title: Sex differences in weight loss among adults with Type II diabetes mellitus Psychological predictors of glycemic change with relaxation training in non-insulin-dependent diabetes mellitus. Stress management improves long-term glycemic control in type 2 diabetes. Motivational Interviewing to Improve Adherence to a Behavioral Weight-Control Program for Older Obese Women With NIDDM: A pilot study Effects of Relaxation Training on Glucose Tolerance and Diabetic Control in Type II Diabetes Effects of a tailored lifestyle self-management intervention in patients with type 2 diabetes. The diabetes network internet-based physical activity intervention: a randomized pilot study. Impact of Intensive Educational Approach to Dietary Change in NIDDM Three psychological treatments for bulimia nervosa. A comparative trial. The Relative Effectiveness of Educational and Behavioral Instruction Programs for Patients With NIDDM: A Randomized Trial Improved control of type 2 diabetes mellitus: a practical education/behavior modification program in a primary care clinic. The course of major depression in diabetes. Relaxation Training for NIDDM: Predicting who may benefit Behavioral Analysis and Behavioral Strategies to Improve Self-Management of Type II Diabetes Management of Obese Patients With Diabetes Mellitus: Comparison of Advice Education With Group Management A "family-based" approach to the treatment of obese type II diabetic patients. A Randomized Clinical Trial Comparing Behavior Modification and Individual Counseling in the Nutritional Therapy of Non-insulin-dependent Diabetes Mellitus: Comparison of the Effect on Blood Sugar, Body Weight, and Serum Lipids Group therapy for binge eating in Type 2 diabetes: a randomized trial. Cognitive behavior therapy for depression in type 2 diabetes mellitus. A randomized, controlled trial.
abstract: The treatment of choice for Type II or non-insulin-dependent diabetes mellitus is a behavioral program for the management of weight . However , compliance with this lifelong dietary regimen is often poor . In the current investigation male and female adults with diagnosed Type II diabetes were r and omly assigned to either a behavior modification , a cognitive modification , a cognitive-behavior modification , or a control group . Patients were evaluated in terms of weight , percentage of body fat , and glycosylated hemoglobin measures . Men lost signficantly more weight than women and subjects in the behavior modification group lost more weight and demonstrated greater decreases in diabetes control than subjects in the cognitive-behavior modification , cognitive , and control groups . A significant interaction indicated that diabetic men may benefit more from  behavioral weight reduction programs  than diabetic women . Several explanations for these findings are considered BACKGROUND Previous findings are unclear regarding the possible glycemic benefits of applying behavioral relaxation training in non-insulin-dependent diabetes mellitus ( NIDDM ) . METHODS Subjects with NIDDM were r and omized to relaxation training ( 6 sessions of progressive muscle relaxation and imagery , n = 12 ) or control treatment ( routine medical care , n = 10 ) . Physiological measures were total glycosylated hemoglobin ( GHb ) and area under the 2-hour oral-glucose-tolerance curve ( AUC ) . Psychological measures of generalized distress , anxiety and daily stress were also administered . All subjects were assessed before and after the 8-week intervention , and again at 16 weeks of long-term follow-up . RESULTS There were no postintervention group differences in physiological variables . Highly distressed subjects and those who rated their glucose as more stress responsive tended to practice relaxation less between sessions . Within the treated group only , lower preintervention stress responsivity was associated with greater improvement in GHb , and lower anxiety and distress levels predicted long-term improvement in AUC . CONCLUSIONS It remains unclear whether relaxation training produces glycemic benefits in NIDDM . Perhaps the least anxious and stress-responsive patients only benefit from group-based relaxation training , whereas anxious individuals require intensive individually administered interventions OBJECTIVE There is conflicting evidence regarding the utility of stress management training in the treatment of diabetes . The few studies that have shown a therapeutic effect of stress management have used time-intensive individual therapy . Unfortunately , widespread use of such interventions is not practical . The aim of the present investigation is to determine whether a cost-effective , group-based stress management training program can improve glucose metabolism in patients with type 2 diabetes and to determine whether a particular subset of patients is more likely to get positive results . RESEARCH DESIGN AND METHODS Patients with type 2 diabetes were r and omized to undergo a five-session group diabetes education program with or without stress management training .  Participants ( n = 108 ) were followed for 1 year , during which HbA(1c ) tests and question naires assessing perceived stress , anxiety , and psychological health were administered at regular intervals to evaluate treatment effects . RESULTS Stress management training was associated with a small ( 0.5 % ) but significant reduction in HbA(1c ) . Compliance with the treatment regimen decreased over time but was similar to that seen in patients receiving stress management for other reasons in the clinic . Trait anxiety ( a measure of stable individual differences in anxiety proneness ) did not predict response to treatment , showing that highly anxious patients did not derive more benefit from training . CONCLUSIONS The current results indicate that a cost-effective , group stress management program in a " real-world " setting can result in clinical ly significant benefits for patients with type 2 diabetes OBJECTIVE The aim of this r and omized pilot study was to examine whether the addition of motivational interviewing strategies to a behavioral obesity intervention enhances adherence and glucose control in older obese women with NIDDM . RESEARCH DESIGN AND METHODS Twenty-two older obese women ( 41 % black ) with NIDDM were r and omly assigned to 1 ) a st and ard 16-week group behavioral weight-control program that provided instruction in diet , exercise , and behavioral modification or 2 ) the same group behavioral program with three individualized motivational interviewing sessions added . RESULTS The motivational group attended significantly more group meetings ( 13.3 vs. 8.9 ) , completed significantly more food diaries ( 15.2 vs. 10.1 ) , and recorded blood glucose significantly more often ( 46.0 vs. 32.2 days ) than the st and ard group . Further , participants in the motivational group had significantly better glucose control post-treatment ( 9.8 vs. 10.8 % ) . Although both groups demonstrated significant weight loss , no differences were apparent between groups . CONCLUSIONS These results suggest that augmenting a st and ard behavioral treatment program for obese women with NIDDM with a motivational interviewing component may significantly enhance adherence to program recommendations and glycemic control . Preliminary data warrant further investigation with larger sample s and a longer follow-up The present study examined the effects of progressive relaxation training and EMG biofeedback on acute glucose disposal in diabetic subjects , as measured by glucose tolerance and three other measures of diabetic metabolic control . Twenty subjects with non-insulin-using Type II diabetes took part in progressive relaxation training and EMG biofeedback in a pre-post treatment versus wait-list experimental design . Treatment effects were assessed on glucose tolerance along with three measures of diabetic control : fasting blood glucose , two-hour postpr and ial blood glucose , and fructosamine . Stress reduction and relaxation was assessed with two physiological measures and two subjective question naires . The training program produced significant reductions in stress , as measured by State Anxiety , and significant changes in physiological measures of muscle activity and skin conductance compared to the control condition . However , no changes were found in glucose tolerance ( while practicing relaxation ) nor in any of the three measures of general diabetic metabolic control . The major implication of this study is that relaxation training does not appear to directly improve diabetic control in mildly stressed non-insulin-using Type II diabetic patients OBJECTIVES The aim of the present study was to develop , implement and evaluate a brief intervention to improve adherence to the recommended lifestyle changes for patients with Type 2 diabetes , in particular to help patients to reduce the total amount of fat consumed and to increase lifestyle physical activity levels . DESIGN AND METHOD A brief , tailored lifestyle self-management intervention for patients with Type 2 diabetes was evaluated in a r and omized controlled trial . One hundred participants ( aged 40 - 70 yrs ) completed assessment s at three time points- baseline , three months and one year . Participants were allocated to either an intervention group who received the brief tailored intervention including follow-up telephone calls , or a usual care control group . RESULTS Results indicate that the intervention was successful in helping patients to reduce fat intake and , to a lesser extent , increase lifestyle physical activity levels . These self-reported changes in behaviour were reflected in the objective data with weight maintenance in the intervention group compared to the control group , together with a significant reduction ( 2 cm ) in waist circumference . CONCLUSIONS These results provide further evidence of the effectiveness of tailored interventions for lifestyle change OBJECTIVE Because of other competing priorities ,  physical activity ( PA ) is seldom addressed in a consistent way in either primary care or diabetes education . This 8-week pilot study evaluated the short-term benefits of an Internet-based supplement to usual care that focused on providing support for sedentary patients with type 2 diabetes to increase their PA levels . RESEARCH DESIGN AND METHODS A total of 78 type 2 diabetic patients ( 53 % female , average age 52.3 years ) were r and omized to the Diabetes Network ( D-Net ) Active Lives PA Intervention or an Internet information-only condition .  The intervention condition received goal - setting and personalized feedback , identified and developed strategies to overcome barriers , received and could post messages to an on-line " personal coach , " and were invited to participate in peer group support areas . Key outcomes included minutes of PA per week and depressive symptomatology . RESULTS There was an overall moderate improvement in PA levels within both intervention and control conditions , but there was no significant improvement in regard to condition effects . There was substantial variability in both site use and outcomes within the intervention and control conditions . Internal analyses revealed that among intervention participants , those who used the site more regularly derived significantly greater benefits , whereas those in the control condition derived no similar benefits with increased program use . CONCLUSIONS Internet-based self-management interventions for  PA and other regimen areas have great potential to enhance the care of diabetes and other chronic conditions . We conclude that greater attention should be focused on methods to sustain involvement with Internet-based intervention health promotion programs over time The aim of this study was to compare the effects of an intensive educational approach incorporating longer time , greater simplicity , repetition , and cognitive motivational techniques with a conventional one in subjects with established non-insulin-dependent diabetes mellitus ( NIDDM ) whose weight , glycemic control , and diet were not optimal . Subjects were r and omly allocated to intensive or conventional education .  Of 350 subjects , 70 met the study criteria , which included established NIDDM ( ≥3 mo ) , suboptimal recent glycemic control , dietary fat intake ≥35 % of total energy intake , and body massindex ≥25 kg/m2 . The intensive approach was associated with significantly greater improvements in dietary compliance , dietary intake ( complex carbohydrate , [ P = 0.013 ] , legumes [ P < 0.0001 ] , fiber [ P < 0.0001 ] , total fat [ P < 0.004 ] , saturated fat [ P < 0.004 ] ) , and total cholesterol level ( P = 0.007 ) . The transient improvement in glycemic control was similar in both groups . An intensive education program can improve dietary compliance in established NIDDM subjects more than a conventional one . These recommended dietary improvements achieve better improvement in total cholesterol but do not necessarily improve glycemic control The specificity and magnitude of the effects of cognitive behavior therapy in the treatment of bulimia nervosa were evaluated . Seventy-five patients who met strict diagnostic criteria were treated with either cognitive behavior therapy , a simplified behavioral version of this treatment , or interpersonal psychotherapy . Assessment was by interview and self-report question naire , and many aspects of functioning were evaluated . All three treatments result ed in an improvement in the measures of the psychopathology .  Cognitive behavior therapy was more effective than  interpersonal psychotherapy  in modifying the disturbed attitudes to shape and weight , extreme attempts to diet , and self-induced vomiting .  Cognitive behavior therapy was more effective than  behavior therapy in modifying the disturbed attitudes to shape and weight and extreme dieting , but it was equivalent in other respects . The findings suggest that cognitive behavior therapy , when applied to patients with bulimia nervosa , operates through mechanisms specific to this treatment and is more effective than both interpersonal psychotherapy and a simplified behavioral version of cognitive behavior therapy In this r and omized trial patients with non-insulin-dependent diabetes were allocated to one of four programs : a minimal instruction program ( n=59 ) . an education program of individual visits ( n=57 ) , an education program incorporating a group education course ( n=66 ) , and a behavioral program ( n=59 ) . Individual and group education programs had higher attrition rates than the behavioral and minimal programs . The four programs , which involved different amounts of patient contact time , delivery format , and instructional strategies . all produced reductions in HbA atid BMI , with no significant differences between the programs . There were no differences between groups over three time periods in total cholesterol , HDL cholesterol , systolic blood pressure , or proportion of patients consulting an ophthalmologist . The behavioral program ploduced a greater reduction in diastolic blood pressure over 12 months that the education programs and a greater reduction in the cholesterol risk ratio over 3 months than the other programs . The behavioral program patients were more likely to have visited a podiatrist after 6 months and reported higher satisfaction BACKGROUND This study was done to determine the efficacy and ease of administration of education/behavior modification classes , provided by a nurse and a dietitian in a primary care clinic for improving control of type 2 diabetes mellitus .  METHODS Patients were divided r and omly into two groups . Eighteen patients completed 6 months of structured , office-based classes , and 20 similar patients served as control subjects . All were patients of the same group practice and had their usual office visits .  Glycemic control , lipid levels , body weight , knowledge about diabetes , medication requirements , and symptoms were monitored during the 6 months , with follow-up at 12 months . RESULTS At the end of 6 months , the intervention group had significant reductions in mean fasting blood glucose , glycosylated hemoglobin , total cholesterol , and low-density lipoprotein cholesterol ( LDL-C ) values . Their mean body weight was significantly reduced at 12 months , and their knowledge of diabetes was improved . Control patients had significant improvement only in glycosylated hemoglobin and body weight at 6 months . Minimal physician time was required . CONCLUSION The education/behavior modification program was clinical ly worthwhile , and it was easy to administer The course of depression in patients with comorbid medical illness is poorly understood . We report a 5-year follow-up study of 25 diabetic patients who had participated in an 8-week depression treatment trial .  When a patient completed the trial , primary physicians were informed of patient outcomes and advised to monitor for relapse and treat those with ongoing depression . At the 5-year reevaluation depression was assessed using DSM-III-R criteria , and a depression severity scale was formed that reflected the presence , severity , frequency , and duration of depression episodes as well as a global assessment of functioning . Recurrence or persistence of depression occurred in 23 ( 92 % ) of the patients with an average of 4.8 depression episodes over the 5-year follow-up period . The duration of the longest episode averaged 16 + /- 4 months . Reversion to major depression occurred frequently and rapidly also in the subset that remitted during the treatment trial : 58.3 % were depressed again within the first year . At the time of the follow-up interview , major depression was evident in 16 ( 64 % ) of the subjects , and glycemic control was significantly worse in this group compared with those without depression ( gHb : 13.3 % + /- 2.6 % vs 11.1 % + /- 1.9 % , P = 0.03 ) . Severity of depression over follow-up was related to the presence of neuropathy at entry and to incomplete remission during the initial treatment trial . Nineteen patients ( 82.6 % of those who relapsed ) received additional courses of antidepressant therapy , but none was treated continuously for depression prophylaxis . In this diabetic sample , depression was a recurrent condition in the vast majority of cases , and initial treatment response did not confer lasting euthymia . Whether maintenance antidepressant medication would be useful in preventing depression recurrence and promoting better glycemic control in diabetes remains to be studied OBJECTIVE To examine the benefits of relaxation training for patients with NIDDM and to investigate individual differences that could predict a positive response to relaxation training . RESEARCH DESIGN AND METHODS Thirty-eight subjects with NIDDM were treated with intensive conventional diabetes therapy after an initial metabolic evaluation and psychological and pharmacological testing . Half were assigned to also receive biofeedback-assisted relaxation training . Treatment effects on GHb levels and glucose tolerance were evaluated after 8 wk . RESULTS Subjects demonstrated significant improvements in GHb level , but not in glucose tolerance , after 8 wk of intensive conventional treatment . These improvements persisted throughout the follow-up period . However , the group provided with relaxation training did not experience greater improvements on either measure than the group given conventional diabetes treatment only . Within the group that received relaxation training , correlations occurred between the improvements in glucose tolerance after treatment and individual differences in trait anxiety and in the effect of alprazolam on glucose tolerance . Differences in the effects of EPI on glucose tolerance and personality measures of neuroticism and perceived locus of control also appeared to be related to improvements in glucose tolerance after training . CONCLUSIONS Relaxation training did not confer added benefit over and above that provided by conventional diabetes treatment for patients with NIDDM . Additional research is needed to determine whether the administration of relaxation training to selected patients , especially those who are most responsive to stress , would provide benefits for glucose control that are not achieved by conventional treatment The implication s of behavioral analysis for practice and research have significant potential for nursing . This present study was conducted to determine the effectiveness of nurses and patients actively participating in behavioral analysis and the implementation of behavioral strategies in order to improve the patients ' self-management of their Type H diabetes . Patients ( N = 156 ) were r and omly assigned to one of four groups . The attention control group ( n = 41 ) received routine care . The compliance group ( n = 32 ) agreed to practice compliance behaviors related to the prescribed medical regimen . The behavioral strategies group ( n = 42 ) participated in behavioral analysis and agreed to practice behavioral strategies . The behavioral strategies with instruction group ( n = 41 ) participated in behavioral analysis , agreed to practice behavioral strategies , and received classes and programmed instruction about behavioral analysis and behavioral strategies . There were no outcome differences between groups relative to glycosylated hemoglobin ( GHb ) and weight loss . There were differences in the outcome measures in subgroups by age , gender , and employment , which have practice and research implication s for the individualization of interventions using behavioral strategies The purpose of our study was to compare the effect on diabetes control of group management with the advice-educational technique traditionally used in managing obese out patients with poorly controlled non-insulin-dependent diabetes mellitus ( NIDDM ) . Forty-one patients were r and omly assigned to these two treatment programs , and 32 patients completed the 6-mo study . Initially , patients were seen for 1-h sessions at 1- and 2-wk intervals and later at 1-mo intervals . Patients were asked to do home blood glucose monitoring , decrease caloric intake , increase exercise , and if they were taking insulin , to adjust the dose to attain approximate euglycemia  and to stabilize food and exercise patterns  . The combined groups reduced mean ± SD glycohemoglobin from 10.9 ± 3.1 to 9.4 ± 2.4 % ( P < .05 ) . Internal Health Locus of Control Scale was negatively and significantly correlated with initial and subsequent glycohemoglobin values ( the more internal , the lower the glycohemoglobin ) . At the end of the study the patients in the group management program had significantly lower blood glucose levels than those given advice and education , but no significant differences in glycohemoglobin values or percentage overweight were observed . One patient had a normal initial glycohemoglobin , and only 4 patients had values in the normal range of 4–6.8 % at the end of the study . Better management programs need to be developed for treating obese out patients with NIDDM Forty-nine obese diabetic patients with obese spouses ( diabetic or nondiabetic ) were r and omly assigned to an alone or together condition . Patients in the alone group participated by themselves in a 20-week behavioral weight control program ; their spouses attended assessment sessions only . Patients in the together group attended the program with their spouses ; both were targeted for weight loss and taught social support strategies .  Weight losses of patients treated alone and together did not differ significantly at posttreatment ( 19.9 vs. 19.1 lb ) or 1-year follow-up ( 11.6 vs. 7.0 lb ) . However , there was a significant interaction of treatment and gender ; women did better when treated with their spouses , whereas men did better when treated alone . A " family-based " approach was not effective for these obese Type II diabetic patients as a whole but may be helpful for women To determine whether a group behavior modification approach might be preferable to individual counseling in the nutritional therapy of non-insulin-dependent diabetes mellitus , 40 adults younger than 65 yr of age with diabetes mellitus who were not receiving insulin were r and omized to either a program of individualized dietary review and recommendations or a program of group meetings aim ed at controlling the signals leading to overeating and noncompliance with a diabetic dietary regimen . Statistically significant ( P < 0.05 ) decreases in body weight , sum skin-fold thickness , fasting serum glucose , and serum triglycerides but not LDL-C or HDL-C were observed . The individual counseling group had a greater amount of weight loss than the behavior modification group . There were no significant ( P < 0.05 ) differences between the two groups with respect to the biochemical outcome variables . Patient characteristics assessed at entry — namely anxiety , internal versus external locus of control and perceived disease severity , and compliance with advice — were significantly associated with weight loss in the behavior modification group while only the latter index was of value in the individual counseling group . Thus , our use of these programs does not identify a clear advantage of either approach in the nutritional therapy of non-insulin-dependent diabetic patients Aims This preliminary study addresses three related issues . First , there is a need to test the effectiveness of cognitive behavioural therapy ( CBT ) for binge eating in population s with Type 2 diabetes . Second , the impact of a treatment for binge eating on diabetes management is unknown . Finally , whilst a number of treatment modalities have been shown to improve binge eating , there has not been a comparison between CBT and a non-specific therapy for binge eating . Methods Group CBT for binge eating was compared with a group non-prescriptive therapy ( NPT ) , a therapy for which there is no theoretical or empirical support in eating disorders , in a r and omized trial which included a post-treatment assessment and a 3-month follow-up . Results There were no differences between CBT and NPT at post-treatment , with both treatments being associated with significant changes in binge eating , mood and body mass index . However , there was a significant relapse in binge eating at the 3-month follow-up in the NPT condition . This was in contrast to the CBT condition , where treatment gains were maintained . Finally , across treatments , reduction in binge eating from pre- to post-treatment was associated with reduction in HbA(1c ) . Conclusions Binge eating in Type 2 diabetes is responsive to psychosocial treatment , and reduction in binge eating appears to improve glycaemic control . However , this is a small study with a short follow-up period . Future studies will need to extend the follow-up period to assess for long-term maintenance of the effects of CBT on binge eating and diabetic control in this population BACKGROUND Psychotherapy is the principal nonpharmacologic method for the management of depression , but its usefulness for depressed patients with diabetes remains unknown . OBJECTIVE To assess the efficacy of cognitive behavior therapy ( CBT ) for depression in patients with diabetes . DESIGN R and omized , controlled trial . SETTING Referral-based academic medical center . PATIENTS 51 patients with type 2 diabetes and major depression . INTERVENTION Patients were assigned either to a group that received 10 weeks of individual CBT or to a control group that received no specific antidepressant treatment . All patients participated in a diabetes education program to control for the effects of supportive attention and the possible influence of enhanced diabetes control on mood . MEASUREMENTS Degree of depression was measured by using the Beck Depression Inventory ; glycemic control was measured by using glycosylated hemoglobin levels . Outcomes were assessed immediately after treatment and 6 months after treatment . RESULTS The percentage of patients achieving remission of depression ( Beck Depression Inventory score < or = 9 ) was greater in the CBT group than in the control group : posttreatment , 85.0 % of patients in the CBT group ( 17 of 20 ) compared with 27.3 % of controls ( 6 of 22 ) achieved remission ( difference , 57.7 percentage points [ 95 % CI , 33 to 82 percentage points ] ) ( P < 0.001 ) ; at follow-up , 70.0 % of patients in the CBT group ( 14 of 20 ) compared with 33.3 % of controls ( 7 of 21 ) achieved remission ( difference , 36.7 percentage points [ CI , 9 to 65 percentage points ] ) ( P = 0.03 ) . Post-treatment glycosylated hemoglobin levels were not different in the two groups , but follow-up mean glycosylated hemoglobin levels were significantly better in the CBT group than in the control group ( 9.5 % compared with 10.9 % ; P = 0.03 ) . CONCLUSIONS The combination of CBT and supportive diabetes education is an effective nonpharmacologic treatment for major depression in patients with type 2 diabetes . It may also be associated with improved glycemic control
target: INTERPRETATION In type 2 diabetes , there are improvements in long-term glycaemic control and psychological distress but not in weight control or blood glucose concentration in people who receive psychological therapies
background: BACKGROUND Adherence difficulties and psychological problems are associated with poor glycaemic control  in diabetes .
  We undertook a systematic review and meta- analysis of psychological therapies to assess their effectiveness in improving glycaemic control in type 2 diabetes .