. Tanofsky-Kraff, J.A. Yanovski,
Prevention of insulin resistance in adolescents at risk for type 2 diabetes with
depressive symptoms: 1-year follow-up of a randomized trial, Depress.
Anxiety 34 (2017) 866–876.
[28] M. Tanofsky-Kraff, L.B. Shomaker, E.A. Stern, R. Miller, N. Sebring, D. Dellavalle,
S.Z. Yanovski, V.S. Hubbard, J.A. Yanovski, Children’s binge eating and
development of metabolic syndrome, Int. J. Obes. 36 (2012) 956–962.
[29] C.M. Depner, E.R. Stothard, K.P. Wright Jr., Metabolic consequences of sleep and
circadian disorders, Curr. Diabetes Rep. 14 (2014) 507.
[30] M. Palizgir, M. Bakhtiari, A. Esteghamati, Association of depression and anxiety
with diabetes mellitus type 2 concerning some sociological factors, Iran. Red
Crescent Med. J. 15 (2013) 644–648.
[31] Y.S. Yang, Y.C. Wu, Y.L. Lu, E. Kornelius, Y.T. Lin, Y.J. Chen, C.L. Li, H.W. Hsiao, C.H.
Peng, C.N. Huang, Adherence to self-care behavior and glycemic effects using
structured education, J. Diabetes Invest. 6 (2015) 662–669.
[32] K. Khunti, T.C. Skinner, S. Heller, M.E. Carey, H.M. Dallosso, M.J. Davies,
DESMOND, Collaborative, Biomedical, lifestyle and psychosocial
characteristics of people newly diagnosed with Type 2 diabetes: baseline data
from the DESMOND randomized controlled trial, Diabetes Med. 25 (2008)
1454–1461.
[33] E.M. Ba-Essa, E.I. Mobarak, A. Alghamdi, N.M. Al-Daghri, Intensified glucose
self-monitoring with education in Saudi DM patients, Int. J. Clin. Exp. Med. 8
(2015) 19374–19380.
[34] M.P. Fort, S. Murillo, E. Lopez, A.L. Dengo, N. Alvarado-Molina, I. de Beausset,
M. Castro, L. Peña, M. Ramírez-Zea, H. Martínez, Impact evaluation of a
healthy lifestyle intervention to reduce cardiovascular disease risk in health
centers in San Josñ, Costa Rica and Chiapas, Mexico, BMC Health Serv. Res. 15
(2015) 577.
[35] X.L. Huang, J.H. Pan, D. Chen, J. Chen, F. Chen, T.T. Hu, Efficacy of lifestyle
interventions in patients with type 2 diabetes: a systematic review and meta-
analysis, Eur. J. Intern. Med. 27 (2016) 37–47.