R eview
Behavioral ProgramsforType 2 Diabetes Mellitus
A Systematic Review and Network Meta-analysis
Jennifer Pillay, BSc; Marni J. Armstrong, PhD, RCEP; Sonia Butalia, MD, MSc; Lois E. Donovan, MD; Ronald J. Sigal, MD, MPH;
Ben Vandermeer, MSc; Pritam Chordiya, BDS, MSc; Sanjaya Dhakal, MBBS, MPH; Lisa Hartling, PhD; Megan Nuspl, BSc;
Robin Featherstone, MLIS; and Donna M. Dryden, PhD
Background: Behavioral programs may improve outcomes for
individuals with type 2 diabetes mellitus, but there is a large di
versity of behavioral interventions and uncertainty about how to
optimize the effectiveness of these programs.
Purpose: To identify factors moderating the effectiveness of be
havioral programs for adults with type 2 diabetes.
Data Sources: 6 databases (1993 to January 2015), conference
proceedings (2011 to 2014), and reference lists.
Study Selection: Duplicate screening and selection of 132 ran
domized, controlled trials evaluating behavioral programs com
pared with usual care, active controls, or other behavioral
programs.
Data Extraction: One reviewer extracted and another verified
data. Two reviewers independently assessed risk of bias.
Data Synthesis: Behavioral programs were grouped on the ba
sis of program content and delivery methods. A Bayesian net
work meta-analysis showed that most lifestyle and diabetes self
management education and support programs (usually offering
>11 contact hours) led to clinically important improvements in
glycemic control (>0.4% reduction in hemoglobin A 1c [HbA1c]),
whereas most diabetes self-management education programs
n 2012, 29.1 m illion Am ericans had diabetes with
I costs o f $245 b illion (1), representing 11% o f the total
U.S. health care expenditure (2). A lthough tig h t glyce
mic control may reduce the risk fo r m icrovascular com
plications in type 2 diabetes m ellitus (T2DM) (3), behav
ioral and pharm acologic m anagem ent o f body weight,
b lo od pressure, and cholesterol levels are often
needed to reduce the risk fo r m ortality and macrovas-
cular com plications. Moreover, other patient-centered
outcomes, such as diabetes-related distress and d e
pression, are im portant to address (4).
Health care experts recom m end that anyone with
diabetes a do pt and adhere to m ultiple self-care behav
iors, including healthy eating, being active, m onitoring,
taking m edication, problem -solving, healthy coping,
and reducing risks (5). Approaches to su pp ort behavior
change include diabetes self-m anagem ent education
(DSME) with or w itho ut an added support (clinical,
behavioral, psychosocial, or educational) phase, and
lifestyle program s. Because know ledge acquisition in
sufficiently prom otes behavioral changes (6), recom
m endations fo r DSME have shifted from traditional di-
See also:
Related a rtic le .........................................................836
848 Annals o f Internal Medicine Vol. 163 No. 11 1 December 2015
Annals of Internal Medicine
without added support-especially those offering 10 or fewer
contact hours-provided little benefit. Programs with higher ef
fect sizes were more often delivered in person than via technol
ogy. Lifestyle programs led to the greatest reductions in body
mass index. Reductions in HbAlc seemed to be greater for par
ticipants with a baseline HbA1c level of 7.0% or greater, adults
younger than 65 years, and minority persons (subgroups with
>75% nonwhite participants).
Limitations: All trials had medium or high risk of bias. Subgroup
analyses were indirect, and therefore exploratory. Most out
comes were reported immediately after the interventions.
Conclusion: Diabetes self-management education offering 10
or fewer hours of contact with delivery personnel provided little
benefit. Behavioral programs seem to benefit persons with sub-
optimal or poor glycemic control more than those with good
control.
Primary Funding Source: Agency for Healthcare Research and
Quality. (PROSPERO registration number: CRD42014010515)
Ann Intern Med. 2015;163:848-860. doi:10.7326/M15-1400 www.annals.org
For author affiliations, see end o f text.
This article was published online first at www.annals.org on 29 September
2015.
dactic educational services to more patient-centered
m ethodologies that incorporate interaction, p ro b le m
solving, and other behavioral approaches. A lthough
evidence shows th a t diabetes-specific behavioral inter
ventions can be effective, which com bination o f p ro
gram com ponents and delivery mechanisms is m ost ef
fective is unclear (7-11).
We conducted a netw ork meta-analysis to identify
factors related to program com ponents and delivery
mechanisms th a t m oderate the effectiveness o f multi-
com ponent behavioral program s fo r T2DM.
M etho ds
Key informants, a technical expert panel, and p u b
lic com m entary inform ed our m ethods. A p rotocol and
a peer- and public-review ed technical rep ort were p ro
duced fo r the A gency fo r Healthcare Research and
Q uality (AHRQ) and are available online (w w w.ahrq.gov
/resea rch/findings/evidence-based-reports/).
Data Sources and Searches
A research librarian searched the fo llo w in g b ib lio
graphic databases from 1993 to January 2015: Ovid
MEDLINE (A p pe nd ix Table 1, available at www.annals
.org) and O vid MEDLINE In-Process & O ther Non-
Indexed Citations, Cochrane Central Register o f C on
tro lle d Trials via the Cochrane Library, EMBASE via
www.annals.org
Behavioral Programs for Type 2 Diabetes Mellitus R eview

O v id , C IN A H L P lu s w ith F u ll Text v ia E B S C O h o s t, e ry fa c to rs (Table). W e s e p a r a t e d D S M E a n d D S M E p lu s

P s y c IN F O v ia O v i d , S c o p u s , a n d P u b M e d v ia t h e N a s u p p o r t , in r e c o g n i t i o n t h a t t h e s u p p o rt phase o f th e
t io n a l C e n te r f o r B io t e c h n o lo g y I n f o r m a t io n D a ta b a s e s . la tte r w a s o fte n o f l o w e r i n t e n s i t y ( le s s f r e q u e n t c o n
W e r e v ie w e d th e r e f e r e n c e lis ts o f r e l e v a n t s y s t e m a t i c ta c ts ) a n d fo c u s e d o n d if fe r e n t c o n te n t, s u c h as p s y c h o
r e v i e w s a n d o f a ll i n c l u d e d s t u d i e s . W e a ls o s e a r c h e d s o c ia l s u p p o r t .
C lin ic a lT r ia ls . g o v and th e W o r ld H e a lt h O r g a n iz a tio n T o s e rv e as a n o v e r v ie w o f p ro g ra m e ffe c tiv e n e s s
I n t e r n a t i o n a l C l in i c a l T r ia ls R e g is t r y P la tfo r m , r e le v a n t and h e lp in t e r p r e t our p r im a r y a n a ly s is of p ro g ra m
c o n fe r e n c e p r o c e e d in g s (2 0 1 1 t h r o u g h 2 0 1 4 ), a n d th e m o d e r a t io n , we p e rfo rm e d p a ir w is e m e t a - a n a ly s e s
U .S . F e d e r a l R e g is t e r . by u s in g th e H a r tu n g - K n a p p - S id ik - J o n k m a n ra n d o m -
e ffe c ts m o d e l (1 6 , 1 7 ) f o r m u ltip le b e h a v i o r a l, c l i n i c a l ,
S tudy S electio n a n d h e a lt h o u t c o m e s , a s w e l l a s h e a lt h c a r e u t i l i z a t i o n
W e in c lu d e d s tu d ie s c o n d u c te d in h ig h ly d e v e l
and p ro g ra m a c c e p t a b i l i t y ( t h e f u l l r e p o r t is a v a i l a b le
oped c o u n tr ie s p u b lis h e d in E n g lis h a fte r 1993 (b e
at w w w . a h r q .g o v /r e s e a r c h /fin d in g s /e v id e n c e - b a s e d
c a u s e m e d ic a l m a n a g e m e n t f o r d i a b e t e s i n t e n s i f i e d a f
-re p o rts /). W e d e fin e d th r e s h o ld s fo r c lin ic a l im p o r
te r th is tim e ) . W e in c lu d e d r a n d o m iz e d , c o n tr o lle d
t a n c e w h e r e t h e r e w a s g u i d a n c e : F o r h e m o g l o b i n A 1c
t r i a l s d o n e in c o m m u n i t y o r o u t p a t i e n t h e a lt h s e t t i n g s
( H b A 1c), w e u s e d a r e d u c t i o n o f a t le a s t 0 . 4 % ( f o r e x a m
and in v o lv in g a d u lt s t h a t c o m p a r e d a b e h a v io r a l p r o
p le , 7 . 6 % v s . 8 . 0 % ) ( 1 8 ) ; f o r q u a l i t y - o f - l i f e m e a s u r e s a n d
g ra m w ith u s u a l c a re ( m e d ic a l m a n a g e m e n t p r o v id e d
o th e r p a tie n t- r e p o r te d o u tc o m e s , w e u s e d a c o n s e rv a
to a ll p a r t i c i p a n t s ) , a n a c t iv e c o n t r o l ( in t e r v e n t io n not
t i v e v a lu e o f o n e - h a l f S D ( 1 9 , 2 0 ) .
m e e tin g o u r d e fin it io n o f b e h a v io r a l p r o g r a m ) , o r a n
W e th e n c o n d u c te d a n e tw o rk m e t a - a n a ly s is t h a t
o th e r b e h a v io r a l p ro g ra m ( c o m p a r a tiv e e ffe c tiv e n e s s
a l l o w e d s i m u l t a n e o u s e v a l u a t i o n o f a s u it e o f c o m p a r i
s tu d y ). A b e h a v io r a l p r o g r a m w a s a m u ltic o m p o n e n t,
s o n s a n d c o n s id e r e d b o t h d ir e c t a n d in d ir e c t e v id e n c e
d ia b e t e s - s p e c if ic p ro g ra m th a t in c lu d e d re p e a te d in
w h ile p r e s e r v in g th e w ith in - s tu d y r a n d o m iz a tio n . T o a s
t e r a c t i o n s w i t h t r a i n e d i n d i v i d u a l s o v e r a t le a s t 4 w e e k s ,
s u re th e tr a n s itiv it y w ith in t h e n e tw o r k , w e c a te g o r iz e d
and th a t c o n s is te d of DSME u s in g a b e h a v io r a l ap
a ll b e h a v i o r a l p r o g r a m s a n d c o m p a ra to rs in to nodes.
p ro a c h o r a n o th e r p ro g ra m f o r m a t i n c l u d i n g a t le a s t a
The n o d e s f o r b e h a v io r a l p r o g r a m s w e re fo rm e d on
s t r u c t u r e d d ie t a r y o r p h y s ic a l a c tiv it y in t e r v e n t io n w ith
th e b a s is o f d i f f e r e n t c o m b i n a t i o n s o f v a r i a b l e s in o u r
a n o th e r com ponent (A ppendix, a v a i l a b le at www
p r o g r a m c a te g o r iz a t io n (A ppendix Table 2, a v a i l a b le a t
. a n n a ls . o r g ) .
w w w . a n n a l s . o r g ); w e i d e n t i f i e d a ll p l a u s i b l e n o d e s d i f
W e e x c l u d e d a b s t r a c t s a n d s t u d i e s in w h i c h t h e i n
f e r i n g b y o n l y o n e v a r i a b l e ( f o r e x a m p l e , a le v e l w i t h i n
t e r v e n t i o n w a s a d is e a s e o r c a r e m a n a g e m e n t p r o g r a m
th e in t e n s it y c a te g o ry ) and th e n " f ille d " th e nodes
(fo r e x a m p le , w ith a c tiv e a d ju s tm e n t of d ia b e te s -
w ith th e a p p lic a b le in te r v e n tio n s o n th e b a s is o f o u r
r e la t e d m e d ic a tio n s ) ( 1 2 ) o r a q u a lit y im p r o v e m e n t p r o
c o d in g . T h e n o d e s f o r th e c o m p a r a t o r g r o u p s w e r e c a t
g ra m i n c o r p o r a t i n g s t r a t e g ie s t a r g e t i n g h e a lt h s y s t e m s
e g o r i z e d a s u s u a l c a r e , a c t iv e n o n - D S M E c o n t r o l ( e d u
or p r o v id e r s (1 3 ). O th e r e x c lu s i o n c r it e r i a in c lu d e d
c a tio n in te r v e n tio n s n o t m e e tin g o u r c r it e r i a ) , a n d a c
s tu d ie s 1) fo c u s in g on p a tie n ts w ith n e w ly d ia g n o s e d
tiv e o t h e r c o n t r o l ( f o r e x a m p le , s ta n d - a lo n e d ie t a r y o r
(< 1 y e a r ) d is e a s e ; 2 ) w i t h n o o u t c o m e o f i n t e r e s t t o t h i s
p h y s ic a l a c t i v i t y i n t e r v e n t i o n s ) .
r e v ie w (fo r e x a m p le , o n ly C - r e a c tiv e p r o te in ) , or in
The a n a ly s is w a s c o n d u c t e d b y u s in g a B a y e s ia n
w h ic h th e o n ly d if fe r e n c e b e tw e e n th e s tu d y g ro u p s
n e t w o r k m o d e l t o c o m p a r e a ll i n t e r v e n t i o n s s i m u l t a n e
w a s a f a c t o r o u t s i d e o f t h e r e v i e w 's s c o p e ( f o r e x a m p l e ,
o u s ly a n d t o u s e a ll a v a i l a b le i n f o r m a t i o n o n t r e a t m e n t
l o w - v s . h i g h - f a t d ie t ) ; a n d 3 ) in w h i c h 2 5 % o r m o r e o f
e f f e c t s in a s i n g l e a n a ly s is ( 2 1 , 2 2 ) . T h e s e m e t h o d s e n
th e p a r t ic ip a n t s had ty p e 1 d ia b e t e s m e llit u s ( u n le s s
s u re th a t c o r r e la tio n in m u l t i g r o u p t r i a l s is p r e s e r v e d .
r e s u lt s w e r e r e p o r t e d f o r t h o s e w i t h T 2 D M ) .
M e a n d i f f e r e n c e s ( M D s ) w e r e m o d e l e d u s in g n o n i n f o r -
Two r e v ie w e r s in d e p e n d e n tly s c re e n e d a ll title s
m a tiv e p r io r d is t r ib u t io n s . A n o r m a l p r io r d is t r ib u t io n
and a b s tra c ts , and th e fu ll te x t of any p u b lic a tio n
w ith m e a n 0 a n d la r g e v a r i a n c e ( 1 0 0 0 0 ) w a s u s e d f o r
m a r k e d f o r i n c l u s io n w a s r e t r i e v e d . T w o r e v i e w e r s i n d e
e a c h o f th e tr ia l m e a n s , w h e re a s t h e ir b e tw e e n s tu d y
p e n d e n t l y a s s e s s e d t h e f u l l t e x t s b y u s in g a p r i o r i i n c l u
v a r ia n c e h a d a u n if o r m p r io r w ith ra n g e 0 to 2. T h e s e
s io n c r it e r ia and a s ta n d a r d fo rm . W e r e s o lv e d d is
p r io r s w e r e c h e c k e d f o r in f lu e n c e w ith s e n s itiv ity a n a l
a g re e m e n ts b y c o n s e n s u s o r c o n s u lt a tio n w ith a th ir d
y s e s . M a r k o v c h a in M o n t e C a r l o s i m u l a t i o n s u s in g W i n -
r e v ie w e r .
B u g s s o ftw a r e w e r e p e r f o r m e d t o o b t a in s im u lta n e o u s

D ata E xtraction an d Q uality A ssessm en t e s t i m a t e s o f a ll i n t e r v e n t i o n s c o m p a r e d w ith p la c e b o ,

O n e r e v i e w e r e x t r a c t e d d a t a b y u s in g a s t r u c t u r e d as w e ll a s e s tim a te s o f w h ic h in t e r v e n tio n s w e re th e

fo rm c r e a t e d in t h e S y s t e m a t ic R e v ie w D a t a R e p o s i t o r y b e s t. A b u r n - in s a m p le o f 20 000 ite r a tio n s w a s fo l

( a v a il a b l e a t h ttp :/ / s r d r . a h r q . g o v / ) (1 4 ); a second re lo w e d by 300 000 ite r a tio n s used to c o m p u te e s ti

v ie w e r v e r if ie d d a ta . T w o r e v ie w e r s in d e p e n d e n t ly a p m a t e s . A s e n s i t i v i t y a n a ly s is t h a t t h i n n e d t h e a m o u n t o f

p l i e d t h e C o c h r a n e r is k o f b ia s t o o l ( 1 5 ) . D i s c r e p a n c i e s u s e d d a t a t o e v e r y 1 0 t h i t e r a t i o n w a s a ls o c o n d u c t e d t o

w e r e r e s o lv e d t h r o u g h d is c u s s io n . c h e c k f o r p r o p e r c h a in c o n v e r g e n c e . T h e a n a ly s is w a s
c h e c k e d f o r c o n s is te n c y b y c o n tr a s t in g d ir e c t a n d i n d i
D ata S y n th esis an d A n alysis r e c t e s t i m a t e s in e a c h t r i a n g u l a r a n d q u a d r a t i c l o o p b y
W ith in p u t fr o m te c h n ic a l e x p e r ts , w e c a te g o r iz e d u s in g th e m e th o d s d e s c r ib e d by V e r o n ik i and c o l
b e h a v io r a l p r o g r a m s b y v a r io u s c o m p o n e n t a n d d e liv - le a g u e s ( 2 3 ) . R e s u lts a r e p r e s e n t e d a s e s t i m a t e s o f t h e

w w w .a n n a ls .o rg Annals o f Internal Medicine Vol. 163 No. 11 1 December 2015 849

R eview Behavioral Programs for Type 2 Diabetes Mellitus

Table. C a te g o riz a tio n o f P ro g ra m C o m p o n e n ts a n d D e liv e ry F actors

P rogram Factors C ateg ories and D escription V ariab les

P ro g ra m c o m p o n e n ts 1. D S M E
2. D S M E p lu s s u p p o r t: D S M E p lu s an a d d e d p h a s e t o e x te n d p r o g r a m d u r a tio n a n d p r o v id e s u p p o r t (o fte n
c lin ic a lly fo c u s e d b u t m a y b e p s y c h o s o c ia l, e d u c a tio n a l, o r b e h a v io r a l)
3. L ife s ty le p r o g ra m s : B e h a v io ra l p r o g r a m s fo c u s e d o n d ie t a n d / o r p h y s ic a l a c tiv ity r a th e r th a n o n d ia b e te s -
s p e c ific s e lf- m a n a g e m e n t b e h a v io r s ; m a y a ls o in c lu d e o th e r c o m p o n e n ts as lo n g as d o e s n o t m e e t th e
c rite ria f o r D S M E w ith e m p h a s is o n e d u c a tio n /tr a in in g
D u ra tio n o f p r o g r a m * N o c a te g o r ie s ; d u r a tio n w a s u s e d as a c o n tin u o u s v a ria b le
In te n s ity (c o n ta c t h o u r s ) f 1. < 1 0 hf:
2. 11 -2 6 h (e .g ., w e e k ly f o r u p t o 6 m o )
3. > 2 7 h (a llo w in g f o r m o n th ly fo llo w - u p f o r 1 y)
F re q u e n c y o f c o n ta c ts * N o c a te g o r ie s ; th is w a s a c o m p o s ite v a r ia b le c o m b in in g d u r a tio n a n d in te n s ity ( h /m o )
M e th o d o f c o m m u n ic a tio n 1. In p e rs o n o n ly
2. M ix tu re o f in p e rs o n a n d t e c h n o lo g y
3. A ll te c h n o lo g y w ith m in im a l in te ra c tio n w ith p r o v id e r s
M e th o d o f d e liv e ry || 1. In d iv id u a l
2. M ix e d in d iv id u a l a n d g r o u p
3. G r o u p
D e liv e r y p e r s o n n e l 1. D e liv e r e d e n tir e ly b y n o n - h e a lth p r o fe s s io n a l (e .g ., la y /c o m m u n ity h e a lth w o rk e r, u n d e r g r a d u a te s tu d e n ts )
a fte r tr a in in g a n d u n d e r s o m e s u p e rv is io n
2. O n e h e a lth p r o fe s s io n a l f o r la rg e m a jo r ity (> 7 5 % ) o f d e liv e ry
3. P ro v is io n b y m u ltid is c ip lin a r y te a m o f h e a lth p ro fe s s io n a ls
D e g r e e o f ta ilo r in g !! 1. N o n e /m in im a l: n o n e o r o n ly a s m a ll p o r tio n is ta ilo r e d (e .g ., p e rs o n a liz e d d ie t p r e s c r ip tio n in o th e rw is e
h ig h ly s tru c tu re d life s ty le p r o g r a m o r d e liv e r y b a s e d o n fle x ib le h o u rs b u t s a m e c o n te n t fo r a ll)
2. M o d e r a te /m a x im u m : m o s t o f t h e p r o g r a m has c o n te n t a n d / o r d e liv e r y t a ilo r in g (e .g ., to p ic s a re b a s e d o n
n e e d s a s s e s s m e n t a n d d e liv e ry tim in g , d u r a tio n , o r lo c a tio n is b a s e d o n th e p a r tic ip a n t's s c h e d u le , n e e d s , o r
lo c a tio n p re fe re n c e s )
L e vel a n d n a tu re o f c o m m u n ity 1. P re s e n t: F o r e x a m p le , p e e r d e liv e r in g p r o g r a m o r p e e r s u p p o r t g r o u p s f o r s u p p o r t s ta g e , use o f c o m m u n ity
e n g a g e m e n t* re s o u rc e s (in fra s tr u c tu r e ) f o r d e liv e ry o r m a in te n a n c e s ta g e s
2. A b s e n t: F o r e x a m p le , n o th in g r e p o r t e d o r, a t m o s t, p r o v id in g w r itte n in fo r m a tio n a b o u t c o m m u n ity
re s o u rc e s

D S M E = d ia b e t e s s e lf - m a n a g e m e n t e d u c a t io n .
* O n ly u s e d f o r r e g r e s s io n a n a ly s e s a s r e p o r t e d in t h e fu ll t e c h n ic a l r e p o r t a n d r e la t e d a r t ic le o n t y p e 1 d ia b e t e s m e llit u s in th is is s u e ,
t W h e r e c o n t a c t h o u r s c o u ld n o t b e c a lc u la t e d , w e u s e d n u m b e r o f c o n ta c ts a s a p r o x y .
t T h e c u t p o in t s u s e d f o r c r e a t in g t h e in t e n s it y c a t e g o r ie s w e r e b a s e d o n p r a c tic a l c o n s id e r a t io n s . T h e 1 0 -h " m in im a l in t e n s it y " l im it w a s b a s e d o n
t h e c u r r e n t n u m b e r o f h o u r s b illa b le f o r p a t ie n t s e l i g i b le f o r p u b lic h e a lth c a r e a d m in is t e r e d b y t h e C e n t e r s f o r M e d ic a r e & M e d ic a id S e rv ic e s in t h e
U n it e d S ta te s ; th is w a s d e s c r ib e d b y o u r t e c h n ic a l e x p e r t p a n e l a s a n i m p o r t a n t p r a c tic a l lim it a t io n o n i m p le m e n t in g p r o g r a m s h a v in g h ig h e r
in te n s ity .
2 a n d 3 w e r e c o m b in e d f o r a n a ly s is .
|| 1 a n d 2 w e r e c o m b in e d f o r a n a ly s is .
Tl U s e d in s u m m a r y t a b le s .

t r e a t m e n t e ffe c ts ( M D ) r e la t iv e t o u s u a l c a re , w ith 9 5 % b u t t h e a u t h o r s a re s o le ly r e s p o n s ib le f o r its c o n t e n t

c r e d ib le in te r v a ls . a n d t h e d e c is io n t o s u b m it f o r p u b lic a t io n . A H R Q s ta ff
To e x a m in e d if f e r e n t p o p u la t io n s u b g ro u p s , we d id n o t p a r t ic ip a t e in t h e c o n d u c t o f t h e r e v ie w , d a ta
c o n d u c te d s u b g ro u p a n a ly s e s o f t h e p a ir w is e m e ta s e le c t io n o r c o lle c t io n , d a ta a n a ly s is , in t e r p r e t a t io n o f
a n a ly s is r e s u lts f o r H b A 1c a t lo n g e s t f o llo w - u p in c o m t h e d a ta , o r p r e p a r a t io n o f t h e m a n u s c r ip t.
p a r is o n w it h u s u a l c a re a n d a c tiv e c o n t r o ls ; s u b g r o u p s
w e r e d e f in e d o n t h e b a s is o f s tu d y - le v e l b a s e lin e H b A 1c
( < 7 % vs. > 7 % ), a g e ( < 6 5 vs. > 6 5 y e a rs ), a n d e t h n ic it y
R e s u lt s
( > 7 5 vs. < 7 5 % n o n w h it e ) , a c c o r d in g t o c a t e g o r ie s t h a t
S e a r c h e s id e n t if ie d 4 7 1 5 2 c ita tio n s ; w e in c lu d e d
w e r e d e f in e d a p r io r i. F o r b a s e lin e F lb A 1c le v e l a n d
132 r a n d o m iz e d , c o n t r o lle d t r ia ls ( 2 4 - 1 5 4 ; Z g ib o r J,
a g e , w e p e r f o r m e d s u b g r o u p a n a ly s e s o f t h e n e t w o r k
P ia tt G . P r o je c t S e e d : s u p p o r t , e d u c a t io n a n d e v a lu a
m e ta - a n a ly s is ; t h e a n a ly s is w a s r e r u n f o r s tu d ie s h a v in g
t io n in d ia b e t e s . 2 0 1 4 . U n p u b lis h e d r e p o r t ) d e s c r ib e d
a m e a n b a s e lin e H b A 1c le v e l o f 7 % o r g r e a t e r a n d f o r
in 161 p u b lic a t io n s ( F ig u r e 1). T h e o n lin e r e p o r t lis ts
t h o s e w it h a m ean p a r t ic ip a n t a g e y o u n g e r th a n 65
e x c lu d e d s tu d ie s a n d a s s o c ia t e d p u b lic a t io n s . A p p e n
y e a rs . F o r s u b g r o u p s b a s e d o n r a c e / e t h n ic it y , t h e n u m
d ix T a b le 2 in c lu d e s c h a r a c te r is t ic s o f s tu d ie s . T e s ts f o r
b e r o f t r ia ls in e it h e r s u b g r o u p w a s in s u f f ic ie n t t o p e r
p u b lic a t io n b ia s s h o w e d n o i m p o r t a n t b ia s ; t h e E g g e r
f o r m a n e t w o r k m e ta - a n a ly s is .
t e s t ( 1 5 5 ) f o r H b A -,c w a s n o t s ig n if ic a n t f o r c o m p a r is o n s
Role o f the Funding Source w it h u s u a l c a re (P = 0 .2 5 ) o r a c tiv e c o n t r o ls (P = 0 .2 1 ) a t
T h is p r o je c t w a s f u n d e d u n d e r c o n t r a c t 2 9 0 - 2 0 1 2 - t h e e n d o f t h e in t e r v e n t io n .
0 0 0 1 3 1 f r o m t h e A H R Q , U.S. D e p a r t m e n t o f H e a lth a n d M o s t r a n d o m iz e d , c o n t r o lle d tr ia ls h a d 2 g r o u p s ,
H u m a n S e rv ic e s . S ta ff a t A H R Q p a r t ic ip a t e d in d e v e lo p b u t s e v e r a l tr ia ls e v a lu a t e d m o r e th a n 1 b e h a v io r a l p r o
m e n t o f t h e s c o p e o f t h e w o r k a n d r e v ie w e d d r a f t s o f g r a m , f o r 1 6 6 in t e r v e n t io n g r o u p s in t o t a l. T ria ls w e r e
t h e m a n u s c r ip t . A p p r o v a l b y A H R Q w a s r e q u ir e d be c o n d u c t e d in 1 6 c o u n t r ie s - t h e m a jo r it y ( 6 3 % ) w e r e in
f o r e t h e m a n u s c r ip t c o u ld b e s u b m it t e d f o r p u b lic a t io n , t h e U n ite d S ta te s , a n d t h e r e m a in d e r w e r e c o n d u c t e d

850 Annals of Internal Medicine Vol. 163 No. 11 1 December 2015 w w w .a n n a ls .o r g

Behavioral Programs for Type 2 Diabetes Mellitus R eview

in C anada (n = 6 ); K o re a and th e U n ite d K in g d o m

F ig u re 1. S u m m a ry o f e v id e n c e s e a rc h a n d s e le c tio n .
(n = 5 e a c h ); A u s tr a lia , H ong Kong, and th e N e th e r
la n d s (n = 4 e a c h ); and G e rm a n y and Japan (n = 3
e a c h ). M e a n p a r t ic ip a n t a g e w a s 4 5 t o 7 2 y e a rs (m e
d ia n , 5 8 y e a r s ) . B a s e lin e H b A 1c le v e l w a s b e t w e e n 6 . 3 %
a n d 1 2 . 3 % ( m e d i a n , 8 % ). B o d y m a s s i n d e x r a n g e d f r o m
2 3 . 8 t o 3 9 .1 k g / m 2 ( m e d i a n , 3 3 . 0 k g / m 2 ). M e d i a n d u r a
tio n o f d i a b e t e s w a s 8 .1 y e a rs (ra n g e , 1 to 1 8 y e a rs ).
T h ir t y - t w o tr ia ls ( 2 4 % ) w e r e c o n d u c t e d w ith p a r tic ip a n ts
w ho s e lf - id e n tifie d as a m in o r it y e th n ic ( n o n w h it e )
b a c k g ro u n d .
A ll tr ia ls had m e d iu m o r h ig h o v e r a l l r is k o f b ia s .
F o r o b je c t iv e o u tc o m e s , 42% had m e d iu m and 58%
had h ig h r is k , l a r g e l y d r iv e n by in c o m p le t e o u tc o m e
d a ta . F o r tr ia ls (n = 92) r e p o r tin g on s u b je c t iv e o u t
c o m e s o f i n t e r e s t ( s u c h a s h e a l t h - r e l a t e d q u a l i t y o f lif e
o r d e p r e s s io n ) , 13% had m e d iu m r is k o f b ia s ; t h e re
m a in d e r (8 7 % ) h a d h ig h r is k o f b ia s , l a r g e l y o w i n g t o
la c k o f b lin d in g o f p a r tic ip a n ts , p e r s o n n e l, and o u t
c o m e a s s e s s o rs .
R e s u lts fro m p a ir w is e m e t a - a n a ly s e s of a ll o u t
com es a re p re s e n te d in A p p e n d i x T a b l e 3 (v s . u s u a l
c a r e ) , A p p e n d i x T a b l e 4 (v s . a c t i v e c o n t r o l s ) , a n d A p
p e n d ix T a b le 5 ( c o m p a r a tiv e e ffe c tiv e n e s s b e tw e e n b e
h a v io r a l p ro g ra m s ) ( a ll a v a i l a b le a t w w w . a n n a l s . o r g ).
R e s u lts f o r H b A 1c a n d B M I a r e p r e s e n t e d h e r e t o h e lp
i n t e r p r e t t h e f i n d i n g s f r o m t h e n e t w o r k m e t a - a n a ly s e s .
C o m p a re d w ith usual c a re , b e h a v io r a l p ro g ra m s
re d u c e d H b A 1c le v e ls a t th e end o f th e in t e r v e n tio n
( M D , - 0 . 3 5 [ 9 5 % C l, 0 . 5 6 t o - 0 . 1 4 ] ; 6 6 c o m p a r i s o n s ; T1DM = typ e 1 d iab etes m ellitus; T2DM = typ e 2 d iab etes m ellitus.
8715 p a r tic ip a n ts ) , 6 m o n th s p o s tin te r v e n tio n (M D , * O ne study was inclu d e d fo r bo th T1DM and T2DM.

-0 .1 6 [ C l, 0 . 3 6 t o 0 . 0 4 ] ; 2 3 c o m p a r i s o n s ; 4 1 3 8 p a r
tic ip a n t s ) , a n d 1 2 m o n th s p o s tin te r v e n tio n ( M D , 0 .1 4 t i m a t e s (v s . u s u a l c a r e ) o f a ll n o d e s , r a n k - o r d e r e d by
[ C l, 0 . 4 t o 0 .1 2 ]; 9 c o m p a r is o n s ; 1 4 9 4 p a r t i c ip a n t s ) ; r e l a t iv e e ffe c tiv e n e s s , f r o m th e m o s t e ffe c tiv e to th e
h o w e v e r, th e r e d u c tio n a c h ie v e d w a s n o t c o n s id e r e d le a s t e f f e c t i v e . E a c h e s t i m a t e d e f f e c t is f o r a g r o u p of
c l i n i c a l l y i m p o r t a n t a t a n y o f t h e 3 t i m e p o i n t s . R e s u lts p ro g ra m s h a v in g a s im ila r c o m b in a tio n of p ro g ra m
w e r e e v e n m o r e m o d e s t f o r b e h a v io r a l p r o g r a m s c o m c o m p o n e n t ; i n t e n s it y ; m e t h o d o f c o m m u n ic a tio n ; d e
p a re d w ith a c t iv e c o n t r o l g r o u p s : T h e M D w a s 0 .2 4 li v e r y m e t h o d ; a n d f o r D S M E p r o g r a m s o n l y , b e c a u s e
( C l, 0 .4 1 to 0 .0 7 ; 25 c o m p a r is o n s ; 7518 p a r tic i o f h a v in g m o r e c o m p a r is o n s , d e liv e r y p e r s o n n e l. P ro
p a n t s ) a t t h e e n d o f t h e i n t e r v e n t i o n , 0 . 1 9 ( C l, 0 . 3 7 g ra m d u r a tio n and c o m m u n ity e n g a g e m e n t w e r e not
t o 0 .0 1 ; 6 c o m p a r is o n s ; 5 9 5 p a r tic ip a n ts ) a t 6 m o n th s , in c o r p o r a t e d b e c a u s e o f o v e r la p w ith in t e n s it y a n d d e
a n d 1 . 1 0 ( C l, 2 . 5 6 t o 0 . 3 6 ; 6 c o m p a r i s o n s ; 4 8 6 p a r li v e r y p e r s o n n e l, r e s p e c tiv e ly ; m ost s tu d ie s w e re
tic ip a n t s ) a t 1 2 m o n th s . H ig h h e t e r o g e n e it y ( / 2 = 6 2 % t o s c o re d as in c lu d in g c o m m u n ity engagem ent s o le l y
9 8 % ) in t h e m e t a - a n a l y s e s s u p p o r t e d o u r p l a n n e d e v a l th ro u g h u s e o f p e e r s o r la y p r o v i d e r s in d e l i v e r y . P r o
u a tio n o f w h ic h p r o g r a m c o m p o n e n ts a n d d e liv e r y fa c g ra m ta ilo r in g w a s n o t in c o r p o r a t e d b e c a u s e o f d if fi
to r s m o d e r a t e e ffe c tiv e n e s s . c u l t y in d i s t i n g u i s h i n g b e t w e e n m i n i m a l a n d m o d e r a t e
In c o m p a r i s o n s w i t h u s u a l c a r e , e f f e c t s o n B M I w e r e t a ilo r in g o n th e b a s is o f r e p o r t i n g . M o s t r e s u lt s w e r e
s ta tis tic a lly s ig n ific a n t a t th e end o f th e in t e r v e n tio n fro m s t u d i e s w i t h f o l l o w - u p o f 6 m o n t h s o r le s s , w i t h 8
( M D , 0 .5 1 k g / m 2 [C l, 0 . 6 6 t o 0 .3 6 ]; 3 6 c o m p a r i s tu d ie s c o n t r ib u t in g 1 2 - m o n t h f o llo w - u p d a ta . W h e n in
sons; 4 2 8 0 p a r tic ip a n ts ) , 6 m o n th s ( M D , - 0 . 2 1 k g /m 2 t e r p r e t i n g r e s u lt s , w e c o n s i d e r e d t h e r e l a t iv e r a n k i n g o f
[C l, 0 .3 2 to 0 .0 1 ]; 14 c o m p a r is o n s ; 1840 p a r tic i n o d e s a n d l o o k e d f o r t r e n d s in f i n d i n g s o n t h e b a s is o f
p a n t s ) , a n d 1 2 m o n t h s ( M D , 0 . 9 2 k g / m 2 [C l, 1 . 4 4 t o p ro g ra m v a r ia b le s t h a t s e e m e d t o d e te r m in e w h e th e r
0 . 0 4 ] ; 5 c o m p a r i s o n s ; 8 6 7 p a r t i c ip a n t s ) . t h e e ffe c ts w o u ld o f f e r c lin ic a l b e n e fit. S o m e n o d e s h a d
v e ry fe w s t u d i e s , s m a ll s a m p le s iz e s , o r w i d e c r e d i b l e
M od eration o f E ffectiven ess, b y P rogram in t e r v a l s ; t h u s , w e d i d n o t m a k e fir m c o n c lu s io n s f o r a
C o m p o n en ts an d D elivery M ech an ism s s i n g l e n o d e ( o r f o r d if f e r e n c e s in 5 6 1 p o t e n t i a l c o m p a r
F ig u r e 2, A p p e n d ix T a b le 6 ( a v a il a b l e at www is o n s ) , b u t r a t h e r f r o m lo o k in g a c ro s s n o d e s w ith s im i
.a n n a ls .o r g ) , and A p p e n d ix F ig u r e 1 ( a v a il a b l e at la r f e a t u r e s . A c o n s i s t e n c y a n a ly s is w a s p e r f o r m e d f o r
w w w . a n n a l s . o r g ) s u m m a r i z e t h e r e s u lt s o f t h e n e t w o r k t h e H b A 1c a n a ly s is ; o n l y 2 q u a d r a t i c l o o p s ( o f a t o t a l o f
m e t a - a n a l y s i s f o r H b A 1c a t l o n g e s t f o l l o w - u p ( 1 0 2 t r i a l s ; 4 3 q u a d r a t ic a n d t r ia n g u la r lo o p s ) s h o w e d s ta tis tic a lly
1 9 5 6 5 p a r tic ip a n ts ) . F ig u r e 2 s h o w s th e c o m b in e d e s - s ig n if ic a n t in c o n s is te n c y .

w w w .a n n a ls .o r g Annals of Internal Medicine Vol. 163 No. 11 1 December 2015 851

R e v ie w Behavioral Programs for Type 2 Diabetes Mellitus

Figure 2. Rank o rd e r o f relative effectiveness fo r H b A lc o f behavioral program s and active com parators versus usual care.

Program Components and Delivery Factors

1. DSME, >27 h, in person, group only, HCP
2. Lifestyle, >27 h, in person, individual and mixed
3. Lifestyle, 11-26 h, some technology, individual and mixed
4. DSME + support, >27 h, in person, group only
5. DSME, 11-26 h, some technology, individual and mixed, non-HCP
6. DSME + support, 11-26 h, in person, group only
7. DSME, >27 h, in person, individual and mixed, HCP
8. DSME + support, <10 h, in person, individual and mixed
9. Lifestyle, 11-26 h, in person, group only
10. DSME + support, >27 h, in person, individual and mixed
4 11. DSME, >27 h, some technology, individual and mixed, HCP
-4 12. Lifestyle, 11-26 h, in person, individual and mixed
4 13. Lifestyle, <10 h, in person, group only
4 14. DSME + support, 11-26 h, in person, individual and mixed
15. Active comparator (single dietary or physical activity intervention)
16. DSME + support, 11-26 h, some technology, individual and mixed
17. DSME + support, <10 h, some technology, individual and mixed
18. Lifestyle, >27 h, some technology, individual and mixed
19. DSME, <10 h, in person, individual and mixed, HCP
20. DSME, 11-26 h, in person, group only, non-HCP
21. DSME, 11-26 h, in person, group only, HCP
22. DSME, <10 h, in person, group only, HCP
23. Lifestyle, 11-26 h, some technology, group only
24. DSME, 11-26 h, in person, individual and mixed, HCP
25. DSME, 11-26 h, some technology, individual and mixed, HCP
26. DSME, <10 h, some technology, individual and mixed, non-HCP
27. DSME, <10 h, some technology, individual and mixed, HCP
28. DSME, 11-26 h, some technology, group, HCP
29. DSME, <10 h, in person, group only, non-HCP
30. Lifestyle, >27 h, in person, group only
31. Active comparator (education not meeting our inclusion criteria)
32. Lifestyle, <10 h, in person, individual and mixed
33. Lifestyle, <10 h, some technology, individual and mixed
34. DSME + support, <10 h, in person, group only

-0.4% HbA,c

r
-4.0 -2.0 0.0 2.0 4.0
Change in HbA1c Relative to Usual Care, %

Results o f a ne tw ork meta-analysis in c o rp o ra tin g d ire c t and in d ire c t com pariso ns fo r th e o u tco m e o f H b A 1c are shown, w ith nodes fo r pro g ra m
co m pone nts and d e live ry factors. A ll arms in each stud y w ere cate gorize d and the n g ro u p e d in to "n o des" o f sim ilar arms. A rm s d e fin e d as
behavioral progra m s w ere g ro u p e d on the basis o f th e ir c o m pone nts and de live ry factors. A ll nodes w ere the n c o m p a re d w ith th e usual care node,
using d ire c t and in d ire c t evidence w hile m a in tainin g th e ra ndom ization w ithin each in d ivid ual study. Each no de o f behavioral pro g ra m s differs fro m
th e others by on ly 1 level in a cate gory o f pro g ra m com p o n e n t, intensity, m o d e o f co m m unica tion, d e live ry m e thod , and (fo r DSME progra m s only)
de live ry personnel. The d o ts and horizontal lines re prese nt th e mean diffe ren ce and 95% c re d ib le interval fo r th e nodes relative to usual care. O u r
p re d e te rm in e d th re s h o ld fo r clinical im p o rta n ce was a re duction in H b A lc o f 0.4% o r greater. Values fo r th e mean diffe ren ces and 95% cre d ib le
intervals are includ ed in A p p e n d ix T a ble 6 (available at w w w .ann als.org). DSME = diab etes self-m ana gem ent e d ucation ; H b A 1c = h e m o g lo b in A 1c;
HCP = health care professional.

W ith usual care as the reference, behavioral p ro
grams showing effect sizes fo r H bA 1c m eeting or ex
ceeding our threshold fo r clinical im portance repre
sented all 3 m ajor program com p on en t categories of
DSME (4 nodes), DSME and su pp ort (5 nodes), and life
style (5 nodes). A m ong program s showing clinically
im p orta nt effects, 6 represented m edium -intensity
program s (11 to 26 contact hours), 6 represented high-
intensity program s (>26 hours), and 2 represented low-
intensity program s (<10 hours). Mean contact hours fo r
the program s represented by these effective nodes
was 26.4 (range, 7 to 40.5 hours); mean total program
duration was 8 m onths (range, 2 to 12 months). None
o f the nodes re p re sen ting low -in te nsity (<10 hours)
DSME pro gram s show ed clinically im p o rta n t effects;
all had a g re a te r e ffe ct on H b A 1c than basic e du ca
tio n a l controls, b u t less e ffe ct than a stand-alone di-
852 Annals of Internal Medicine Vol. 163 No. 11 1 December 2015
etary or physical activity in te rve n tio n . Three o f fo u r
nodes re p re sen ting DSME p ro gram s w ith e ffe ct e sti
mates show ing clinically im p o rta n t effects w ere d e liv
ered by health care professionals. Eleven o f th e 14
nodes re p re sen ting clinically im p o rta n t effects were
d e liv e re d in person rath er than in c o rp o ra tin g some
fo rm o f te c h n o lo g y ; e ffective p ro gram s in c o rp o ra tin g
te c h n o lo g y w ere all o f m od erate or high intensity
(> 1 0 hours).
N etw ork meta-analysis was also conducted fo r BMI
(Appendix Figure 2 and Appendix Table 7, both avail
able at ww w.annals.org). The mean study-level baseline
BMI was sim ilar fo r program s classified as DSME (32.4
kg /m 2), DSME and su pp ort (33.0 k g /m 2), and lifestyle
(32.9 k g /m 2). Behavioral program s changed BMI by
1.77 kg /m 2 to 3.29 kg /m 2. Lifestyle program s resulted
in the greatest changes. Program intensity seemed to
www.annals.org
Behavioral Programs for Type 2 Diabetes Mellitus R eview

b e le s s i m p o r t a n t t h a n m e t h o d o f d e liv e r y . T h e m a jo r it y le s s t h a n 75% m in o r it y p a r t ic ip a n t s (M D , 0 .1 6 [C l,
o f p r o g r a m s w it h t h e h ig h e s t M D s ( th a t is, 8 o f t h e h ig h 0 .3 1 t o 0 .0 0 ]; I2 = 7 5 % ; 2 4 c o m p a r is o n s ; 5 1 1 0 p a r t ic
e s t 1 0 n o d e s ) o f f e r e d s o m e in d iv id u a l d e liv e r y . ip a n ts ). F o r c o m p a r is o n s w it h a c tiv e c o n t r o ls , t h e r e w a s
n o s t a tis tic a lly s ig n if ic a n t r e d u c t io n in H b A 1c a m o n g m i
S u b g r o u p A n a ly s e s n o r it ie s ( M D , - 0 . 3 2 [C l, - 0 . 6 7 t o 0 .0 4 ]; 5 c o m p a r is o n s ,
For b e h a v io r a l p ro g ra m s c o m p a re d w it h usual 4 0 0 p a r t ic ip a n t s ) (5 4 , 6 4 , 7 3 , 9 1 , 1 2 5 ); s tu d ie s w it h a
c a re , t h e r e w a s a s m a ll b e n e f it ( M D , 0 .1 2 [C l, 0 .2 2 t o la r g e r p r o p o r t io n o f w h it e p a r t ic ip a n t s a ls o s h o w e d n o
0 .0 1 ]; I2 = 3 % ) in t e r m s o f H b A 1c r e d u c t io n in s tu d ie s d if f e r e n c e ( M D , 0 .5 0 [C l, 1 .2 4 t o 0 .2 3 ]; 1 0 c o m p a r
w h e re p a r t ic ip a n t s h a d a m e a n b a s e lin e H b A lc le v e l is o n s ; 6 2 1 4 p a r t ic ip a n t s ) (5 9 , 6 0 , 6 6 , 7 6 , 9 4 , 9 5 , 1 4 5 ,
le s s t h a n 7 .0 % (6 t r ia ls ; 1 2 3 9 p a r t ic ip a n t s ) (8 7 , 8 9 , 1 1 8 , 1 5 0 ). O f n o te , g ly c e m ic c o n t r o l a t b a s e lin e s e e m e d t o
1 4 3 , 1 4 7 , 1 5 4 ). T h e r e s u lts in c o m p a r is o n s w it h a c tiv e b e w o r s e f o r m in o r it y p a r t ic ip a n t s th a n f o r m a jo r it y o r
c o n t r o ls w e r e n o n s ig n if ic a n t ( M D , 1 .4 3 [C l, 3 .5 7 t o w h it e s u b g ro u p s ( H b A 1c le v e l, 8 .8 0 % vs. 7 .6 0 % ,
0 .7 1 ]; I2 = 9 9 % ; 3 tr ia ls , 1 6 9 p a r t ic ip a n t s ) (6 5 , 7 8 , 9 4 ). r e s p e c tiv e ly ) .
T h e a n a ly s is s h o w e d b e n e f it ( a lt h o u g h n o t c lin ic a lly im
p o r t a n t ) f o r p a r t ic ip a n t s w it h a b a s e lin e H b A 1c le v e l o f
7 .0 % o r g r e a t e r in c o m p a r is o n s w it h u s u a l c a re ( M D , D is c u s s io n
0 .3 2 [C l, 0 .4 2 t o 0 .2 1 ]; 7 6 t r ia ls ; 11 0 8 6 p a r t ic i W e f o u n d t h a t m o s t life s t y le a n d D S M E p lu s s u p
p a n ts ) a n d a c tiv e c o n t r o ls ( M D , -0 .1 8 [C l, 0 .3 0 t o p o r t p r o g r a m s ( u s u a lly o f f e r in g > 1 1 c o n t a c t h o u r s ) le d
- 0 . 0 6 ] ; 2 5 t r ia ls ; 7 7 0 9 p a r tic ip a n ts ) . t o c lin ic a lly i m p o r t a n t im p r o v e m e n t s in g ly c e m ic c o n
W h e n 9 tr ia ls o f p a r t ic ip a n t s w h o h a d g o o d b a s e tr o l (> 0 .4 % r e d u c t io n in H b A 1c), b u t t h a t m o s t D S M E
lin e g ly c e m ic c o n t r o l w e r e e x c lu d e d (6 5 , 7 8 , 8 7 , 8 9 , 9 4 , p r o g r a m s w it h o u t a n a d d e d s u p p o r t c o m p o n e n t p r o
1 1 8 , 1 4 3 , 1 4 7 , 1 5 4 ), t h e r e s u lts o f t h e n e t w o r k m e t a v id e d lit t le b e n e f it - p a r t ic u la r ly w h e n 1 0 o r f e w e r h o u r s
a n a ly s is w e r e e s s e n tia lly t h e s a m e as w h e n d a ta f r o m a ll of c o n ta c t w ith d e liv e r y p e rs o n n e l w as p r o v id e d .
t r ia ls w e r e in c o r p o r a t e d . E ffe c t s iz e s f o r n o d e s r a n k e d 1 P r o g r a m s t h a t w e r e e ff e c t iv e m o s t o f t e n in c lu d e d in -
a n d 1 3 (s e e Figure 2 f o r c a t e g o r iz a t io n o f t h e s e n o d e s ) p e r s o n d e liv e r y r a t h e r th a n in c o r p o r a t io n o f t e c h n o l
d e c r e a s e d t o r a n k s o f 31 a n d 2 3 ( f r o m - 1 . 3 7 t o 0 .0 9 o g y . W e a ls o f o u n d t h a t p r o g r a m s f o c u s e d o n lif e s t y le
a n d fro m 0 .4 5 t o - 0 .1 5 , r e s p e c tiv e ly ) ; t h e p ro g ra m o fte n s tr u c t u r e d w e ig h t lo s s and p h y s ic a l a c tiv it y
fo rm a ts re p re s e n te d b y th e s e nodes seem to have i n t e r v e n t i o n s - o r o n D S M E c a n h a v e s im ila r b e n e f it in
b e e n m o r e e f f e c t iv e f o r p a r t ic ip a n t s w it h g o o d g ly c e t e r m s o f g ly c e m ic c o n t r o l, a n d t h a t life s t y le p r o g r a m s
m ic c o n t r o l. In a d d it io n , t h e a c tiv e ( d ie t a r y o r p h y s ic a l a p p e a r b e t t e r f o r r e d u c in g B M I. B e h a v io r a l p r o g r a m s
a c tiv it y ) c o n t r o l b e c a m e le s s e f f e c t iv e ( M D , - 0 . 1 4 vs. s e e m t o b e n e f it p e r s o n s w it h s u b o p t im a l o r p o o r g ly
0 .3 9 ) f o r p a r t ic ip a n t s w it h H b A 1c le v e ls o f 7% or c e m ic c o n t r o l m o r e t h a n t h o s e w it h g o o d c o n t r o l. T a i
g re a te r. lo r in g p r o g r a m s t o e t h n ic m in o r it y g r o u p s , s u c h as in
T h e p a r t ic ip a n t s in 9 s tu d ie s r e p o r t in g on H b A 1c c o r p o r a t in g g r o u p in t e r a c t io n w it h p e e rs , s e e m s t o b e
h a d a m e a n a g e o f 6 5 y e a r s o r o ld e r (3 6 , 4 4 , 5 5 , 8 9 , 9 7 , b e n e fic ia l.
1 1 3 , 1 1 6 , 1 1 8 , 1 2 5 , 1 3 2 ). O l d e r a d u lt s ( > 6 5 y e a r s ) d id W e b u ilt u p o n p r e v io u s r e v ie w s e x a m in in g f a c to r s
n o t b e n e f it t o a s t a tis tic a lly s ig n if ic a n t e x t e n t a t lo n g e s t t h a t in f lu e n c e e f fe c tiv e n e s s o f in t e r v e n t io n s f o r T 2 D M
f o llo w - u p in t e r m s o f r e d u c t io n in H b A 1c c o m p a r e d w ith (8 , 1 0 , 1 1 , 1 5 6 ). W e in c lu d e d t h e h ig h e s t n u m b e r o f
u s u a l c a re ( M D , 0 .2 4 [C l, 0 .5 0 t o 0 .0 3 ]; I2 = 50% ; 7 s tu d ie s t o d a t e a n d f o c u s e d o n p r o g r a m s m e e t in g c u r
c o m p a r is o n s ; 7 3 4 p a r t ic ip a n t s ) o r a c tiv e c o n t r o ls ( M D , r e n t r e c o m m e n d a t io n s t o change p a t ie n t b e h a v io r s .
0 .2 3 [C l, 0 .6 0 t o 0 .1 4 ]; I2 = 0 % ; 3 c o m p a r is o n s ; 2 0 6 W e r e lie d o n s t r ic t in c lu s io n c r it e r ia t o s tu d y in t e r a c t iv e
p a r t ic ip a n t s ) . In a d u lt s y o u n g e r th a n 6 5 y e a rs , t h e e f f e c t p r o g r a m s in c o r p o r a t in g b e h a v io r a l s tr a t e g ie s a im in g t o
c o m p a re d w it h u s u a l c a re w a s s ta tis tic a lly s ig n if ic a n t change m u lt ip le b e h a v io r s , w it h o u t c o n f o u n d in g by
(M D , 0 .3 1 [C l, 0 .4 2 to 0 .2 1 ]; 76 c o m p a r is o n s ; changes to m e d ic a l m anagem ent ( e .g ., m e d ic a t io n
11 4 9 1 p a r t ic ip a n t s ) ; w it h a c tiv e c o m p a r a t o r s , t h e e f c h a n g e s ) . O u r f in d in g t h a t s in g le - t o p ic , n o n e d u c a t io n a l
f e c t s w e r e c lin ic a lly i m p o r t a n t ( M D , 0 .4 1 [C l, 0 .7 0 t o in t e r v e n t io n s ( a c tiv e c o n t r o ls o f d ie t a r y o r p h y s ic a l a c
0 .1 2 ]; I2 = 9 3 % ; 2 6 c o m p a r is o n s ; 7 6 6 9 p a r tic ip a n ts ) . t iv it y in t e r v e n t io n s ) o f f e r m o r e b e n e f it th a n do b a s ic
T h e f in d in g s o f t h e n e t w o r k m e ta - a n a ly s is c h a n g e d l i t e d u c a t io n in t e r v e n t io n s s u p p o r t s t h e n e e d t o c a r e f u lly
t le w h e n it w a s b a s e d o n s t u d ie s in w h ic h t h e m e a n a g e d is t in g u is h b e t w e e n a n d a c c o u n t f o r d if f e r e n t c o m p a r
w a s y o u n g e r th a n 6 5 y e a r s ; t h e e f f e c t s iz e f o r t h e a c tiv e a to r s d u r in g t h e s y s te m a tic r e v ie w p r o c e s s . O u r u s e o f
c o n t r o l o f a d ie t a r y o r p h y s ic a l a c t iv it y in t e r v e n t io n b e a n e t w o r k m e ta - a n a ly s is e n a b le d d if f e r e n t ia t io n o f t h e
c a m e c lin ic a lly im p o r t a n t ( M D , 0 .5 5 [ c r e d ib le in te r v a l, v a r io u s c o m p a r a t o r s , a n d in c o r p o r a t io n o f c o m p a r is o n s
1 .1 9 t o 0 .1 0 ]) . T h is s u g g e s ts t h a t y o u n g e r a d u lt s m a y ( e .g ., in t e r v e n t io n vs. in t e r v e n t io n ) o f t e n n o t a m e n a b le
b e n e fit s u b s t a n t ia lly fro m s in g l e - c o m p o n e n t in te r t o o t h e r a n a ly t ic a l s tr a t e g ie s .
v e n t io n s , b u t o l d e r a d u lt s r e q u ir e m u ltic o m p o n e n t O u r n e t w o r k m e ta - a n a ly s is r e s u lts f o r H b A 1c s u g
p ro g ra m s . g e s t t h a t b o t h in d iv id u a l a n d g r o u p d e liv e r y a re b e n e
In c o m p a r is o n s w it h u s u a l c a re a m o n g e t h n ic m i fic ia l, c o n s is t e n t w it h o th e r w o rk in th is a re a (1 5 7 ).
n o r it y p a r t ic ip a n t s , p r o g r a m s h a d a c lin ic a lly i m p o r t a n t O t h e r fa c t o r s ( o r a c o m b in a t io n o f f a c to r s ) m a y in f lu
e ffe c t on F lb A 1c ( M D , -0 .4 2 [C l, -0 .5 6 to 0 .2 7 ]; e n c e o u t c o m e s ; f o r in s ta n c e , d e liv e r y f o r m a t m a y b e
/2 = 55% ; 33 c o m p a r is o n s ; 4774 p a r t ic ip a n t s ) th a t h ig h ly d e p e n d e n t u p o n t h e p o p u la t io n s e r v e d a n d p r o
s e e m e d to b e g r e a t e r t h a n f o r t h e c o m p a r is o n s w ith g r a m c o n t e n t . T h e s tu d ie s o f f e r in g g r o u p d e liv e r y t h a t

w w w .a n n a ls .o r g Annals of Internal Medicine Vol. 163 No. 11 1 December 2015 853

R eview
had high effect sizes te nd ed to be those offered to m i
nority groups, including Mexican Am ericans (39, 41,
102), w here su pp ort from peers was a key program
feature.
We were unable to draw conclusions about the ef
fectiveness o f professional healthcare versus lay p ro vid
ers fo r delivery o f behavioral program s. Evaluating the
pairwise meta-analysis results fo r com parative effective
ness between 2 or more behavioral program s (A p p e n
d ix Table 5), 4 trials (575 p articip a nts) fo u n d no
difference when program s were delivered by peers
com pared with health care professionals (MD, 0.00 [Cl,
- 0 .2 3 to 0.23]) (33, 63, 122; Z g ib o r J, Piatt G. 2014.
U npublished report). M ost trials reported on extensive
training program s fo r personnel delivering th eir p ro
grams, including the lay providers. Diabetes educators,
highly regarded fo r th e ir th orou g h know ledge and
skills in diabetes education, may require substantial
training and supervision when starting to apply ad
vanced behavioral techniques, such as m otivational in
terview ing; this technique was shown to be beneficial
fo r im proved glycem ic control in the short term when
delivered by clinical psychologists (127, 148) b ut not by
diabetes educators (146).
The m ore positive findings fo r patients with poorer
glycem ic control are consistent with those o f previous
systematic reviews (157). Intuitively, individuals with
goo d glycem ic control may not achieve as much bene
fit from behavioral p ro g ra m s-th e re is little room fo r im
provem ent, and g oo d self-m anagem ent behaviors may
already be practiced regularly. The findings fo r the eth
nicity subgroups need to be interpreted in lig h t o f d if
ferences in baseline glycem ic control, which seem ed to
be worse fo r the m inority subgroup (H b A 1c level,
8.80%) com pared with the m ajority/w hite subgroup
(H b A 1c level, 7.60%); it is thus hard to distinguish
w hether ethnicity or glycem ic control is m ore likely to
have the g re a te r influence in m oderating program
effectiveness.
Many trials with a large p ro po rtio n o f ethnic m in or
ities also adapted program s to make them more cu ltur
ally and linguistically a c c e p ta b le -o fte n by including
peers in delivering or im plem enting social support
g ro u p s-w h ich may have enhanced th e ir effectiveness.
A previous systematic review (158), which found benefit
o f culturally tailored diabetes education, found that
lower baseline H bA lc levels b etter predicted positive
responses to the program s. O ur reliance on study-level
data to create subgroups may have lim ited our ability
to capture differences in effects from program s deliv
ered to a w ide r population base, which may reflect rou
tine practice in many com m unity health settings.
O ur study has lim itations. First, our full search was
conducted to January 2015; however, a search update
to June 2015 in MEDLINE did not identify any large
study with low risk o f bias that may affect findings. In
addition, systematic reviews are threatened by risks of
selective rep orting bias (e.g., studies only reporting
positive outcomes); publication bias, in which unex
pectedly strong results from large trials are selectively
published; and selection bias. We were able to locate
854 Armais of Internal Medicine Vol. 163 No. 11 1 December 2015
Behavioral Programs for Type 2 Diabetes Mellitus
several trial registries and protocols to com pare
planned and published outcom e rep orting ; m ost in
cluded studies had low bias in this respect. Our
prespecified tests fo r publication bias p rovided no in
dication o f im portant bias. Effect sizes in language-
restricted reviews have shown not to d iffer significantly
from those w itho ut restrictions (159). Many trials had
m ethodological lim itations introducing some risk o f
bias.
O ur findings should be interpreted on the basis of
our approach to address program durability. O ur anal
yses used outcom e data at longest postintervention fo l
low up, which fo r the m ajority o f studies was between
the end o f the intervention and 6 m onths o f follow -up.
Only 8 o f 112 trials had fo llo w -u p lon ge r than 6
months; longer follo w -u p w ould allow fo r further eval
uation o f the effectiveness o f these program s. Results
from our pairwise meta-analyses fo r H bA 1c in T2DM at
each fo llo w -u p tim e p oint indicated reduced effective
ness at fo llo w -u p durations longer than the end o f in
tervention; this suggests that the mean effect sizes from
our netw ork meta-analysis at longest fo llo w -u p may un
derestim ate the effects at the end o f the intervention.
In conclusion, the effectiveness o f behavioral p ro
grams on glycem ic control was shown to be m oderated
to the greatest extent by program intensity and to a
lesser extent by delivery personnel or fo rm a t (e.g., in
dividual vs. group). It seems th a t program s require a
substantial am ount o f contact tim e or, fo r DSME-based
program s, a su pp ort com p on en t to best train people in
th e ir self-care. Programs ta ilo re d to ethnic m inorities
seem to be beneficial; subgroup results by age suggest
that tailo rin g o f program s to o ld e r adults is needed.
The add itio n o f a technological aspect in the delivery
did not seem to be as beneficial as in-person delivery,
although more d irect com parisons on this variable
w ould be beneficial because o f the potential fo r
te chn olo gy to enable participation o f hard-to-reach
populations.
From th e University o f A lb erta Evidence-based Practice Cen
ter, University o f Alberta, Edm onton, and A lb erta Health Ser
vices, Calgary Zone, and University o f Calgary, Calgary, A l
berta, Canada.
Disclaimer: The authors o f this re p o rt are responsible fo r its
content. Statements in the re p o rt should not be construed as
en dorsem ent by the AHRQ o r the U.S. D e pa rtm e nt o f Health
and Human Services.
Acknowledgment: The authors thank AHRQ task o rd e r officer
Aysegul Gozu, MD, MPH, and AHRQ associate e d ito r Jona
than Treadwell, PhD, w ho reviewed our review pro to co l and
the full re p o rt sub m itte d to AHRQ, fo r th e ir o n g o in g support.
W e also thank the key inform ants and technical exp ert panel
m em bers (listed in th e full re p o rt online at ww w.effective
he althcare.ahrq.gov/reports/final.cfm ) w ho p ro vid ed in pu t
into the review. Several technical exp ert panel m em bers also
p ro vid ed peer review o f the dra ft re p o rt sub m itte d to AHRQ
and available online.
www.annals.org
Behavioral Programs for Type 2 Diabetes Mellitus
Grant Support: By the AHRQ (contract 290-2012-000131); a
New Investigator Salary Aw ard from the Canadian Institutes of
Health Research (Dr. Hartling); do ctoral awards from the A lli
ance fo r Canadian Health O utcom es fo r Research in Diabetes,
A lb erta Innovates-H ealth Solutions, and the University o f Cal-
gary-Eyes High pro gra m (Dr. A rm strong); and a Health Senior
Scholar award from A lb erta Innovates-H ealth Solutions (Dr.
Sigal).
Disclosures: Ms. Pillay reports grants from AHRQ du rin g the
con du ct o f the study. Dr. Sigal reports salary su p p o rt from
A lb erta Innovates-Health Solutions (Health Senior Scholar sal
ary award) du rin g the c o n d u ct o f the study. Mr. V anderm eer
reports grants from AHRQ d u rin g the con du ct o f the study.
Dr. C hordiya reports grants from AHRQ du rin g the con du ct o f
the study. Ms. Nuspl reports grants from AHRQ du rin g the
con du ct o f the study. Ms. Featherstone reports grants from
AHRQ d u rin g the con du ct o f the study. Dr. Dryden reports
o th e r from AHRQ (contract betw een AHRQ and research
g ro u p to prepare a re p o rt on th e to p ic; this p u blicatio n rep
resents one part o f the rep ort) du rin g the c o n d u ct o f the
study. A uthors not nam ed here have disclosed no conflicts o f
interest. Forms can be view ed at w w w .acpo nline .org/au thors
/icm je /C o n flictO fln te re stF o rm s.d o ? m sN u m = M 1 5-1400.
Reproducible Research Statement: Study protocol: PROSPERO
registration num ber CRD42014010515. Statistical code and data
set: Available from Ms. Pillay (e-mail, jpillay@ualberta.ca).
Requests for Single Reprints: Jennifer Pillay, BSc, A lberta Re
search Centre fo r Health Evidence, D epa rtm e nt o f Pediatrics,
4th Floor, E dm onton C linic Health Academ y, University o f A l
berta, 1 1405 87th Avenue, Edm onton, A lb erta T6G 1C9, Can
ada; e-mail, jpillay@ ualberta.ca.
C u rrent au thor addresses and au thor con tribu tions are avail
able at w w w .annals.org.
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A d Libitum
Revelation
There was pink m edicine. A nd green. They
sloshed inside bo ttles o f m o ttle d glass so thick
th a t not even my brothers could shatter it. And
castor o il! Nemesis o f ou r honeyed lives, our
parents' secret w eapon. O ne dose could fend
all run -of-th e-m ill ills; it d id n 't m atter to them
th a t w e kep t o u r lips clenched, it slid in sidewise.
W e had ty p h o id once, all three o f us at the
same tim e. They gave up th e ir room (the tw o
others small), transfo rm e d it in to an isolation
ward. O u r skin raged, our guts churned; they
held calm th ro u g h th e w o rst - helpless seeps into
an alum inum pan (its stark sheen etched by black
pits o f age), th a t each parent in turn w o u ld fetch
and clean betw een bouts. They flitte d in and out,
first lig h t th ro u g h night, sans sleep o r surcease.
A n d the re was the tim e, when I, an accident-
prone nine, was rushed by m y fa th e r to the local
hospital, after my head m et the pa vem ent - hard.
He held me astutely lig h t in his arms, corra lling
the seizure b irth e d by my fall; stood vig il fo r
hours, my m othe r beside, until I came back to
earth, ta kin g fo r granted th e ir hovering concern.
In th e spring o f my life, I never th o u g h t
o f th e ir sum m er, lost in th e caring,
the constant rep airing , all season long.
Bhuvana Chandra, MD
Porter Ranch, California
2015 American College of Physicians
860 Annals of Internal Medicine Vol. 163 No. 11 1 December 2015
Behavioral Programs for Type 2 Diabetes Mellitus
interventions in adults with type 2 diabetes: a meta-analysis. Am J
Med. 2004;117:762-74. [PMID: 15541326]
157. Duke SA, Colagiuri S, Colagiuri R. Individual patient education
for people with type 2 diabetes mellitus. Cochrane Database Syst
Rev. 2009:CD005268. [PMID: 19160249] doi: 10.1002/14651858
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158. Nam S, Janson SL, Stotts NA, Chesla C, Kroon L. Effect of cul
turally tailored diabetes education in ethnic minorities with type 2
diabetes: a meta-analysis. J Cardiovasc Nurs. 2012;27:505-18.
[PMID: 21747287] doi:10.1097/JCN.0b013e31822375a5
159. Moher D, Pham B, Klassen TP, Schulz KF, Berlin JA, Jadad AR,
et al. What contributions do languages other than English make on
the results o f meta-analyses? J Clin Epidemiol. 2000;53:964-72.
[PMID: 11004423]
In his seventh decade, my father's balance
frayed; leg broken, he lay in unspoken pain
un de r his guava tree, lim b like a w ishbone, askew.
Soon after, my m other's ro ta to r cuff tore. Two
oceans away, I never knew. A d a u g h te r in the dark
o f a pa ren t asunder - how m any missed breaks
th ro u g h the larks and the hijinks o f my you thful days?
Those ages past, seem ed then, to me, a tim e w ith o u t
Tim e - the days pristine as a bo xed deck o f cards still
cellophane-sealed. W ith the shuffles o f gro w th, came
slow understanding, o f the care-full dealing th a t sent
aces my way. The years d o m in o e d ; as each leaned on
the next, I gleaned the w o rds o f the poet, w hich until
then I'd only g ro p e d at. The child is fa th e r o f the man.
Their m edicines now o u tn u m b e r those w e fo u g h t
o ff as kids; no lo n g e r slim e-green o r g a g-w orthy
pink, b u t sleek, shiny capsules w ro u g h t in m anifold
hues th a t my fa th e r arranges in o rd e rly queues. They
take them exactly as the d o c to r prescribes, de spite
the te d iu m o f the da ily d rill. My m othe r fills the w ater
ju g , keeps an eye on the tim e; he ticks the calendar
on th e ir be d ro o m wall. They live as the y always have -
raise no ado, w e athe r all squalls. They ow n th e ir days.
In the fall o f my life, I look at th e ir w in te r
and see only spring: lush from the te n d in g
and careful m ending, a fo u n t gushing strong.
w w w .a n n a ls .o rg
Copyright American College of Physicians 2015.