Abstract
Diabetes mellitus is a chronic disease characterized by high glucose levels (hyperglycemia) due to metabolic disorders that prevent patients from producing sufficient amounts of insulin. This research aims to test the effectiveness of implementing diabetes self-management education in patients with Type 2 diabetes mellitus. The search for relevant articles was carried out through Google Scholar, PubMed, ProQuest, and Science Direct using the keywords diabetes mellitus, management education, self-care, diabetes self-management education, DSME, T2DM. The articles were then selected based on inclusion and exclusion criteria. Furthermore, the data were extracted, grouped, and concluded. Based on 15 articles, diabetes self-management education intervention provides significant effectiveness to lifestyle changes and the self-care of T2DM patients. In conclusion, diabetes self-management education intervention has been shown to be effective in dealing with type 2 diabetes mellitus. Furthermore, DSME has a positive effect on lifestyle changes and the self-care of T2DM patients.
Introduction
Significance for public health
Globally, there are various pillars of diabetes mellitus management. One of the important pillars for the prevention and management is education. When properly carried out, it provides benefits to people with diabetes mellitus. Furthermore, the Association of Diabetes Care and Education (AADE) has guidelines for diabetes self-management education (DSME). In reality, there are many health workers that provide education without paying attention to these guidelines. Therefore, this study on the effectiveness of diabetes self-management education (DSME) would provide information regarding the importance of using these guidelines.
Diabetes mellitus (DM) is a chronic disease characterized by high glucose levels (hyperglycemia) due to metabolic disorders that prevent the patient from producing sufficient amounts of insulin. The disease can be prevented and controlled by engaging in certain behaviors and lifestyles such as regular exercise, healthy eating patterns, avoiding smoking, and controlling fat and glucose in the blood. 1 The World Health Organization stated that the number of people living with diabetes mellitus (DM) worldwide reached 422 million, and every year 1.6 million deaths are recorded. 2 The prevalence of the disease in the world is estimated to reach 642 million people by 2040. In 2019, the countries with the highest number of DM sufferers were China, India, the United States, Pakistan, Brazil, Mexico, and Indonesia, with an estimated number of 10 million patients. 3 The number of people living with diabetes could be much greater than the prevalence described, because most sufferers only seek medical help after complications occur. The rising prevalence of diabetes mellitus is due to several factors, such as unhealthy behavior. 1 This behavior is still rampart in Indonesian society, and is evidenced by the results of the Basic Health Research 2018, 1 where 13.6% of the residents were overweight, 21.8% had obesity, and 31% central obesity. Other unhealthy habits include the use of tobacco by men (62.9%) and smoking by adolescents (10-18 years) (23.91%). 4 There are seven major behaviors related to diabetes self-care management, they include diet, physical activity, monitoring blood glucose levels, adherence to proper medication consumption, good problem solving, coping skills, and risk reduction behavior. 5 Continuous selfcare will reduce the incidence of DM complications. However, most DM sufferers do not practice adequate self-care techniques such as controlling fasting blood glucose levels. 6
DM management focuses on several aspects, namely education, meal planning, changes in lifestyle, physical activity, habits. 7 One study explained that educational interventions influence knowledge, physical activity, food intake, self-efficacy, and health literacy. 8 Diabetes self-management education (DSME) plays a key role in empowering people with diabetes to engage and sustain lifestyle changes, which have been shown to improve health outcomes. DSME is the process of facilitating the knowledge, attitudes, and abilities necessary for self-management. 9 In addition to this, DSME play an important role in influencing the self-care practices of patients with diabetes mellitus. Based on this phenomenon, a literature review was prepared to highlight effectiveness of DSME on T2DM.
Design and Methods
The collection and review of articles was carried during the month of October 2020. Furthermore, published articles were obtained through several electronic databases, such as Google Scholar, PubMed, ProQuest, and ScienceDirect using the keywords diabetes mellitus, self-care, diabetes self-management education, and DSME. The articles obtained from these databases were then selected based on the inclusion and exclusion criteria in order to obtain relevant articles. In addition to this, articles designs were selected using cross-sectional, randomized controlled trials (RCT), systematic reviews, and quasi-experimental studies. Subsequently, the data was then extracted, grouped, and concluded; 137 articles were obtained through the selection process (inclusion and exclusion criteria) (Table 1). These articles were then assessed for criticism and 15 were found to be relevant to the criteria.
Inclusion and exclusion criteria.
Results and discussions
The effectiveness of DSME in T2DM is the main focus of this literature review. The heterogeneity of DSME implementation were seen based on the number of sessions, the time span, and the methods used. The study presented 6 articles with homogeneous results showing that DSME has a good effect on T2DM patients (Table 2).
Article review result.
The DSME intervention given to T2DM patients in Ethiopia had a positive impact, such as an increase in knowledge and adherence to diet therapy, exercise, glucose monitoring, and wound care. 10 In line with that, another study explained that DSME significantly improved medication adherence, self-management behavior, knowledge, self-efficacy, and quality of life.11-13 Several studies show that DSME interventions improve the quality of life.14-17 Through these interventions, bad behavior such as smoking and alcohol consumption can also be avoided or reduced. 10
Several interventions are also able to influence lifestyle changes such as increasing the duration of exercises (cycling, walking, aerobics), reducing smoking habits, and increasing the consumption of fruits and vegetables. 18 Lifestyle changes caused by DSME interventions are expected to improve the clinical and health status of T2DM patients. One study proved this showing DSME's effectiveness in controlling fasting blood glucose, random blood glucose, total cholesterol, and triglycerides. 11 In line with that, other studies also showed that DSME can influence glycemic control, body weight and BMI control.11,19-21 Apart from data homogeneity in the article, another difference was found regarding the effect of DSME on HbA1c. Cunningham 14 states that DSME does not significantly affect HbA1c. This is in contrast with other studies which explain that this intervention can significantly affect HbA1c.21-26 After reviewing several studies, it is proven that DSME has a positive effect on the lifestyle and clinical or health status of T2DM patients. However, the implementation process could be influenced by several factors, namely: i) limited resources, ii) culture, iii) relationship with diabetes, and iv) relationship with clinic.
This systematic review focuses on the effectiveness of DSME on T2DM disease progression. It is known that the DSME intervention provides benefits to the development of T2DM disease. The demonstrated benefits point to efforts to increase T2DM development through lifestyle changes and self-care for T2DM patients. Lifestyle changes such as exercising diligently, increasing consumption of fruits and vegetables, and avoiding smoking can improve the patient's clinical condition and the patient's health status. 18 The clinical condition can be seen from the levels of blood glucose and HbA1c.
DSME has a positive effect on T2DM patients to improve their knowledge, behavior, self-efficacy, and clinical conditions of patients such as blood glucose levels, HbA1c, lipid profiles.10,11,19-21 However, there were differences in results in studies involving HbA1c levels. The difference that lies in the presence or absence of this effect on HbA1c can be a concern in future studies to consider the determining factors that can influence it. Several studies in this review show that the effectiveness of DSME is influenced by education providers and support systems.17,22,25,26
Conclusions
Based on the 15 articles reviewed, it was found that DSME intervention provides significant effectiveness to lifestyle changes and the self-care of T2DM patients. Therefore, it improves the clinical or health status of T2DM patients.
Footnotes
Acknowledgment
The authors are grateful to the co-authors and reviewers for this research.