title: Comprehensive discharge planning and home follow-up of hospitalized elders: a randomized clinical trial. Diabetes and mortality following acute coronary syndromes. Effects of intensive multiple risk factor reduction on coronary atherosclerosis and clinical cardiac events in men and women with coronary artery disease. The Stanford Coronary Risk Intervention Project (SCRIP). Medication Compliance in Non-insulin-dependent Diabetes: A Randomized Comparison of Chlorpropamide and Insulin Effects of diet and exercise interventions on control and quality of life in non-insulin-dependent diabetes mellitus Implications of diabetes in patients with acute coronary syndromes. The Global Registry of Acute Coronary Events. 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The effect of a structured behavioral intervention on poorly controlled diabetes: a randomized controlled trial.
abstract: CONTEXT Comprehensive discharge planning by advanced practice nurses has demonstrated short-term reductions in readmissions of elderly patients , but the benefits of more intensive follow-up of hospitalized elders at risk for poor outcomes after discharge has not been studied . OBJECTIVE To examine the effectiveness of an advanced practice nurse-centered discharge planning and home follow-up intervention for elders at risk for hospital readmissions .  DESIGN R and omized clinical trial with follow-up at 2 , 6 , 12 , and 24 weeks after index hospital discharge . SETTING Two urban , academically affiliated hospitals in Philadelphia , Pa. PARTICIPANTS Eligible patients were 65 years or older , hospitalized between August 1992 and March 1996 , and had 1 of several medical and surgical reasons for admission . INTERVENTION Intervention group patients received a comprehensive discharge planning and home follow-up protocol design ed specifically for elders at risk for poor outcomes after discharge and implemented by advanced practice nurses . MAIN OUTCOME MEASURES Readmissions , time to first readmission , acute care visits after discharge , costs , functional status , depression , and patient satisfaction . RESULTS A total of 363 patients ( 186 in the control group and 177 in the intervention group ) were enrolled in the study ; 70 % of intervention and 74 % of control subjects completed the trial . Mean age of sample was 75 years ; 50 % were men and 45 % were black . By week 24 after the index hospital discharge , control group patients were more likely than intervention group patients to be readmitted at least once ( 37.1 % vs 20.3 % ; P<.001 ) . Fewer intervention group patients had multiple readmissions ( 6.2 % vs 14.5 % ; P = .01 ) and the intervention group had fewer hospital days per patient ( 1.53 vs 4.09 days ; P<.001 ) . Time to first readmission was increased in the intervention group ( P<.001 ) . At 24 weeks after discharge , total Medicare reimbursements for health services were about $ 1.2 million in the control group vs about $ 0.6 million in the intervention group ( P<.001 ) . There were no significant group differences in post-discharge acute care visits , functional status , depression , or patient satisfaction . CONCLUSIONS An advanced practice nurse-centered discharge planning and home care intervention for at-risk hospitalized elders reduced readmissions , lengthened the time between discharge and readmission , and decreased the costs of providing health care . Thus , the intervention demonstrated great potential in promoting positive outcomes for hospitalized elders at high risk for rehospitalization while reducing costs CONTEXT The worldwide epidemic of diabetes mellitus is increasing the burden of cardiovascular disease , the leading cause of death among persons with diabetes . The independent effect of diabetes on mortality following acute coronary syndromes ( ACS ) is uncertain . OBJECTIVE To evaluate the influence of diabetes on mortality following ACS using a large data base spanning the full spectrum of ACS . DESIGN , SETTING , AND PATIENTS A subgroup analysis of patients with diabetes enrolled in r and omized clinical trials that evaluated ACS therapies .  Patients with ACS in 11 independent Thrombolysis in Myocardial Infa rct ion ( TIMI ) Study Group clinical trials from 1997 to 2006 were pooled , including 62,036 patients ( 46,577 with ST-segment elevation myocardial infa rct ion [ STEMI ] and 15,459 with unstable angina/non-STEMI [ UA/NSTEMI ] ) , of whom 10 613 ( 17.1 % ) had diabetes . A multivariable model was constructed to adjust for baseline characteristics , aspects of ACS presentation , and treatments for the ACS event . MAIN OUTCOME MEASURES Mortality at 30 days and 1 year following ACS among patients with diabetes vs patients without diabetes . RESULTS Mortality at 30 days was significantly higher among patients with diabetes than without diabetes presenting with UA/NSTEMI ( 2.1 % vs 1.1 % , P < .001 ) and STEMI ( 8.5 % vs 5.4 % , P < .001 ) . After adjusting for baseline characteristics and features and management of the ACS event , diabetes was independently associated with higher 30-day mortality after UA/NSTEMI ( odds ratio [ OR ] , 1.78 ; 95 % confidence interval [ CI ] , 1.24 - 2.56 ) or STEMI ( OR , 1.40 ; 95 % CI , 1.24 - 1.57 ) . Diabetes at presentation with ACS was associated with significantly higher mortality 1 year after UA/NSTEMI ( hazard ratio [ HR ] , 1.65 ; 95 % CI , 1.30 - 2.10 ) or STEMI ( HR , 1.22 ; 95 % CI , 1.08 - 1.38 ) . By 1 year following ACS , patients with diabetes presenting with UA/NSTEMI had a risk of death that approached patients without diabetes presenting with STEMI ( 7.2 % vs 8.1 % ) . CONCLUSION Despite modern therapies for ACS , diabetes confers a significant adverse prognosis , which highlights the importance of aggressive strategies to manage this high-risk population with unstable ischemic heart disease BACKGROUND Recent clinical trials have shown that modification of plasma lipoprotein concentrations can favorably alter progression of coronary atherosclerosis , but no data exist on the effects of a comprehensive program of risk reduction involving both changes in lifestyle and medications . This study tested the hypothesis that intensive multiple risk factor reduction over 4 years would significantly reduce the rate of progression of atherosclerosis in the coronary arteries of men and women compared with subjects r and omly assigned to the usual care of their physician .  METHODS AND RESULTS Three hundred men ( n = 259 ) and women ( n = 41 ) ( mean age , 56 + /- 7.4 years ) with angiographically defined coronary atherosclerosis were r and omly assigned to usual care ( n = 155 ) or multifactor risk reduction ( n = 145 ) . Patients assigned to risk reduction were provided individualized programs involving a low-fat and -cholesterol diet , exercise , weight loss , smoking cessation , and medications to favorably alter lipoprotein profiles . Computer-assisted quantitative coronary arteriography was performed at baseline and after 4 years . The main angiographic outcome was the rate of change in the minimal diameter of diseased segments . All subjects underwent medical and risk factor evaluations at baseline and yearly for 4 years , and reasons for all hospitalizations and deaths were documented . Of the 300 subjects r and omized , 274 ( 91.3 % ) completed a follow-up arteriogram , and 246 ( 82 % ) had comparative measurements of segments with visible disease at baseline and follow-up . Intensive risk reduction result ed in highly significant improvements in various risk factors , including low-density lipoprotein cholesterol and apolipoprotein B ( both , 22 % ) , high-density lipoprotein cholesterol ( + 12 % ) , plasma triglycerides ( -20 % ) , body weight ( -4 % ) , exercise capacity ( + 20 % ) , and intake of dietary fat ( -24 % ) and cholesterol ( -40 % ) compared with relatively small changes in the usual-care group . No change was observed in lipoprotein(a ) in either group . The risk-reduction group showed a rate of narrowing of diseased coronary artery segments that was 47 % less than that for subjects in the usual-care group ( change in minimal diameter , -0.024 + /- 0.066 mm/y versus -0.045 + /- 0.073 mm/y ; P < .02 , two-tailed ) . Three deaths occurred in each group . There were 25 hospitalizations in the risk-reduction group initiated by clinical cardiac events compared with 44 in the usual-care group ( rate ratio , 0.61 ; P = .05 ; 95 % confidence interval , 0.4 to 0.9 ) . CONCLUSIONS Intensive multifactor risk reduction conducted over 4 years favorably altered the rate of luminal narrowing in coronary arteries of men and women with coronary artery disease and decreased hospitalizations for clinical cardiac events Medication compliance may be a problem in the management of patients with diabetes . Some physicians initially treat patients having non-insulin-dependent diabetes with oral sulfonylureas because they fear greater compliance problems with insulin therapy . We compared compliance with insulin and chlorpropamide in patients newly beginning medication for NIDDM . Seventy-seven adults with hyperglycemia despite diet therapy were r and omly assigned to chlorpropamide or insulin . Compliance was measured four times over 24 wk . Patients then crossed over to the other medication and were followed for 24 additional weeks . Overall , there were no differences in compliance with the two medications in terms of percent of prescription used , proportion taking at least 80 % of prescribed medication , self-report of medication or diet compliance , or protocol dropout rates . However , treatment satisfaction was higher with chlorpropamide , and most patients preferred chlorpropamide to insulin ( P < 0.0001 ) . While such differences in satisfaction may affect long-term compliance , physicians should not assume that their patients will be less compliant with insulin than with oral sulfonylureas Evidence suggests that diet and exercise are associated with improved glucose tolerance for patients with non-insulin-dependent diabetes mellitus ( NIDDM ) . Seventy-six volunteer adult patients with NIDDM were each assigned to one of four programs : 1 ) diet , 2 ) exercise , 3 ) diet plus exercise , or 4 ) education ( control ) . Each program required ten weekly meetings . Detailed evaluations were completed prior to the program and after three , six , 12 , and 18 months . Evaluations included various psychosocial measures , measures of the quality of life , and fasting blood glucose , glycosylated hemoglobin , and relative weight determinations . Of the 76 original participants , 70 completed the 18-month follow-up study . At 18 months , the combination diet- and -exercise group had achieved the greatest reductions in glycosylated hemoglobin measures . In addition , this group showed significant improvements on a general quality of life measure . These improvements were largely uncorrelated with changes in weight . The authors conclude that the combination of dietary change and physical conditioning benefits NIDDM patients , and that the benefits may be independent of substantial weight loss BACKGROUND There are limited data describing the presenting characteristics , management , and outcomes of diabetic and nondiabetic patients with an acute coronary syndrome ( ACS ) . OBJECTIVE To examine differences in these factors , patients with ST-segment elevation acute myocardial infa rct ion , non-ST-segment elevation acute myocardial infa rct ion , and unstable angina were enrolled in a large multinational coronary disease registry . METHODS The Global Registry of Acute Coronary Events is a prospect i ve observational study of patients hospitalized with an ACS at 94 hospitals in 14 countries . The study sample consisted of 5403 patients with ST-segment elevation acute myocardial infa rct ion , 4725 with non-ST-segment elevation acute myocardial infa rct ion , and 5988 with unstable angina . RESULTS Approximately 1 in 4 patients presented to participating hospitals with a history of diabetes . Patients with diabetes were older , more often women , with a greater prevalence of comorbidities , and they were less likely to be treated with effective cardiac therapies than nondiabetic patients . Patients with diabetes who developed an ACS were at increased risk for each hospital outcome examined including heart failure , renal failure , cardiogenic shock , and death . These differences remained after adjustment for potentially confounding prognostic factors . CONCLUSIONS A considerable proportion of patients with an ACS has diabetes and is at increased risk for adverse outcomes compared with patients without diabetes . There are certain proven therapeutic strategies that remain underused in the diabetic population . A more widespread awareness of this increased risk and a more diligent use of proven cardiac treatment approaches are indicated for patients with diabetes who develop an ACS Abstract Objective : To evaluate the effects of secondary prevention clinics run by nurses in general practice on the health of patients with coronary heart disease . Design : R and omised controlled trial of clinics over one year with assessment by self completed postal question naires and audit of medical records at the start and end of the trial . Setting : R and om sample of 19 general practice s in northeast Scotl and . Subjects : 1173 patients ( 685 men and 488 women ) under 80 years with working diagnoses of coronary heart disease who did not have terminal illness or dementia and were not housebound . Intervention : Clinic staff promoted medical and lifestyle aspects of secondary prevention and offered regular follow up . Main outcome measures : Health status measured by the SF-36 question naire , chest pain by the angina type specification , and anxiety and depression by the hospital anxiety and depression scale . Use of health services before and during the study . Results : There were significant improvements in six of eight health status domains ( all functioning scales , pain , and general health ) among patients attending the clinic . Role limitations attributed to physical problems improved most ( adjusted difference 8.52 , 95 % confidence interval 4.16 to 12.9 ) . Fewer patients reported worsening chest pain ( odds ratio 0.59 , 95 % confidence interval 0.37 to 0.94 ) . There were no significant effects on anxiety or depression . Fewer intervention group patients required hospital admissions ( 0.64 , 0.48 to 0.86 ) , but general practitioner consultation rates did not alter . Conclusions : Within their first year secondary prevention clinics improved patients ' health and reduced hospital admissions . Key messages Nurse led clinics in general practice were used to promote secondary prevention to patients with coronary heart disease Within the first year the health of patients invited to the clinics improved Most benefit was in functional status , but chest pain improved too There was no effects on anxiety or depression There were significant reductions in hospital admissions in the first Background Intensive lifestyle interventions in well-controlled setting s are effective in lowering the risk of chronic diseases such as type 2 diabetes ( T2DM ) and cardiovascular diseases ( CVD ) , but there are still no effective lifestyle interventions for everyday practice . In the Hoorn Prevention Study we aim ed to assess the effectiveness of a primary care based lifestyle intervention to reduce the estimated risk of developing T2DM and for CVD mortality , and to motivate changes in lifestyle behaviors . Methods The Hoorn Prevention Study is a parallel group r and omized controlled trial , implemented in the region of West-Friesl and , the Netherl and s. 622 adults with ≥10 % estimated risk of T2DM and /or CVD mortality were r and omly assigned and monitored over a period of 12 months . The intervention group ( n=314 ) received a theory-based lifestyle intervention based on an innovative combination of motivational interviewing and problem solving treatment , provided by trained practice nurses in 12 general practice s. The control group ( n=308 ) received existing health brochures . Primary outcomes was the estimated diabetes risk according to the formula of the Atherosclerosis Risk In Communities ( ARIC ) Study , and the estimated risk for CVD mortality according to the Systematic COronary Risk Evaluation ( SCORE ) formula . Secondary outcomes included lifestyle behavior ( diet , physical activity and smoking ) . The research assistants , the principal investigator and the general practitioners were blinded to group assignment . Linear and logistic regression analysis was applied to examine the between-group differences in each outcome measure , adjusted for baseline values . Results 536 ( 86.2 % ) of the 622 participants ( age 43.5 years ) completed the 6-month follow-up , and 502 ( 81.2 % ) completed the 12-month follow-up . The mean baseline T2DM risk was 18.9 % ( SD 8.2 ) and the mean CVD mortality risk was 3.8 % ( SD 3.0 ) . The intervention group participated in a median of 2 sessions . Intention-to-treat analyses showed no significant differences in outcomes between the two groups at 6 or 12-months follow-up . Conclusions The lifestyle intervention was not more effective than health brochures in reducing risk scores for T2DM and CVD or improving lifestyle behavior in an at-risk population .Trial registration Current Controlled Trials : IS RCT Purpose The purpose of this study was to evaluate the effectiveness of integrative health ( IH ) coaching on psychosocial factors , behavior change , and glycemic control in patients with type 2 diabetes . Methods Fifty-six patients with type 2 diabetes were r and omized to either 6 months of IH coaching or usual care ( control group ) . Coaching was conducted by telephone for fourteen 30-minute sessions . Patients were guided in creating an individualized vision of health , and goals were self-chosen to align with personal values . The coaching agenda , discussion topics , and goals were those of the patient , not the provider . Preintervention and postintervention assessment s measured medication adherence , exercise frequency , patient engagement , psychosocial variables , and A1C . Results Perceived barriers to medication adherence decreased , while patient activation , perceived social support , and benefit finding all increased in the IH coaching group compared with those in the control group . Improvements in the coaching group alone were also observed for self-reported adherence , exercise frequency , stress , and perceived health status . Coaching participants with elevated baseline A1C ( ≥7 % ) significantly reduced their A1C . Conclusions A coaching intervention focused on patients ’ values and sense of purpose may provide added benefit to traditional diabetes education programs . Fundamentals of IH coaching may be applied by diabetes educators to improve patient self-efficacy , accountability , and clinical outcomes Background Virtual world environments have the potential to increase access to diabetes self-management interventions and may lower cost . Objective We tested the feasibility and comparative effectiveness of a virtual world versus a face-to-face diabetes self-management group intervention . Methods We recruited African American women with type 2 diabetes to participate in an 8-week diabetes self-management program adapted from Power to Prevent , a behavior-change in-person group program for African Americans with diabetes or pre-diabetes . The program is social cognitive theory – guided , evidence -based , and culturally tailored . Participants were r and omized to participate in the program via virtual world ( Second Life ) or face-to-face , both delivered by a single intervention team . Blinded assessors conducted in-person clinical ( HbA1c ) , behavioral , and psychosocial measurements at baseline and 4-month follow-up . Pre-post differences within and between intervention groups were assessed using t tests and chi-square tests ( two-sided and intention-to-treat analyses for all comparisons ) . Results Participants ( N=89 ) were an average of 52 years old ( SD 10 ) , 60 % had ≤high school , 82 % had household incomes < US $ 30,000 , and computer experience was variable . Overall session attendance was similar across the groups ( 6.8/8 sessions , P=.90 ) . Compared to face-to-face , virtual world was slightly superior for total activity , light activity , and inactivity ( P=.05 , P=.07 , and P=.025 , respectively ) . HbA1c reduction was significant within face-to-face ( −0.46 , P=02 ) but not within virtual world ( −0.31 , P=.19 ) , although there were no significant between group differences in HbA1c ( P=.52 ) . In both groups , 14 % fewer patients had post-intervention HbA1c ≥9 % ( virtual world P=.014 ; face-to-face P=.002 ) , with no significant between group difference ( P=.493 ) . Compared to virtual world , face-to-face was marginally superior for reducing depression symptoms ( P=.051 ) . The virtual world intervention costs were US $ 1117 versus US $ 931 for face-to-face . Conclusions It is feasible to deliver diabetes self-management interventions to inner city African American women via virtual worlds , and outcomes may be comparable to those of face-to-face interventions . Further effectiveness research is warranted . Trial Registration Clinical Trials.gov NCT01340079 ; http:// clinical trials.gov/show/NCT01340079 ( Archived by WebCite at http://www.webcitation.org/6T2aSvmka ) Background Culturally adapted interventions are needed to reduce diabetes-related morbidity and mortality among Native Hawaiian and Pacific People . Purpose The purpose of this study is to pilot test the effectiveness of a culturally adapted diabetes self-management intervention . Methods Participants were r and omly assigned in an unbalanced design to the Partners in Care intervention ( n = 48 ) or wait list control group ( n = 34 ) . Assessment s of hemoglobin A1c , underst and ing of diabetes self-management , performance of self-care activities , and diabetes-related distress were measured at baseline and 3 months ( post intervention ) . Analysis of covariance was used to test between-group differences . The community steering committee and focus group data informed the cultural adaptation of the intervention . Results There were significant baseline adjusted differences at 3 months between the Partners in Care and wait list control group in intent-to-treat ( p < 0.001 ) and complete case analyses ( p < 0.0001 ) for A1c , underst and ing ( p < 0.0001 ) , and performing diabetes self-management ( p < 0.0001 ) . Conclusions A culturally adapted diabetes self-management intervention of short duration was an effective approach to improving glycemic control among Native Hawaiian and Pacific Isl and ers Purpose The purpose of this study is to determine the effectiveness of a community-based diabetes self-management program comparing treatment participants to a r and omized usual-care control group at 6 months . Methods A total of 345 adults with type 2 diabetes but no criteria for high A1C were r and omized to a usual-care control group or 6-week community-based , peer-led diabetes self-management program ( DSMP ) . R and omized participants were compared at 6 months . The DSMP intervention participants were followed for an additional 6 months ( 12 months total ) . A1C and body mass index were measured at baseline , 6 months , and 12 months . All other data were collected by self-administered question naires . Results At 6 months , DSMP participants did not demonstrate improvements in A1C as compared with controls . Baseline A1C was much lower than in similar trials . Participants did have significant improvements in depression , symptoms of hypoglycemia , communication with physicians , healthy eating , and reading food labels ( P < .01 ) . They also had significant improvements in patient activation and self-efficacy . At 12 months , DSMP intervention participants continued to demonstrate improvements in depression , communication with physicians , healthy eating , patient activation , and self-efficacy ( P < .01 ) . There were no significant changes in utilization measures . Conclusions These findings suggest that people with diabetes without elevated A1C can benefit from a community-based , peer-led diabetes program . Given the large number of people with diabetes and lack of low-cost diabetes education , the DSMP deserves consideration for implementation Purpose The purpose of this pilot study was to evaluate a culturally tailored intervention for rural African Americans . Social Cognitive Theory provided the framework for the study . Methods Twenty-two participants were recruited and r and omly assigned to either Group or Individual diabetes self-management ( DSME ) . Group DSME included story-telling , h and s-on activities , and problem-solving exercises . Individual DSME sessions focused on goal - setting and problem-solving strategies . Sessions were offered in an accessible community center over a 10-week period . Results Outcomes included glycosylated hemoglobin ( A1C ) , self-care actions , self-efficacy level , goal attainment , and satisfaction with DSME . Participants in both Group and Individual DSME improved slightly over the 3-month period in self-care activities , A1C level , and goal attainment . Although differences were not statistically significant , trends indicate improved scores on dietary actions , foot care , goal attainment , and empowerment for those experiencing Group DSME . Conclusions The culturally tailored approach was well received by all participants . Improvements among those receiving Individual DSME may indicate that brief sessions using a culturally tailored approach could enhance self-care and glycemic control . Additional testing among more participants over a longer time period is recommended In a prospect i ve , r and omised , controlled trial to determine whether comprehensive lifestyle changes affect coronary atherosclerosis after 1 year , 28 patients were assigned to an experimental group ( low-fat vegetarian diet , stopping smoking , stress management training , and moderate exercise ) and 20 to a usual-care control group . 195 coronary artery lesions were analysed by quantitative coronary angiography  . The average percentage diameter stenosis regressed from 40.0 ( SD 16.9)% to 37.8 (16.5)% in the experimental group yet progressed from 42.7 (15.5)% to 46.1 (18.5)% in the control group . When only lesions greater than 50 % stenosed were analysed , the average percentage diameter stenosis regressed from 61.1 (8.8)% to 55.8 (11.0)% in the experimental group and progressed from 61.7 (9.5)% to 64.4 (16.3)% in the control group . Overall , 82 % of experimental-group patients had an average change towards regression .  Comprehensive lifestyle changes may be able to bring about regression of even severe coronary atherosclerosis after only 1 year , without use of lipid-lowering drugs OBJECTIVE We hypothesized that people with type 2 diabetes in an online diabetes self-management program  , compared with usual-care control subjects , would 1 ) demonstrate reduced A1C at 6 and 18 months , 2 ) have fewer symptoms , 3 ) demonstrate increased exercise , and 4 ) have improved self-efficacy and patient activation . In addition , participants r and omized to listserve reinforcement would have better 18-month outcomes than participants receiving no reinforcement . RESEARCH DESIGN AND METHODS A total of 761 participants were r and omized to 1 ) the program  , 2 ) the program with e-mail reinforcement , or 3 ) were usual-care control subjects ( no treatment ) . This sample included 110 American Indians/Alaska Natives ( AI/ANs ) . Analyses of covariance models were used at the 6- and 18-month follow-up to compare groups . RESULTS At 6 months , A1C , patient activation , and self-efficacy were improved for program participants compared with usual care control subjects ( P < 0.05 ) . There were no changes in other health or behavioral indicators . The AI/AN program participants demonstrated improvements in health distress and activity limitation compared with usual-care control subjects . The subgroup with initial A1C > 7 % demonstrated stronger improvement in A1C ( P = 0.01 ) . At 18 months , self-efficacy and patient activation were improved for program participants . A1C was not measured . Reinforcement showed no improvement . CONCLUSIONS An online diabetes self-management program is acceptable for people with type 2 diabetes . Although the results were mixed they suggest 1 ) that the program may have beneficial effects in reducing A1C , 2 ) AI/AN population s can be engaged in and benefit from online interventions , and 3 ) our follow-up reinforcement appeared to have no value Background The physical and psychosocial benefits of participation in cardiac rehabilitation following a coronary event have well been established . Despite these benefits there is strong evidence that participation in traditional cardiac rehabilitation programs remains low . Various models of cardiac rehabilitation have been implemented including the use of brief structured interventions to enable modification of coronary risk factors . Objectives The objective of this review was to determine the effect of brief structured interventions on risk factor modification in patients with coronary heart disease . Search strategy A literature search was performed using the following data bases MEDLINE ( 1966‐2006 ) , CINAHL ( 1982‐2006 ) , EMBASE ( 1980‐current ) and up to the Cochrane Controlled Trials Register ( Issue 2 , 2006 of Cochrane Library ) . In addition , the reference lists of relevant trials and conference proceedings were also scrutinised . Company representatives , experts and investigators were contacted to elicit further information . Selection criteria All r and omised and quasi‐r and omised controlled trials that compared the effects of brief structured interventions on risk factor modification in patients with coronary heart disease were considered for inclusion in the review . Data collection and analysis Eligibility of the trials for inclusion in the review , details of eligible trials and the method ological quality of the trials were assessed independently by two review ers . Relative risks for dichotomous data and a weighted mean difference for continuous data were calculated with 95 % confidence intervals . Where synthesis was inappropriate , trials were considered separately . Main results Seventeen trials involving a total of 4725 participants were included in the final review : three trials compared the effects of brief structured interventions  on diet modification ; seven on smoking cessation ; and seven on multiple risk factors . Two trials involving 76 patients compared brief structured intervention versus usual care for dietary modification . Although there was a tendency for more participants in the intervention arm to lose weight at the 12‐week follow up and achieve target cholesterol levels at the 6‐month follow up , these results were not statistically significant . Only one small trial involving 36 patients compared brief structured intervention and extensive intervention for dietary  modification and demonstrated a significant reduction in the percentage of energy obtained from fat and saturated fat intake among participants receiving extensive intervention . However , no difference in fish , fruit and vegetable intake between the groups was evident . Six trials involving 2020 patients compared brief structured intervention versus usual care for smoking cessation . There was no difference in the smoking cessation rates at the 3‐ and 6‐week follow up , however , there was evidence of a benefit of brief structured interventions  for smoking cessation at the 3‐ , 6‐ and 12‐month follow up . In the only trial that and compared brief structured intervention and extensive intervention for smoking cessation in 254 participants there was no clear difference of a likelihood of smoking cessation between the two groups . In the seven trials that compared brief structured intervention and usual care for multiple risk factor modification there was evidence of a benefit of the intervention on behavioural changes such as fat intake , weight loss and consequently on reduction in the body mass index , smoking cessation and physical activity among the participants . The findings concerning the effect on blood pressure , blood glucose levels and the lipid profile , however , remain inconclusive . Conclusions There is suggestive but inconclusive evidence from the trials of a benefit in the use of brief interventions for risk factor modification in patients with coronary heart disease . This review , however , supports the concept that brief interventions for patients with coronary heart disease can have beneficial effects on risk factor modification and consequently on progression of coronary heart disease . Further trials using larger sample sizes need to be undertaken to demonstrate the benefits of brief structured intervention targeted at the modification of single or multiple risk factors OBJECTIVE The objective of this study was to compare two diabetes self-management interventions design ed for Mexican Americans : " extended "  ( 24 h of education , 28 h of support groups ) and " compressed " ( 16 h of education , 6 h of support groups ) . Both interventions were culturally competent regarding language , diet , social emphasis , family participation , and incorporating cultural beliefs . RESEARCH DESIGN AND METHODS We recruited 216 persons between 35 and 70 years of age diagnosed with type 2 diabetes > /=1 year . Intervention groups of eight participants and eight support persons were r and omly assigned to the compressed or extended conditions . The interventions differed in total number of contact hours over the year-long intervention period , with the major difference being the number of support group sessions held . The same information provided in the educational sessions of the extended intervention was compressed into fewer sessions , thus providing more information during each group meeting . RESULTS The interventions were not statistically different in reducing HbA(1c ) ; however , both were effective . A " dosage effect " of attendance was detected with the largest HbA(1c ) reductions achieved by those who attended more of the extended intervention . For individuals who attended > /=50 % of the intervention , baseline to 12-month HbA(1c ) change was -0.6 percentage points for the compressed group and -1.7 percentage points for the extended group . CONCLUSIONS Both culturally competent diabetes self-management education interventions were effective in promoting improved metabolic control and diabetes knowledge . A dosage effect was evident ; attending more sessions result ed in greater improvements in metabolic control BACKGROUND It was the aim of this study to assess the long-term effects of physical exercise and low-fat diet on the progression of coronary artery disease . At the beginning of the study , 113 male patients with coronary artery disease were r and omized to an intervention group ( n=56 ) or a control group ( n=57 ) ; 90 patients ( 80 % ) could be reevaluated after 6 years . METHODS AND RESULTS Patients in the intervention group ( n=40 ) showed a reduction in total serum cholesterol ( 6.03+/-1.03 versus 5.67+/-1.01 mmol/L ; P<.03 ) and triglyceride levels ( 1.94+/-0.8 versus 1.6+/-0.89 mmol/L ; P<.005 ) and maintained their initial body mass index ( 26+/-2 versus 27+/-2 kg/m2 ; P = NS ) , but results were not statistically different from the control group ( n=50 ) ( total serum cholesterol , 6.05+/-1.02 versus 5.79+/-0.88 mmol/L ; triglycerides , 2.25+/-1.28 versus 1.85+/-0.96 mmol/L [ both P = NS ] ; body mass index , 26+/-2 versus 28+/-3 kg/m2 [ P<.0001 ] ) . In the intervention group , there was a significant 28 % increase in physical work capacity ( 166+/-59 versus 212+/-89 W ; P<.001 ) , whereas values remained essentially unchanged in the control group ( 165+/-51 versus 170+/-60 W ; P = NS ; between groups , P<.05 ) . In the intervention group , coronary stenoses progressed at a significantly slower rate than in the control group ( P<.0001 ) . Energy expenditure during exercise was assessed in a subgroup ; patients with regression of coronary stenoses spent an average of 1784+/-384 kcal/wk ( approximately 4 hours of moderate aerobic exercise per week ) . Multivariate regression analysis identified only physical work capacity as independently contributing to angiographic changes . CONCLUSIONS After 6 years of multifactorial risk intervention , there is significant and persistent improvement in lipoprotein levels and physical work capacity , which results in a significant retardation of disease progression . These beneficial effects appear to be largely due to chronic physical exercise CONTEXT Observational studies suggest that surgically induced loss of weight may be effective therapy for type 2 diabetes . OBJECTIVE To determine if surgically induced weight loss results in better glycemic control and less need for diabetes medications than conventional approaches to weight loss and diabetes control . DESIGN , SETTING , AND PARTICIPANTS Unblinded r and omized controlled trial conducted from December 2002 through December 2006 at the University Obesity Research Center in Australia , with general community recruitment to established treatment programs . Participants were 60 obese patients ( BMI > 30 and < 40 ) with recently diagnosed ( < 2 years ) type 2 diabetes . INTERVENTIONS Conventional diabetes therapy with a focus on weight loss by lifestyle change vs laparoscopic adjustable gastric b and ing with conventional diabetes care . MAIN OUTCOME MEASURES Remission of type 2 diabetes ( fasting glucose level < 126 mg/dL [ 7.0 mmol/L ] and glycated hemoglobin [ HbA1c ] value < 6.2 % while taking no glycemic therapy ) . Secondary measures included weight and components of the metabolic syndrome . Analysis was by intention-to-treat . RESULTS Of the 60 patients enrolled , 55 ( 92 % ) completed the 2-year follow-up . Remission of type 2 diabetes was achieved by 22 ( 73 % ) in the surgical group and 4 ( 13 % ) in the conventional-therapy group . Relative risk of remission for the surgical group was 5.5 ( 95 % confidence interval , 2.2 - 14.0 ) . Surgical and conventional-therapy groups lost a mean ( SD ) of 20.7 % ( 8.6 % ) and 1.7 % ( 5.2 % ) of weight , respectively , at 2 years ( P < .001 ) . Remission of type 2 diabetes was related to weight loss ( R2 = 0.46 , P < .001 ) and lower baseline HbA1c levels ( combined R2 = 0.52 , P < .001 ) . There were no serious complications in either group . CONCLUSIONS Participants r and omized to surgical therapy were more likely to achieve remission of type 2 diabetes through greater weight loss . These results need to be confirmed in a larger , more diverse population and have long-term efficacy assessed . TRIAL REGISTRATION actr.org Identifier : ACTRN012605000159651 Twenty-eight male cardiac patients who had either experienced myocardial infa rct ion or undergone coronary bypass surgery were assigned to a treatment condition and participated in a 3-month , exercise-based Cardiac Rehabilitation Program , whereas 20 other cardiac patients were assigned to a routine-care condition and did not participate in the rehabilitation program .  Cardiovascular , psychological , and psychosocial functioning were assessed before treatment or routine care was begun , after 3 months of treatment or routine care , and 4 months later . Results indicated that patients in the treatment condition evidence d reliably more efficient cardiovascular functioning ( resting heart rate , resting diastolic blood pressure , treadmill exercise performance , exercise heart rate , exercise systolic blood pressure ) , better underst and ing of heart disease , better underst and ing of and reported compliance with treatment recommendations , more positive self-perceptions ( health , body concept , self-concept , progress toward goals ) , and better psychosocial functioning ( e.g. , decreased employmentrelated stress , more active use and enjoyment of leisure time , more physical and sexual activity ) .  Chronic patients benefited as much from the treatment as did acute patients , and the beneficial effects for all treated patients were evident not only just after rehabilitation , but also 4 months later . This investigation appears to be the first such test of effects of this type of treatment , and the results have wide generalizability and applicability The aim of the review was to assess the effect of patient education in ischaemic heart disease . Thirteen r and omised controlled trials of moderate to good quality including 68,556 patients were selected . The effect on mortality , cardiac morbidity , hospitalisation and health-related quality of life was assessed and only non-significant tendencies of effect were found . The authors of the review nevertheless conclude that the review supports current rehabilitation programmes that include patient education . Further research in patient education , especially concerning the most effective methods of education delivery , is needed Aim : To verify if Group Care , a model to manage Type 2 diabetes ( T2DM ) by systemic continuing group education , can be administered by nurses and dieticians under pedagogic guidance , and improve metabolic control , quality of life , Locus of Control , and insulin resistance . Material and subjects : Twenty-five patients with non-insulin-treated T2DM were r and omized to Group Care and 24 to continued habitual individual care and education delivered by a diabetes specialist and pedagogist , respectively . Six nurses and 1 dietician received training by an accredited programme , a detailed operating manual and pedagogical supervision throughout the study . Follow-up was for 2 yr and included measurements of fasting blood glucose , glycated hemoglobin ( HbA1c ) , body mass index , waist circumference , lipids , creatinine , blood pressure , serum insulin , homeostasis model assessment ( HOMA ) index of insulin resistance , health behaviors , quality of life , state and trait anxiety , and Locus of Control . Results : One patient on Group Care and 3 controls dropped out . At the end of study , the patients on Group Care had lower HbA1c ( 7.6± 0.8 vs 8.4± 1.3 , p<0.05 ) , insulin ( 18.0± 9.6 vs 24.3± 13.7 , p<0.001 ) , HOMA index ( 6.9± 5.4 vs 9.2± 6.6 , p<0.05 ) , and fatalistic attitude ( 17.2± 5.9 vs 24.9± 4.2 , p<0.001 ) and better quality of life ( 65.0± 11.0 vs 78.4± 19.6 , p<0.001 ) than controls . Conclusions : Group Care delivered by trained nurses and dietitan is associated with better outcomes than those obtained by a medically and pedagogically qualified team . It may offer a model for health operators to re-organize clinical practice and for patients to improve lifestyle and strengthen the therapeutic alliance with their carers Objective : To investigate the impact of intensive lifestyle education on dietary practice s , exercise and metabolic measurements in people with insulin-dependent diabetes mellitus ( IDDM ) . Design : Sixty-one volunteer subjects with IDDM were r and omised to intensive ( Group 1 ) or st and ard ( Group 2 ) education programmes for six months . During a second six month period of observation Group 1 subjects received routine surveillance for their condition and those in Group 2 were given intensive advice ( phase 2 ) . Current insulin regimens were modified to optimise glycaemic control before the start of the intervention phase . Nutrient intakes , weight , blood pressure , glycated haemoglobin ( HbA ) , plasma lipids , lipoproteins and maximal oxygen consumption ( VO max ) were measured at the time of recruitment and at three monthly intervals during the trial and phase 2 . Setting : Department of Human Nutrition at the University of Otago . Results : Glycated haemoglobin decreased significantly in both groups between recruitment and r and omisation , the improvement being sustained during the six months of the r and omised trial and for group 1 during the six months of post trial observation . A further decrease was seen in Group 2 during the second six month period when they were given intensive advice . Comparable changes were seen with total and low density lipoprotein ( LDL ) cholesterol in Group 1 during the trial , but significant decreases were only seen in Group 2 in association with intensive intervention ( phase 2 ) . These changes occurred in parallel with increases in intakes of carbohydrate and monounsaturated fatty acids , a reduction in intakes of total and saturated fat , and an improvement in maximum oxygen consumption . Conclusions : A lifestyle programme for people with IDDM results in modest changes in diet and exercise habits sufficient to improve measures of glycaemic control and lipoprotein mediated risk of coronary heart disease independent of changes in insulin regime . More innovative approaches to achieve lifestyle changes are required to meet current recommendations which in turn are likely to produce even greater beneficial changes than those observed here . Sponsorship : This study was supported by the Eli Lilly Research Grant ( Eli Lilly and Company ( New Zeal and ) Ltd ) , The Deans Research Grant ( Otago Medical School , New Zeal and ) and The New Zeal and Dietetic Association ( Abbott Award ) Objective This study was design ed to examine whether a brief hospital intervention design ed to alter patients ’ perceptions about their myocardial infa rct ion ( MI ) would result in a better recovery and reduced disability . Design In a prospect i ve r and omized study , 65 consecutive patients with their first MI aged were assigned to receive an intervention design ed to alter their perceptions about their MI or usual care from rehabilitation nurses . Patients were assessed in hospital before and after the intervention and at 3 months after discharge from hospital . Results The intervention caused significant positive changes in patients ’ views of their MI . Patients in the intervention group also reported they were better prepared for leaving hospital ( p < .05 ) and subsequently returned to work at a significantly faster rate than the control group ( p < .05 ) . At the 3-month follow-up , patients in the intervention group reported a significantly lower rate of angina symptoms than control subjects ( 14.3 vs. 39.3 , p < .03 ) . There was no significant differences in rehabilitation attendance between the two groups . Conclusions An in-hospital intervention design ed to change patients ’ illness perceptions can result in improved functional outcome after MI One hundred and forty nine diabetic patients were ophthalmologically assessed seven years after r and omisation to a low carbohydrate or modified fat diet ( rich in linoleic acid ) .  Glycaemic control , regardless of the type of diet , was a major determinant of the development of retinopathy . Poorly controlled patients ( haemoglobin A1c greater than 8 % ) with low levels of linoleic acid in cholesterol ester had a significantly greater frequency of retinopathy than well controlled patients or patients with similarly unsatisfactory control but higher levels of linoleic acid . The findings support an earlier suggestion that linoleic acid might protect against diabetic retinopathy OBJECTIVES The goal of this study was to determine the effects of exercise training ( ET ) on functional capacity and quality of life ( QOL ) in patients who received percutaneous transluminal coronary angioplasty ( PTCA ) or coronary stenting ( CS )  , the effects on the restenosis rate and the outcome . BACKGROUND It is unknown whether ET induces beneficial effects after coronary angioplasty . METHODS We studied 118 consecutive patients with coronary artery disease ( mean age 57+/-10 years ) who underwent PTCA or CS on one ( 69 % ) or two ( 31 % ) native epicardial coronary arteries . Patients were r and omized into two matched groups . Group T ( n = 59 ) was exercised three times a week for six months at 60 % of peak VO2 . Group C ( n = 59 ) was the control group . RESULTS Only trained patients had significant improvements in peak VO2 ( 26 % , p < 0.001 ) and quality of life ( 26.8 % , p = 0.001 vs. C ) . The angiographic restenosis rate was unaffected by ET ( T : 29 % ; C : 33 % , P = NS ) and was not significantly different after PTCA or CS . However , residual diameter stenosis was lower in trained patients ( -29.7 % , p = 0.045 ) . In patients with angiographic restenosis , thallium uptake improved only in group T ( 19 % ; p < 0.001 ) . During the follow-up ( 33+/-7 months ) trained patients had a significantly lower event rate than controls ( 11.9 vs. 32.2 % , RR : 0.71 , 95 % confidence interval [ CI ] : 0.60 to 0.91 , p = 0.008 ) and a lower rate of hospital readmission ( 18.6 vs. 46 % , RR : 0.69 , 95 % CI : 0.55 to 0.93 , p < 0.001 ) . CONCLUSIONS Moderate ET improves functional capacity and QOL after PTCA or CS . During the follow-up , trained patients had fewer events and a lower hospital readmission rate than controls , despite an unchanged restenosis rate BACKGROUND Patient involvement in the choice of antihyperglycemic agents could improve adherence and optimize glycemic control in patients with type 2 diabetes mellitus . METHODS We conducted a pilot , cluster r and omized trial of Diabetes Medication Choice , a decision aid that describes 5 antihyperglycemic drugs , their treatment burden ( adverse effects , administration , and self-monitoring dem and s ) , and impact on hemoglobin A(1c ) ( HbA(1c ) ) levels . Twenty-one clinicians were r and omized to use the decision aid during the clinical encounter and 19 to dispense usual care and an educational pamphlet . We used surveys and video analysis to assess postvisit decisional outcomes , and medical and pharmacy records to assess 6-month medication adherence and HbA(1c ) levels . RESULTS Compared with usual care patients ( n = 37 ) , patients receiving the decision aid ( n = 48 ) found the tool more helpful ( clustered-adjusted mean difference [ AMD ] in a 7-point scale , 0.38 ; 95 % confidence interval [ CI ] , 0.04 - 0.72 ) ; had improved knowledge ( AMD , 1.10 of 10 questions ; 95 % CI , 0.11 - 2.09 ) ; and had more involvement in making decisions about diabetes medications ( AMD , 21.8 of 100 ; 95 % CI , 13.0 - 30.5 ) . At 6-month follow-up , both groups had nearly perfect medication use ( median , 100 % of days covered ) , with better adherence ( AMD , 9 % more days covered ; 95 % CI , 4%-14 % ) and persistence ( AMD , 12 more days covered ; 95 % CI , 3 - 21 days ) in the usual care group , and no significant impact on HbA(1c ) levels ( AMD , 0.01 ; 95 % CI , -0.49 to 0.50 ) . CONCLUSION An innovative decision aid effectively involved patients with type 2 diabetes mellitus in decisions about their medications but did not improve adherence or HbA(1c ) levels . Trial Registration clinical trials.gov Identifier : NCT00388050 OBJECTIVE There is a pressing need for brief practical interventions that address diabetes management . Using a r and omized design , we evaluated a medical office-based intervention focused on behavioral issues relevant to dietary self-management . RESEARCH DESIGN AND METHODS There were 206 adult diabetes patients r and omized to usual care or brief intervention  , which consisted of touchscreen computer-assisted assessment to provide immediate feedback on key barriers to dietary self-management , and goal setting and problem-solving counseling for patients . Follow-up components to the single session intervention included phone calls and interactive video or videotape instruction as needed . RESULTS Multivariate analyses of covariance revealed that the brief intervention produced greater improvements than usual care on a number of measures of dietary behavior ( e.g. , fewer calories from saturated fat , fewer high-fat eating habits and behaviors ) at the 3-month follow-up . There were also significant differences favoring intervention on changes in serum cholesterol levels and patient satisfaction but not on glycosylated hemoglobin . The intervention effects were relatively robust across a variety of patient characteristics , the two participating physicians , and intervention staff members . CONCLUSIONS If the long-term results are equally positive and generalize to other setting , this intervention could provide a prototype for a feasible cost-effective way to integrate patient views and behavioral management into office-based care for diabetes Abstract BACKGROUND : Poor mood adjustment to chronic medical illness is often accompanied by decrements in function . OBJECTIVE : To evaluate the effectiveness of a telephone-based intervention for psychologic distress and functional impairment in cardiac illness . DESIGN : R and omized , controlled trial . METHODS : We recruited survivors of acute coronary syndromes using the Hospital and Anxiety Depression Scale ( HADS ) with scores indicative of mood disturbances at 1-month postdischarge . Recruited patients were r and omized to experimental or control status . Intervention patients received 6 30-minute telephone counseling sessions to identify and address illness-related fears and concerns . Control patients received usual care . Patients ’ responses to the HADS and the Workplace Social Adjustment Scale ( WSAS ) were collected at baseline , 2 , 3 , and 6 months using interactive voice recognition technology . At baseline , the PRIME-MD was used to establish diagnosis of depression . We used mixed effects regression to study changes in outcomes . RESULTS : We enrolled 100 patients . Mean age was 60 ; 67 % of the patients were male . Findings confirmed that the intervention group had a 27 % improvement in depression symptoms ( P=.05 ) , 27 % in anxiety ( P=.02 ) , and a 38 % improvement in home limitations ( P=.04 ) compared with controls . Symptom improvement tracked those for WSAS measures of home function ( P=.04 ) but not workplace function . CONCLUSIONS : The intervention had a moderate effect on patient ’s emotional and functional outcomes that were observed during a critical period in patients ’ lives . Patient convenience , ease of delivery , and the effectiveness of the intervention suggest that the counseling can help patients adjust to chronic illness BACKGROUND In the 2.8 years of the Diabetes Prevention Program ( DPP ) r and omised clinical trial ,  diabetes incidence  in high-risk adults was reduced by 58 % with intensive lifestyle intervention and by 31 % with metformin , compared with placebo . We investigated the persistence of these effects in the long term . METHODS All active DPP participants were eligible for continued follow-up . 2766 of 3150 ( 88 % ) enrolled for a median additional follow-up of 5.7 years ( IQR 5.5 - 5.8 ) . 910 participants were from the lifestyle , 924 from the metformin , and 932 were from the original placebo groups .  On the basis of the benefits from the intensive lifestyle intervention in the DPP , all three groups were offered group-implemented lifestyle intervention . Metformin treatment was continued in the original metformin group ( 850 mg twice daily as tolerated ) , with participants unmasked to assignment , and the original lifestyle intervention group was offered additional lifestyle support . The primary outcome was development of diabetes according to American Diabetes Association criteria . Analysis was by intention-to-treat . This study is registered with Clinical Trials.gov , number NCT00038727 . FINDINGS During the 10.0-year ( IQR 9.0 - 10.5 ) follow-up since r and omisation to DPP , the original lifestyle group lost , then partly regained weight . The modest weight loss with metformin was maintained . Diabetes incidence rates during the DPP were 4.8 cases per 100 person-years ( 95 % CI 4.1 - 5.7 ) in the intensive lifestyle intervention group , 7.8 ( 6.8 - 8.8 ) in the metformin group , and 11.0 ( 9.8 - 12.3 ) in the placebo group . Diabetes incidence rates in this follow-up study were similar between treatment groups : 5.9 per 100 person-years ( 5.1 - 6.8 ) for lifestyle , 4.9 ( 4.2 - 5.7 ) for metformin , and 5.6 ( 4.8 - 6.5 ) for placebo . Diabetes incidence in the 10 years since DPP r and omisation was reduced by 34 % ( 24 - 42 ) in the lifestyle group and 18 % ( 7 - 28 ) in the metformin group compared with placebo . INTERPRETATION During follow-up after DPP , incidences in the former placebo and metformin groups fell to equal those in the former lifestyle group , but the cumulative incidence of diabetes remained lowest in the lifestyle group . Prevention or delay of diabetes with lifestyle intervention or metformin can persist for at least 10 years . FUNDING National Institute of Diabetes and Digestive and Kidney Diseases ( NIDDK ) Type 2 diabetes disproportionately affects Latinos increasing their risk of diabetes-related complications . This study used a r and omized controlled design with a community-based approach to evaluate the impact of a culturally tailored pharmacist intervention on clinical outcomes in Latino diabetics . The intervention included a focused discussion and two individual pharmacist counseling sessions on medication , nutrition , exercise , and self-care to promote behavior changes . Sessions were culturally adapted for language , diet , family participation , and cultural beliefs . Clinical outcomes were measured at baseline and three months . Nineteen intervention and 24 control participants completed the study . Mean BMI reduction was greater for intervention than for control group participants ( –0.73± 0.07 kg/m2 versus + 0.37±0.02 kg/m2 p<.009 respectively ) . Hemoglobin A1c was significantly reduced by 0.93±0.45 % in the intervention group only . There was no significant difference in blood glucose , blood pressure , or lipid levels . An innovative culturally-sensitive pharmacist intervention improved selected clinical outcomes among Latino diabetics OBJECTIVE To demonstrate improvements in diabetes care stimulated by comprehensive evaluation of community-based diabetic patients with feedback to the patients and their physicians . RESEARCH DESIGN AND METHODS A comprehensive evaluation of community-based diabetic patients with annotated reporting of results to both patients and their physicians ( universal intervention ) was followed by r and om assignment of 50 % of patients to individual counseling ( r and omized intervention ) . In four communities , two large and two small , 55 type 1 and 376 type 2 diabetic patients were recruited , evaluated , and reassessed at 1 year . Outcome measures were HbA1c , serum cholesterol , and systolic and diastolic blood pressure . RESULTS There were significant improvements in all outcome measures for type 2 diabetic patients r and omized to individual counseling ( P = 0.03 ; follow-up rate 84 % ) and significant improvements in all outcome measures for all high-risk type 2 patients ( highest P value = 0.004 ; follow-up rate 85 % ) . CONCLUSIONS Comprehensive evaluation of diabetic patients at the community level with annotated reporting of results to the patients and their physicians was associated with improvement of mean HbA1c , cholesterol , and systolic and diastolic blood pressure , particularly in patients in high-risk status for these outcome variables . Individual counseling of 50 % of patients , r and omly selected , enhanced these results This prospect i ve study evaluated the effect of an individualized , comprehensive , home-based cardiac rehabilitation program combining exercise training with risk factor modification and psychosocial counseling on risk factors , psychological well-being , functional capacity , and work resumption in 99 post-percutaneous coronary interventions ( PCI ) patients r and omized to control ( st and ard care plus telephone follow-up  , n=49 ) or intervention ( individualized , comprehensive , home-based cardiac rehabilitation , n=50 ) groups . Data were collected at time 1 ( T(1 ) ) during hospital admission , time 2 ( T(2 ) ) approximately 2 months post-PCI , and time 3 ( T(3 ) ) approximately 12 months post-PCI . Results suggest that the allocation to an individualized , comprehensive , home-based cardiac rehabilitation program provided more advantageous outcomes . At both follow-ups , the intervention group showed within-group improvement in serum cholesterol levels ( P<0.02 ; P<0.01 ) and exercise participation ( P<0.001 ; P<0.001 ) with differences in exercise participation favoring the intervention group ( P<0.01 ) at T(2 ) . Repeated measures ANOVA showed significant improvements over time in body mass index ( BMI ) ( P<0.01 ) , psychological well-being ( P<0.001 ) , and functional capacity ( P<0.001 ) for both groups . More patients in the intervention group had returned to work at T(2 ) ( P<0.001 ) and did so more quickly ( P<0.01 ) . These findings suggest that an individualized , comprehensive , home-based cardiac rehabilitation program improves risk factor profiles and work resumption patterns for patients following PCI AIM To determine whether glycemic control is improved when motivational interviewing ( MI ) , a patient-centered behavior change strategy , is used with diabetes self management education ( DSME ) as compared to DSME alone . METHODS poorly controlled type 2 diabetes ( T2DM ) patients ( n=234 ) were r and omized into 4 groups : MI+DSME or DSME alone , with or without use of a computerized summary of patient self management barriers . We compared HbA1c changes between groups at 6 months and investigated mediators of HbA1c change . RESULTS study patients attended the majority of the four intervention visits ( mean 3.4 ) , but drop-out rate was high at follow-up research visits ( 35 % ) . Multiple regression showed that groups receiving MI had a mean change in HbA1c that was significantly lower ( less improved ) than those not receiving MI ( t=2.10 ; p=0.037 ) . Mediators of HbA1c change for the total group were diabetes self-care behaviors and diabetes distress ; no between-group differences were found . CONCLUSIONS DSME improved blood glucose control , underlining its benefit for T2DM management . However , MI+DSME was less effective than DSME alone . Overall , weak support was found for the clinical utility of MI in the management of T2DM delivered by diabetes educators OBJECTIVE To compare three sets of dietary guidelines for the treatment of non-insulin-dependent diabetes ( NIDDM ) in free-living individuals and to observe the effects on metabolic control over an 18-month period . RESEARCH DESIGN AND METHODS Seventy volunteer subjects with NIDDM were r and omly assigned to one of three diets , a weight-management diet , a high-carbohydrate/fiber diet , or a modified-lipid diet and followed for 18 months . Nutrient intakes , weight , blood lipids , and glycemic control were measured . RESULTS In all diet groups , glycated hemoglobin ( HbA1 ) fell significantly before diet intervention began , remaining lower throughout the study and at follow-up 9 months later . Low-density lipoprotein ( LDL ) cholesterol showed a sustained fall in all groups after diet intervention . Apart from transient changes in high-density lipoprotein ( HDL ) cholesterol and triglyceride ( TG ) in the diet groups with the higher carbohydrate intake , no lasting differences were found between the three diet groups . CONCLUSIONS In the long term , there were few differences in the outcome of the three dietary prescriptions . Even with intensive instruction , participants found it difficult to meet recommended nutrient intakes ; however , specific dietary advice did result in an improvement in LDL cholesterol . Adverse changes in HDL cholesterol and TG because of diet intervention were transient . The significant improvement in glycemic control during the recruitment phase may have been the result of particpants ' previous dietary knowledge and the increased attention that they received during the intervention AIMS We evaluate the efficacy of the " Active Body Control ( ABC ) Program " for weight reduction in patients with type 2 diabetes . METHODS The ABC program combines telemonitoring of the physical activity with a low-calorie diet also preferring carbohydrates with low glycemic indexes . In this 6-month , r and omized , clinical trial 35 patients ( aged 57 ± 9 years ; BMI = 35.3 ± 5.7 kg/m(2 ) ) were treated according to the ABC program and 35 control patients ( aged 58 ± 7 years ; BMI = 34.8 ± 5.9 kg/m(2 ) ) received st and ard therapy . RESULTS After 6 months the mean weight loss in the intervention group was 11.8 kg ± 8.0 kg . Glucose and HbA1c were lowered by respectively 1.0 mmol/l and 0.8 percentage points ( p=0.000 , respectively ) . The proportion of patients with HbA1c>7 % fell from 57 % to 26 % . Antidiabetic drugs were discontinued in 13 patients ( 39 % ) and reduced in 14 ( 42 % ) . The reduction of costs on medication per patient was € 83 in 6 months . In the control group , there were no relevant changes in body weight , laboratory values or drug treatment . CONCLUSIONS The ABC program  effectively lowers body weight , Hb1Ac and antidiabetic drug use in patients with type 2 diabetes OBJECTIVE To compare three interventions to reduce diabetes distress ( DD ) and improve self-management among non– clinical ly depressed adults with type 2 diabetes mellitus ( T2DM ) . RESEARCH DESIGN AND METHODS In REDEEM , 392 adults with T2DM and DD were r and omized to computer-assisted self-management ( CASM ) , CASM plus DD-specific problem solving ( CAPS ) , or a computer-administered minimal supportive intervention . Primary outcomes were Diabetes Distress Scale ( DDS ) total , the Emotional Burden ( EB ) and Regimen Distress ( RD ) DDS subscales , and diet , exercise , and medication adherence . RESULTS Significant and clinical ly meaningful reductions in DD ( DDS , EB , and RD ) and self-management behaviors occurred in all three conditions ( P < 0.001 ) , with no significant between-group differences . There was , however , a significant group × baseline distress interaction ( P < 0.02 ) , in which patients with high baseline RD in the CAPS condition displayed significantly larger RD reductions than those in the other two conditions . RD generated the most distress and displayed the greatest distress reduction as a result of intervention . The pace of DD reduction varied by patient age : older patients demonstrated significant reductions in DD early in the intervention , whereas younger adults displayed similar reductions later . Reductions in DD were accompanied by significant improvements in healthy eating , physical activity , and medication adherence , although not by change in HbA1c . CONCLUSIONS DD is malleable and highly responsive to intervention . Interventions that enhance self-management also reduce DD significantly , but DD-specific interventions may be necessary for patients with high initial levels of DD . Future research should identify the minimal , most cost-effective interventions to reduce DD and improve self-management BACKGROUND Physical activity ( PA ) is a cornerstone in the management of type 2 diabetes ( T2DM ) . This pilot investigation explores the effects of a st and ard diabetes education program compared with a supplemental PA intervention on diabetes-related health outcomes . METHODS Using a prospect i ve 2-armed design , 96 adults with T2DM were r and omly assigned to either st and ard care ( diabetes education program ; n = 49 ) or st and ard care supplemented with an 8-week , individualized-counseling and community-based PA component ( n = 47 ) . Measurements were taken at baseline , 3 , 6 , and 12 months . Primary outcomes were changes in PA ( self-report ) and HbA1c . Between group changes were compared using analysis of covariance ( ANCOVA ) and changes over time using repeated- measures ANOVA . RESULTS In comparison with st and ard care , the supplemental group demonstrated an increase in PA ( Ps < 0.01 ) and cardiorespiratory fitness ( Ps < 0.05 ) from baseline to all follow-up time-points . HbA1c levels declined ( P < .05 ) from baseline to all time points in the st and ard care group . Reduction in cholesterol-ratio ( P < .01 ) , increase in HDL ( P < .05 ) , and reductions in blood pressure , resting heart rate and BMI ( approaching statistical significance Ps < 0.10 ) were also reported for both groups . CONCLUSIONS PA counseling in addition to st and ard care is effective for promoting PA behavior change and positive health-related outcomes among individuals with T2DM OBJECTIVE To evaluate an online disease management system supporting patients with uncontrolled type 2 diabetes . MATERIAL S AND METHODS Engaging and Motivating Patients Online With Enhanced Re sources for Diabetes was a 12-month parallel r and omized controlled trial of 415 patients with type 2 diabetes with baseline glycosylated hemoglobin ( A1C ) values ≥7.5 % from primary care sites sharing an electronic health record . The intervention included : ( 1 ) wirelessly uploaded home glucometer readings with graphical feedback ; ( 2 ) comprehensive patient-specific diabetes summary status report ; ( 3 ) nutrition and exercise logs ; ( 4 ) insulin record ; ( 5 ) online messaging with the patient 's health team ; ( 6 ) nurse care manager and dietitian providing advice and medication management ; and ( 7 ) personalized text and video educational ' nuggets ' dispensed electronically by the care team . A1C was the primary outcome variable . RESULTS Compared with usual care ( UC , n=189 ) , patients in the intervention ( INT , n=193 ) group had significantly reduced A1C at 6 months ( -1.32 % INT vs -0.66 % UC ; p<0.001 ) . At 12 months , the differences were not significant ( -1.14 % INT vs -0.95 % UC ; p=0.133 ) . In post hoc analysis , significantly more INT patients had improved diabetes control ( > 0.5 % reduction in A1C ) than UC patients at 12 months ( 69.9 ( 95 % CI 63.2 to 76.5 ) vs 55.4 ( 95 % CI 48.4 to 62.5 ) ; p=0.006 ) . CONCLUSIONS A nurse-led , multidisciplinary health team can manage a population of diabetic patients in an online disease management program . INT patients achieved greater decreases in A1C at 6 months than UC patients , but the differences were not sustained at 12 months . More INT than UC patients achieved improvement in A1C ( > 0.5 % decrease ) . Trial registered in clinical trials.gov : # NCT00542204 OBJECTIVE To compare a peer leader ( PL ) versus a community health worker ( CHW ) telephone outreach intervention in sustaining improvements in HbA1c over 12 months after a 6-month diabetes self-management education ( DSME ) program . RESEARCH DESIGN AND METHODS One hundred and sixteen Latino adults with type 2 diabetes were recruited from a federally qualified health center and r and omized to 1 ) a 6-month DSME program followed by 12 months of weekly group sessions delivered by PLs with telephone outreach to those unable to attend or 2 ) a 6-month DSME program followed by 12 months of monthly telephone outreach delivered by CHWs . The primary outcome was HbA1c . Secondary outcomes were cardiovascular disease risk factors , diabetes distress , and diabetes social support . Assessment s were conducted at baseline , 6 , 12 , and 18 months . RESULTS After DSME , the PL group achieved a reduction in mean HbA1c ( 8.2–7.5 % or 66–58 mmol/mol , P < 0.0001 ) that was maintained at 18 months ( −0.6 % or −6.6 mmol/mol from baseline [ P = 0.009 ] ) . The CHW group also showed a reduction in HbA1c ( 7.8 vs. 7.3 % or 62 vs. 56 mmol/mol , P = 0.0004 ) post–6 month DSME ; however , it was attenuated at 18 months ( −0.3 % or −3.3 mmol/mol from baseline , within-group P = 0.234 ) . Only the PL group maintained improvements achieved in blood pressure at 18 months . At the 18-month follow-up , both groups maintained improvements in waist circumference , diabetes support , and diabetes distress , with no significant differences between groups . CONCLUSIONS Both low-cost maintenance programs led by either a PL or a CHW maintained improvements in key patient-reported diabetes outcomes , but the PL intervention may have additional benefit in sustaining clinical improvements beyond 12 months To evaluate the efficacy of exercise training for increasing functional capacity in the 6 months after clinical ly uncomplicated myocardial infa rct ion , 198 men 52 + /- 9 years of age participated in a training study . They were r and omly assigned to one of four exercise protocol s : 8 to 26 weeks of training at home ( group 1 , n = 66 ) or in a group program ( group 2 , n = 61 ) following treadmill testing performed 3 weeks after infa rct ion , treadmill testing at 3 weeks without subsequent training ( group 3 , n = 34 ) , and treadmill testing for the first time at 26 weeks ( control , n = 37 ) . At 26 weeks functional capacity was significantly higher in patients training at home or in a group program than that in patients without training or in control patients : 8.1 + /- 1.5 , 8.5 + /- 1.3 , 7.5 + /- 1.8 , and 7.0 + /- 1.7 METs , respectively ( p less than .05 and p less than .001 ) . No significant differences in functional capacity were noted between patients training at home and those in a group program . No training-related complications occurred . Home and group training are equally effective in increasing functional capacity of low-risk patients after myocardial infa rct ion OBJECTIVE Few multiple lifestyle behavior change programs have been design ed to reduce the risk of coronary heart disease in postmenopausal women with type 2 diabetes . This study tested the effectiveness of the Mediterranean Lifestyle Program ( MLP ) , a comprehensive lifestyle self-management program ( Mediterranean low-saturated fat diet , stress management training , exercise , group support , and smoking cessation ) , in reducing cardiovascular risk factors in postmenopausal women with type 2 diabetes . RESEARCH DESIGN AND METHODS Postmenopausal women with type 2 diabetes ( n = 279 ) were r and omized to either usual care ( control ) or treatment ( MLP ) conditions . MLP participants took part in an initial 3-day retreat , followed by 6 months of weekly meetings , to learn and practice program components . Biological end points were changes in HbA(1c ) , lipid profiles , BMI , blood pressure , plasma fatty acids , and flexibility . Impact on quality of life was assessed . RESULTS Multivariate ANCOVAs revealed significantly greater improvements in the MLP condition compared with the usual care group on HbA(1c ) , BMI , plasma fatty acids , and quality of life at the 6-month follow-up . Patterns favoring intervention were seen in lipids , blood pressure , and flexibility but did not reach statistical significance . CONCLUSIONS These results demonstrate that postmenopausal women with type 2 diabetes can make comprehensive lifestyle changes that may lead to clinical ly significant improvements in glycemic control , some coronary heart disease risk factors , and quality of life Objective — To evaluate Diabeto , a computer-assisted diet education system . Research Design And Methods — One hundred five patients with insulin-dependent diabetes mellitus ( IDDM ) or non-insulin-dependent diabetes mellitus ( NIDDM ) were divided into two r and omized groups to participate in the evaluation of Diabeto . With free access through Minitel , the French public videotex network , Diabeto helps diabetic patients self-monitor their diets and balance their meals with personalized counseling . Results — During the first 6-mo study , group A ( 54 patients ) used Diabeto , whereas group B ( 51 patients ) were control subjects . For the second 6-mo study , group B used the system . Evaluation was based on patients ' dietetic knowledge , dietary habits , and metabolic balance . Conclusions –Diabeto led to a significant improvement of dietetic , knowledge in group A ( P < 0.0005 ) and also to improved dietary habits ; decreased caloric intake in patients initially overeating ( P < 0.05 ) , increase of dietary carbohydrate from 39.7 ± 0.7 to 42.9 ± 0.9 % in patients with an initial intake < 45 % carbohydrate , and decrease of fat intake from 41.9 ± 0.9 to 37.4 ± 1.1 % in patients with an initial intake of > 35 % fat ( P < 0.0005 ) . In the second study , in addition to similar improvements to those observed in the first study , HbA1 decreased from 11.0 ± 0.4 to 9.9 ± 0.4 % ( P < 0.005 ) and fructosamine from 5.00 ± 0.17 to 4.57 ± 0.17 % ( P < 0.001 ) . Diabeto appears to be an effective therapeutic tool in the control of metabolic diseases OBJECTIVE To evaluate the effectiveness of a cluster visit model led by a diabetes nurse educator for delivering outpatient care management to adult patients with poorly controlled diabetes . RESEARCH DESIGN AND METHODS This study involved a r and omized controlled trial among patients of Kaiser Permanente 's Pleasanton , CA , center who were aged 16 - 75 years and had either poor glycemic control ( HbA1c > 8.5 % ) or no HbA1c test performed during the previous year . Intervention subjects received multidisciplinary outpatient diabetes care management delivered by a diabetes nurse educator , a psychologist , a nutritionist , and a pharmacist in cluster visit setting s of 10 - 18 patients /month for 6 months . Outcomes included change ( from baseline ) in HbA1c levels ; self-reported changes in self-care practice s , self-efficacy , and satisfaction ; and utilization of inpatient and outpatient health care . RESULTS After the intervention , HbA1c levels declined by 1.3 % in the intervention subjects versus 0.2 % in the control subjects ( P < 0.0001 ) . Several self-care practice s and several measures of self-efficacy improved significantly in the intervention group . Satisfaction with the program was high . Both hospital ( P = 0.04 ) and outpatient ( P < 0.01 ) utilization were significantly lower for intervention subjects after the program . CONCLUSIONS A 6-month cluster visit group model of care for adults with diabetes improved glycemic control , self-efficacy , and patient satisfaction and result ed in a reduction in health care utilization after the program CONTEXT Reduction of 50 % excess body weight , using a very low-calorie diet ( VLCD ; 450 kcal/d ) improves insulin sensitivity in obese type 2 diabetes mellitus patients . OBJECTIVE The objective of the study was to evaluate whether adding exercise to the VLCD has additional benefits . DESIGN This was a r and omized intervention study . SETTING The study was conducted at a clinical research center in an academic medical center . SUBJECTS Twenty-seven obese [ body mass index 37.2 ± 0.9 kg/m(2 ) ( mean ± sem ) ] insulin-treated type 2 diabetes mellitus patients . INTERVENTION Patients followed a 16-wk VLCD . Thirteen of them simultaneously participated in an exercise program ( E ) consisting of 1-h , in-hospital training and four 30-min training sessions on a cycloergometer weekly . OUTCOME MEASURES Insulin resistance was measured by a hyperinsulinemic euglycemic clamp . Insulin signaling , mitochondrial DNA ( mtDNA ) content , and intramyocellular lipid content was measured in skeletal muscle biopsies . RESULTS Baseline characteristics were identical in both groups . Substantial weight loss occurred ( -23.7 ± 1.7 kg VLCD-only vs. -27.2 ± 1.9 kg VLCD+E , P = NS within groups ) . The exercise group lost more fat mass . Insulin-stimulated glucose disposal increased similarly in both study groups [ 15.0 ± 0.9 to 39.2 ± 4.7 μmol/min(-1 ) · kg lean body mass ( LBM(-1 ) ) VLCD-only vs. 17.0 ± 1.0 to 37.5 ± 3.5 μmol/min(-1 ) · kg LBM(-1 ) in VLCD+E ] , as did phosphorylation of the phosphatidylinositol 3-kinase-protein kinase B/AKT insulin signaling pathway . In contrast , skeletal muscle mtDNA content increased only in the VLCD+E group ( 1211 ± 185 to 2288 ± 358 , arbitrary units , P = 0.016 vs. 1397 ± 240 to 1196 ± 179 , P = NS , VLCD-only group ) . Maximum aerobic capacity also only increased significantly in the VLCD+E group ( + 6.6 ± 1.7 ml/min(-1 ) · kg LBM(-1 ) vs. + 0.7 ± 1.5 ml/min(-1 ) · kg LBM(-1 ) VLCD-only , P = 0.017 ) . CONCLUSION Addition of exercise to a 16-wk VLCD induces more fat loss . Exercise augments maximum aerobic capacity and skeletal muscle mtDNA content . These changes are , however , not reflected in a higher insulin-stimulated glucose disposal rate Aims : With the increase in the number of systematic review s available , a logical next step to provide decision makers in healthcare with the evidence they require has been the conduct of review s of existing systematic review s. Syntheses of existing systematic review s are referred to by many different names , one of which is an umbrella review . An umbrella review allows the findings of review s relevant to a review question to be compared and contrasted . An umbrella review 's most characteristic feature is that this type of evidence synthesis only considers for inclusion the highest level of evidence , namely other systematic review s and meta-analyses . A methodology working group was formed by the Joanna Briggs Institute to develop method ological guidance for the conduct of an umbrella review , including diverse types of evidence , both quantitative and qualitative . The aim of this study is to describe the development and guidance for the conduct of an umbrella review . Methods : Discussion and testing of the elements of methods for the conduct of an umbrella review were held over a 6-month period by members of a methodology working group . The working group comprised six participants who corresponded via teleconference , e-mail and face-to-face meeting during this development period . In October 2013 , the methodology was presented in a workshop at the Joanna Briggs Institute Convention . Workshop participants , review authors and method ologists provided further testing , critique and feedback on the proposed methodology . Results : This study describes the methodology and methods developed for the conduct of an umbrella review that includes published systematic review s and meta-analyses as the analytical unit of the review . Details are provided regarding the essential elements of an umbrella review , including presentation of the review question in a Population , Intervention , Comparator , Outcome format , nuances of the inclusion criteria and search strategy . A critical appraisal tool with 10 questions to help assess risk of bias in systematic review s and meta-analyses was also developed and tested . Relevant details to extract from included review s and how to best present the findings of both quantitative and qualitative systematic review s in a reader friendly format are provided . Conclusions : Umbrella review s provide a ready means for decision makers in healthcare to gain a clear underst and ing of a broad topic area . The umbrella review methodology described here is the first to consider review s that report other than quantitative evidence derived from r and omized controlled trials . The methodology includes an easy to use and informative summary of evidence table to readily provide decision makers with the available , highest level of evidence relevant to the question posed Patients with diabetes receiving instruction in group classes utilizing audiovisual teaching techniques achieved significantly higher post-test scores than those taught individually in the traditional bedside manner . In addition to the significantly greater learning , the dietitian 's time was reduced by 100 per cent , based on classes of eight patients . The study was conducted by r and omly allocating forty-five qualified patients to control or experimental groups , pre-testing them using a question aire-interview , giving bedside or class dietary instruction , and post-testing , using the same question aire . Various personal characteristcs of the participants , as well as data relating to the diabetic state , were also examined for possible relationships to test scores and to one another OBJECTIVE The triglyceride-lowering effects of ω-3 fats and HDL cholesterol-raising effects of exercise may be appropriate management for dyslipidemia in NIDDM . However , fish oil may impair glycemic control in NIDDM . The present study examined the effects of moderate aerobic exercise and the incorporation of fish into a low-fat ( 30 % total energy ) diet on serum lipids and glycemic control in dyslipidemic NIDDM patients . RESEARCH DESIGN AND METHODS In a controlled , 8-week intervention , 55 sedentary NIDDM subjects with serum triglycerides > 1.8 mmol/l and /or HDL cholesterol < 1.0 mmol/l were r and omly assigned to a low-fat diet ( 30 % daily energy intake ) with or without one fish meal daily ( 3.6 g ω-3/day ) and further r and omized to a moderate ( 55–65 % VO2max ) or light ( heart rate < 100 bpm ) exercise program .  An oral glucose tolerance test ( 75 g ) , fasting serum glucose , insulin , lipids , and GHb were measured before and after intervention . Self-monitoring of blood glucose was performed throughout . RESULTS In the 49 subjects who completed the study , moderate exercise  improved aerobic fitness ( VO2max ) by 12 % ( from 1.87 to 2.07 l/min , P = 0.0001 ) . Fish consumption  reduced triglycerides ( 0.80 mmol/l , P = 0.03 ) and HDL3 cholesterol ( 0.05 mmol/l , P = 0.02 ) and increased HDL2 cholesterol ( 0.06 mmol/l , P = 0.01 ) . After adjustment for age , sex , and changes in body weight , fish diets were associated with increases in GHb ( 0.50 % , P = 0.05 ) and self-monitored glucose ( 0.57 mmol/l , P = 0.0002 ) , which were prevented by moderate exercise . CONCLUSIONS A reduced fat diet incorporating one daily fish meal reduces serum triglycerides and increases HDL2 cholesterol in dyslipidemic NIDDM patients . Associated deterioration in glycemic control can be prevented by a concomitant program of moderate exercise Self-management has been described as the cornerstone of care for diabetes . Many self-management studies are limited by poor methodology and poor descriptions of the intervention . The current study developed a theoretically based self-management programme for patients with type 2 diabetes , which was evaluated via a r and omized controlled trial . At immediate post-intervention and three-month follow-up the intervention group showed significant improvement relative to controls on self-management behaviours , quality of life and illness beliefs . A trend towards improved HbA1c was also observed . Documentation in a manual and development of a training programme for facilitators ensures the programme is replicable OBJECTIVE The purpose of this study was to evaluate the effects of a combination weight loss program using intermittent low-calorie diets , energy-controlled meal replacement products , and sibutramine on weight loss , diabetes control , and cardiovascular risk factors in overweight or obese subjects with type 2 diabetes . RESEARCH DESIGN AND METHODS Overweight or obese individuals with type 2 diabetes treated with diet or oral medication were r and omly assigned to either a st and ard therapy or combination therapy group . Both groups received a st and ardized program to facilitate weight loss . The combination therapy group also received 10 - 15 mg sibutramine daily , low-calorie diets using meal replacement products for 1 week every 2 months , and between low-calorie diet weeks , once daily use of meal replacement product and snack bars to replace one usual meal and snack . Primary outcome measures were changes in body weight , glycemic control , plasma lipids , blood pressure , pulse , and body composition at 1 year . RESULTS At 1 year , combination therapy , compared with st and ard therapy , result ed in significantly more weight loss ( -7.3 + /- 1.3 kg vs. -0.8 + /- 0.9 kg , P < 0.001 ) and reduction in HbA(1c ) ( -0.6 + /- 0.3 vs. 0.0 + /- 0.2 % , P = 0.05 ) . Combination therapy result ed in reduced requirement for diabetes medications and decreased fat mass and lean body mass . A 5-kg decrease in weight at 1 year was associated with a decrease of 0.4 % in HbA(1c ) ( P = 0.006 ) . Changes in fasting glucose , lipids , pulse , and blood pressure did not differ between groups . CONCLUSIONS This combination weight loss  program result ed in greater weight loss and improved diabetes control compared with a st and ard weight loss program in overweight or obese subjects with type 2 diabetes OBJECTIVES To evaluate whether outcomes from diabetes self-management education for patients with suboptimal control were sustained . STUDY DESIGN A r and omized controlled trial of 623 adults with type 2 diabetes and glycated hemoglobin ( A1C ) > 7 % assigned to receive conventional individual education ( IE ) , group education ( GE ) using US Diabetes Conversation Maps , or usual care ( UC ) with no education . METHODS A1C tests , Problem Areas in Diabetes ( PAID ) , Diabetes Self-Efficacy ( DES ) , Recommended Food Score ( RFS ) , physical activity , and medication use were quantified at baseline and 1 year of follow-up through electronic health records and quarterly mailed surveys . Short-term ( mean 6.8 months ) and long-term ( 12.8 months ) outcomes were evaluated using linear mixed models . In addition , follow-up trajectories were plotted in a r and om effects generalized additive model with smooth splines . RESULTS Compared with UC , IE result ed in long-term improved DES and PAID scores ( DES , + .11 , P = .03 and PAID , -2.94 , P = .04 ) , but not significantly improved long-term RFS or physical activity change . The A1C trajectory declined more steeply in IE than GE and UC for the first 150 days post r and omization . However , by 250 days , there was no treatment group A1C difference . The model fit likelihood ratio test for A1C intervention trends was significant for 3 distinct non-linear trajectories ( P = .02 ) . CONCLUSIONS Conventional IE ( but not GE ) result ed in significant and sustained improvements in self-efficacy and reduced diabetes distress compared with UC , but short-term improvements in A1C , nutrition , and physical activity were not sustained . Patients may need ongoing reinforcement to achieve lasting behavioral change and glucose control 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 CONTEXT The Lifestyle Heart Trial demonstrated that intensive lifestyle changes may lead to regression of coronary atherosclerosis after 1 year . OBJECTIVES To determine the feasibility of patients to sustain  intensive lifestyle changes  for a total of 5 years and the effects of these lifestyle changes ( without lipid-lowering drugs ) on coronary heart disease . DESIGN R and omized controlled trial conducted from 1986 to 1992 using a r and omized invitational design . PATIENTS Forty-eight patients with moderate to severe coronary heart disease were r and omized to an  intensive lifestyle change group  or to a  usual-care control group  , and 35 completed the 5-year follow-up quantitative coronary arteriography . SETTING Two tertiary care university medical centers . INTERVENTION Intensive lifestyle changes ( 10 % fat whole foods vegetarian diet , aerobic exercise , stress management training , smoking cessation , group psychosocial support ) for 5 years . MAIN OUTCOME MEASURES Adherence to intensive lifestyle changes , changes in coronary artery percent diameter stenosis , and cardiac events . RESULTS Experimental group patients ( 20 [ 71 % ] of 28 patients completed 5-year follow-up ) made and maintained comprehensive lifestyle changes for 5 years , whereas control group patients ( 15 [ 75 % ] of 20 patients completed 5-year follow-up ) made more moderate changes . In the experimental group , the average percent diameter stenosis at baseline decreased 1.75 absolute percentage points after 1 year ( a 4.5 % relative improvement ) and by 3.1 absolute percentage points after 5 years ( a 7.9 % relative improvement ) . In contrast , the average percent diameter stenosis in the control group increased by 2.3 percentage points after 1 year ( a 5.4 % relative worsening ) and by 11.8 percentage points after 5 years ( a 27.7 % relative worsening ) ( P=.001 between groups . Twenty-five cardiac events occurred in 28 experimental group patients vs 45 events in 20 control group patients during the 5-year follow-up ( risk ratio for any event for the control group , 2.47 [ 95 % confidence interval , 1.48 - 4.20 ] ) . CONCLUSIONS More regression of coronary atherosclerosis occurred after 5 years than after 1 year in the experimental group . In contrast , in the control group , coronary atherosclerosis continued to progress and more than twice as many cardiac events occurred AIMS To investigate whether a secondary - primary care partnership education package could improve underst and ing of diabetes care among South Asians . METHODS In a pilot r and omized controlled trial , in the setting of eight general practice s r and omized to intervention or control , patients were invited to four or more rotating visits per year by one of a diabetes specialist nurse , dietician or chiropodist working with general practice staff . Participants were from lists of South Asian patients with known Type 2 diabetes in each ( general ) practice . RESULTS Patients and practice scores at baseline and 1-year follow-up , from an interview using a question naire on knowledge , awareness and self-management of diabetes . Responses were developed into educational packages used during intervention . Of the 411 patients listed at baseline only 211 were traced for interview ( refusal only 4 % ) . Mean age was 55.4 years , age of diabetes onset 47.1 years . Fourteen percent were employed and 35 % were able to communicate in English fluently . Only 118 could be traced and interviewed at 1 year , although there was no significant difference in demography between those who completed the study and those who did not . Despite a mean of four visits/patient , intervention had no impact on scores for diabetes knowledge , or awareness [ score change 0.14 , 95 % confidence interval ( CI ) -0.20 , 0.49 ] or self-management ( -0.05 , 95 % CI -0.48 , 0.39 ) between baseline and 1 year . CONCLUSIONS This form of secondary / primary care support did not transfer information effectively , and we suspect similar problems would arise in other similar communities . Different methods of clinician/patient information exchange need to be developed for diabetes in this South Asian group The British Heart Foundation and the Chest , Heart and Stroke Association have allocated funds to develop cardiac rehabilitation programmes . We have recently completed and now evaluate an exercise-based rehabilitation course reinforced with advice about return to normal activity for 110 patients who had suffered acute myocardial infa rct ion . Patients admitted to the Plymouth cardiac care unit were r and omised into groups : a control group to receive st and ard hospital care , and a rehabilitation group who , in addition , received an exercise programme reinforced with advice . Patients were assessed at entry to the study and at intervals thereafter . Assessment was by question naire and objective tests consisting of a 12-minute walking test and weekly outpatient pedometry . In the rehabilitation group patients were able to walk further and faster , return to work earlier , undertake more housework , and resume normal sexual activity ; they were less short of breath and did not experience more angina . However , the rehabilitation course brought little benefit to the patients ' perception of well-being and their anxiety about health or their outlook on life .  Exercise and advice are important components of a rehabilitation programme , but more attention needs to be given to the psychological aspects of recovery from a heart attack OBJECTIVE To evaluate the effectiveness of a nurse-managed smoking cessation intervention in diabetic patients . RESEARCH DESIGN AND METHODS This r and omized controlled clinical trial involved 280 diabetic smokers ( age range 17 - 84 years ) who were r and omized either into control ( n = 133 ) or intervention ( n = 147 ) groups at 12 primary care centers and 2 hospitals located in Navarre , Spain . The intervention consisted of a 40-min nurse visit that included counseling , education , and contracting information ( a negotiated cessation date ) . The follow-up consisted of telephone calls , letters , and visits . The control group received the usual care for diabetic smokers . Baseline and 6-month follow-up measurements included smoking status ( self-reported cessation was verified by urine cotinine concentrations ) , mean number of cigarettes smoked per day , and stage of change . RESULTS At the 6-month follow-up , the smoking cessation incidence was 17.0 % in the intervention group compared with 2.3 % in the usual care group , which was a 14.7 % difference ( 95 % CI 8.2 - 21.3 % ) . Among participants who continued smoking , a significant reduction was evident in the average cigarette consumption at the 6-month follow-up . The mean number of cigarettes per day decreased from 20.0 at baseline to 15.5 at 6 months for the experimental group versus from 19.7 to 18.1 for the control group ( P < 0.01 ) . CONCLUSIONS A structured intervention managed by a single nurse was shown to be effective in changing the smoking behavior of diabetic patients A structured treatment and teaching programme for non-insulin-treated non-insulin-dependent ( type 2 ) diabetes was evaluated prospect ively in general practice . The four group sessions were mainly conducted by paramedical personnel . 65 patients from five general practice s were assessed at the start of the programme and 50 ( mean age 65 years , diabetes duration 7 years ) completed the 1 year follow-up ( intervention group ) . The control group consisted of 49 patients ( mean age 63 years , diabetes duration 7 years ) from three other general practice s without the programme . In the intervention group the percentage of patients receiving sulfonylureas  fell from 68 % at the start of the study to 38 % after 1 year ( mean difference 30 % , 95 % confidence interval [ CI ] 16 - 44 % ) ; the mean weight loss was 2.7 kg ( 95 % CI 1.6 - 3.8 kg ) , and non-fasting triglycerides were reduced by 0.77 mmol/1 ( 95 % CI 0.35 - 1.19 mmol/l ) ; and glycosylated haemoglobin remained unchanged ( 7.1 % of total haemoglobin ) . In the control group none of these indices was changed during the study year , and 10 % of patients started insulin treatment . The structured treatment and teaching programme improved the overall quality of patient care in elderly non-insulin-dependent diabetic patients treated by general practitioners ABSTRACT Background Several trials have demonstrated the efficacy of nurse telephone case management for diabetes ( DM ) and hypertension ( HTN ) in academic or vertically integrated systems . Little is known about the real-world potency of these interventions . Objective To assess the effectiveness of nurse behavioral management of DM and HTN in community practice s among patients with both diseases . Design The study was design ed as a patient-level r and omized controlled trial . Participants Participants included adult patients with both type 2 DM and HTN who were receiving care at one of nine community fee-for-service practice s. Subjects were required to have inadequately controlled DM ( hemoglobin A1c [ A1c ] ≥ 7.5 % ) but could have well-controlled HTN . Interventions All patients received a call from a nurse experienced in DM and HTN management once every two months over a period of two years , for a total of 12 calls . Intervention patients received tailored DM- and HTN- focused behavioral content ; control patients received non-tailored , non-interactive information regarding health issues unrelated to DM and HTN ( e.g. , skin cancer prevention).Main Outcomes and Measures Systolic blood pressure ( SBP ) and A1c were co- primary outcomes , measured at 6 , 12 , and 24 months ; 24 months was the primary time point . Results Three hundred seventy-seven subjects were enrolled ; 193 were r and omized to intervention , 184 to control . Subjects were 55 % female and 50 % white ; the mean baseline A1c was 9.1 % ( SD = 1 % ) and mean SBP was 142 mmHg ( SD = 20 ) . Eighty-two percent of scheduled interviews were conducted ; 69 % of intervention patients and 70 % of control patients reached the 24-month time point . Expressing model estimated differences as ( intervention – control ) , at 24 months , intervention patients had similar A1c [ diff = 0.1 % , 95 % CI ( −0.3 , 0.5 ) , p = 0.51 ] and SBP [ diff = −0.9 mmH g , 95 % CI ( −5.4 , 3.5 ) , p = 0.68 ] values compared to control patients . Likewise , DBP ( diff = 0.4 mmHg , p = 0.76 ) , weight ( diff = 0.3 kg , p = 0.80 ) , and physical activity levels ( diff = 153 MET-min/week , p = 0.41 ) were similar between control and intervention patients . Results were also similar at the 6- and 12-month time points . Conclusions In nine community fee-for-service practice s , telephonic nurse case management did not lead to improvement in A1c or SBP . Gains seen in telephonic behavioral self-management interventions in optimal setting s may not translate to the wider range of primary care setting OBJECTIVE To study the effects of a comprehensive discharge planning protocol , design ed specifically for the elderly and implemented by nurse specialists , on  patient and caregiver outcomes and cost of care . DESIGN R and omized clinical trial . SETTING Hospital of the University of Pennsylvania . PATIENTS 276 patients and 125 caregivers . Patients were 70 years and older and were placed in selected medical and surgical cardiac diagnostic-related groups . MEASUREMENTS Group differences in patient outcomes ( length of initial hospital stay , length of time between initial hospital discharge and readmission , and rehospitalization rates ) and charges for care ( charges for initial hospitalization , rehospitalizations , health services after discharge , and nurse specialist services ) were measured 2 , 6 , and 12 weeks after discharge . RESULTS From the initial hospital discharge to 6 weeks after discharge , patients in the medical intervention group had fewer readmissions , fewer total days rehospitalized , lower readmission charges , and lower charges for health care services after discharge . No differences in these outcomes were found between the surgical intervention and control groups during this period . CONCLUSIONS Study findings support the need for comprehensive discharge planning design ed for the elderly and implemented by nurse specialists to improve their outcomes after hospital discharge and to achieve cost savings . The findings also suggest that this intervention had its greatest effect in delaying or preventing rehospitalization of patients in the medical intervention group during the first 6 weeks after discharge OBJECTIVE The objective of this study was to evaluate the impact of a problem-based empowerment patient education program specifically tailored for urban African Americans with type 2 diabetes . RESEARCH DESIGN AND METHODS The study used a r and omized controlled trial ( RCT ) pretest/post-test design with repeated measures . Patients were r and omly assigned to either a six-week intervention group or a six-week wait-listed control group . After completing the six sessions , patients were invited to participate in one of two follow-up conditions ; attend a monthly support group or receive a monthly phone call from a nurse . Assessment measures included HbA1C , lipids , blood pressure , weight , self-management behavior and psychosocial adaptation . RESULTS Both control and intervention patients showed a broad array of small-to-modest positive changes during the six-week RCT . These gains were maintained or improved upon during the one-year follow-up period . For patients in the two follow-up conditions , a positive correlation was seen between the number of follow-up contacts and their one-year HbA1C values . CONCLUSIONS We believe that results of this study can be attributed to volunteer bias , study effects ( ie , providing study data on several occasions to patients and their physicians during the one-year study period ) , and impact of the interventions . However , the study design does not allow us to examine the relative impact of these three factors on the patient improvements seen over the one-year study period 1 . A prospect i ve r and omized study of two dietary regimens has been started in newly-diagnosed diabetics to determine their effect on circulating metabolites and on diabetic complications . 2 . During the first year of treatment the fasting plasma glucose concentrations on both the low-carbohydrate diet and the high-carbohydrate , modified-fat ( MF ) diet showed a similar decrease . 3 . Plasma cholesterol showed a sustained decrease only in patients recommended a MF diet . Transient changes in plasma triglyceride concentrations occurred in patients on both dietary regimens . 4 . Increased plasma cholesterol levels are associated with atheromatous disease which is common in diabetics in Europe and North America . A MF diet may therefore have an advantage in that it lowers the plasma cholesterol as well as being effective in lowering the plasma glucose PURPOSE To evaluate a year-long behavioral weight control program , used with and without an intermittent very-low-calorie diet ( VLCD ) in the treatment of type II diabetes mellitus . PATIENTS AND METHODS Subjects ( n = 93 ) were r and omly assigned to 50-week treatment programs that used either a balanced low-calorie diet ( LCD ) of 1,000 to 1,000 kilocalories ( kcal ) per day throughout or included 2 12-week periods of a VLCD of 400 to 500 kcal per day alternating with the balanced LCD .  Weight , glycemic control , blood pressure , and lipids were assessed at baseline , at the end of the year-long treatment , and at 2-year follow-up . RESULTS Subjects in the VLCD program lost significantly more weight than did LCD subjects at the end of the 50-week program ( 14.2 kg versus 10.5 kg ; P = 0.057 ) and remained off diabetes medication longer ( P < 0.05 ) . These benefits of the VLCD were due primarily to the first 12 weeks of the diet ; the second diet maintained , but did not increase , these effects . Subjects in both groups experienced marked improvements in glycemic control and cardiovascular risk factors over the year-long program , but attendance declined in the latter weeks of treatment and weight was regained . There was also marked recidivism in both groups in the year following treatment . CONCLUSIONS The intermittent VLCD improved weight loss and glycemic control , but these effects were quite modest and do not appear to justify the clinical use of an intermittent VLCD . Moreover , lengthening treatment to a full year did not prevent relapse . Thus , further research is needed to develop a successful approach to long-term weight control AIMS To examine the influence of a pharmaceutical care programme on disease control and health-related quality of life in Type 2 diabetes patients in the United Arab Emirates . METHODS A total of 240 Type 2 diabetes patients were recruited into a r and omized , controlled , prospect i ve clinical trial with a 12-month follow-up . A range of clinical measures , medication adherence and health-related quality of life ( Short Form 36 ) were evaluated at baseline and up to 12 months . Intervention group patients received pharmaceutical care from a clinical pharmacist , whereas control group patients received their usual care from medical and nursing staff . The primary outcome measure was change in HbA(1c ) . British National Formulary and Framingham scoring methods were used to estimate changes in 10-year coronary heart disease risk scores in all patients . RESULTS A total of 234 patients completed the study . Significant reductions ( P < 0.001 ) in mean values ( baseline vs. 12 months ; 95 % confidence interval ) of HbA(1c)[8.5 % ( 8.3 , 8.7 ) vs. 6.9 % ( 6.7 , 7.1 ) ] , systolic [ 131.4 mmHg ( 128.1 , 134.7 ) vs. 127.2 mmHg ( 124.4 , 130.1 ) ] and diastolic blood pressure [ 85.2 mmHg ( 83.5 , 86.8 ) vs. 76.3 mmHg ( 74.9 , 77.7 ) ] were observed in the intervention group ; no significant changes were noted in the control group . The mean Framingham risk prediction score in the intervention group was 10.56 % ( 9.7 , 11.4 ) at baseline ; this decreased to 7.7 % ( 6.9 , 8.5 ) ( P < 0.001 ) at 12 months but remained unchanged in the control group . CONCLUSIONS The pharmaceutical care programme result ed in better glycaemic control and reduced cardiovascular risk scores in Type 2 diabetes patients over a 12-month period This study evaluated long-term effects of 12 weeks of supervised training , of at least 45 minutes duration with two sessions per week , on physical performance and  psychological well-being after myocardial infa rct ion ( MI ) . Sixty-nine patients were r and omized to either an exercise or a nonexercise group .  Maximum exercise capacity 6 weeks post-MI was inversely related to the acute peak aspartate aminotransferase values in serum , as an index of infa rct size . One year post-MI , the increase in level of fitness ( 10 % ) in the training group did not significantly exceed ( p = .10 ) that of the controls ( 2 % ) . No intergroup differences were registered in self-rated psychological well-being and physical scores or in the return to work rate . In the training group , but not in the controls , the change in perceived dyspnoea at leisure-time activities was positively related to the objective ly measured peak exercise capacity . We conclude that after MI only marginal improvements in physical performance are achieved 6 months after training is finished , with no long-term psychological benefits apparent versus a usual care program . The adaptive implication s of supervised conventional exercise programs post-MI are therefore question ed OBJECTIVE To assess the effectiveness of a programme to coordinate and support follow up care in general practice after a hospital diagnosis of myocardial infa rct ion or angina . DESIGN R and omised controlled trial ; stratified r and om allocation of practice s to intervention and control groups . SETTING All 67 practice s in Southampton and south west Hampshire , Engl and . SUBJECTS 597 adult patients ( 422 with myocardial infa rct ion and 175 with a new diagnosis of angina ) who were recruited during hospital admission or attendance at a chest pain clinic between April 1995 and September 1996 . INTERVENTION Programme to coordinate preventive care led by specialist liaison nurses which sought to improve communication between hospital and general practice and to encourage general practice nurses to provide structured follow up . MAIN OUTCOME MEASURES Serum total cholesterol concentration , blood pressure , distance walked in 6 minutes , confirmed smoking cessation , and body mass index measured at 1 year follow up . RESULTS Of 559 surviving patients at 1 year , 502 ( 90 % ) were followed up . There was no significant difference between the intervention and control groups in smoking ( cotinine vali date d quit rate 19 % v 20 % ) , lipid concentrations ( serum total cholesterol 5.80 v 5.93 mmol/l ) , blood pressure ( diastolic pressure 84 v 85 mm Hg ) , or fitness ( distance walked in 6 minutes 443 v 433 m ) . Body mass index was slightly lower in the intervention group ( 27.4 v 28.2 ; P=0.08 ) . CONCLUSIONS Although the programme was effective in promoting follow up in general practice , it did not improve health outcome . Simply coordinating and supporting existing NHS care is insufficient . Ischaemic heart disease is a chronic condition which requires the same systematic approach to secondary prevention applied in other chronic conditions such as diabetes mellitus AIMS The efficacy of three education programmes for Type 2 diabetic patients was tested in a r and omized trial . A didactic-oriented training programme ( treatment A ) was compared with a self-management-oriented programme delivered in group sessions ( treatment B ) . The latter programme was compared with a more individualized approach ( treatment C ) . METHODS One hundred and eighty-one Type 2 diabetic patients ( age 55.6 + /- 6.3 years , diabetes duration 6.6 + /- 6.2 years , HbA(1c ) 7.8 + /- 1.6 % , female 49.7 % ) took part . Efficacy was assessed 3 months ( t1 ) after baseline ( t0 ) and at a follow-up 15 months ( t2 ) after baseline . RESULTS The fall in HbA(1c ) in treatment B at t1 was sustained at t2 ( t0 8.1 + /- 1.8 % , t1 7.3 + /- 1.7 % , t2 7.4 + /- 1.9 % ) . In treatment A , HbA(1c ) was unchanged throughout ( t0 7.6 + /- 1.5 % , t1 7.5 + /- 1.3 % , t2 7.7 + /- 1.7 % ; treatment A vs. treatment B ; P < 0.05 ) . With the more individualized approach of treatment C , there was a fall in HbA(1c ) at t1 , but this was not sustained at t2 ( t0 7.8 + /- 1.6 % , t1 7.1 + /- 1.3 % , t2 7.6 + /- 1.6 % ; treatment B vs. treatment C ; P = 0.73 ) . There were also significant benefits in treatment B subjects compared with treatment A in further medical ( body mass index and fasting blood glucose ) , psychological ( control , irritability and hunger dependency of eating behaviour , and trait anxiety ) and behavioural ( exercise ) variables . There were no significant benefits of the more individualized treatment C compared with group treatment B. No significant differences were found regarding triglyceride levels , high-density lipoprotein , diabetes-related knowledge , negative well-being , urine or blood glucose levels or foot care . CONCLUSION Self-management training had a significantly higher medium-term efficacy than didactic diabetes education . The group sessions were more effective than a more individualized approach Background Current guidelines consider diabetes per se as a coronary artery disease ( CAD ) risk equivalent . We aim ed at investigating the contribution of baseline coronary atherosclerosis to the risk of diabetic patients for future vascular events . Design Prospect i ve cohort study . Methods Vascular events were recorded over 4 years in 750 consecutive patients undergoing coronary angiography for the evaluation of stable CAD . Results From our patients , 244 had neither type 2 diabetes ( T2DM ) nor significant CAD ( i.e. coronary stenoses ≥ 50 % ) at the baseline angiography , 50 had T2DM but not significant CAD , 342 did not have T2DM but had significant CAD , and 114 had both T2DM and significant CAD . Nondiabetic patients without significant CAD had an event rate of 9.0 % . The event rate was similar in T2DM patients without significant CAD ( 8.0 % , P = 0.951 ) , but higher in nondiabetic patients with significant CAD ( 24.9 % , P < 0.001 ) . Patients with T2DM and significant CAD had the highest event rate ( 43.0 % ) . Importantly , T2DM patients without significant CAD had a significantly lower event rate than nondiabetic patients with significant CAD ( P = 0.008 ) . Conclusion T2DM per se is not a CAD risk equivalent . Moderate-risk diabetic patients without significant CAD and very high-risk diabetic patients with significant CAD add up to a gr and total of high-risk diabetic patients , this is why diabetes seems to be a CAD risk equivalent in many epidemiological studies Six weeks after acute myocardial infa rct ion , 303 men were r and omly divided into exercise and control groups . The exercise group attended the hospital gymnasium twice weekly for a three-month supervised exercise course . Both groups were exercise tested before and after the course and at subsequent follow-up . The exercise group increased their physical fitness greatly compared with the control group . Eight per cent of the exercise group died during the period of follow-up , compared with 14 per cent of the control group ; this difference is not significant . There was an apparent improvement in mortality in those with inferior MI who completed the exercise course , which was not seen in those with MI in other sites . For many patients after MI progressive exercise is safe , improves physical fitness and may reduce mortality for those after inferior MI A pilot study was conducted to assess the feasibility and potential efficacy of a couples focused diabetes intervention in which a collaborative problem-solving approach to diabetes self-care was promoted . Couples ( N = 44 ) , in which one partner had Type 2 diabetes and was in poor blood glucose control were r and omly assigned to one of three groups : a couples intervention , an individual intervention , or individual diabetes education . The intervention included goal - setting , dietary behavior change , and a focus on emotions . For those in the couples arm , this was done within the framework of promoting collaborative communication between the partners . All intervention contacts were over the telephone to increase reach . Results showed that both the individual and couples interventions yielded meaningful clinical improvements in medical outcomes . Diabetes education also result ed in improved blood glucose control . Despite the small number , mixed-model regression analyses found statistically significant treatment effects for total cholesterol . This pilot demonstrates the feasibility and potential efficacy of a telephone intervention for Type 2 diabetes patients and their partners . Information from implementing this pilot led to refinement and further development of the intervention , which is being assessed in a larger , more comprehensive trial Two hundred patients who had suffered an acute myocardial infa rct ion 4 - 6 weeks before entered a r and omised controlled trial of  exercise treatment  at a community sports centre supervised by a general practitioner . Eighty one per cent of the treatment group continued to exercise until they returned to work and 73 % completed three months ' exercise . There were no serious complications of the exercise course . The prevalence of angina pectoris fell by 10 % in the treatment group but rose by 60 % in the control group . The perceived energy level rose by significantly more in the treatment group than in the controls . The rise in predicted maximum oxygen uptake was significantly greater in the treatment group than in the control group as was the reduction in the double product ( a reflection of myocardial workload ) at peak exercise . Coronary rehabilitation in the community can be both safe and effective OBJECTIVE To assess the effect of medical nutrition therapy ( MNT ) provided by dietitians on medical and clinical outcomes for adults with non-insulin-dependent diabetes mellitus ( NIDDM ) , and to compare MNT administered according to practice guidelines nutrition care ( PGC ) to MNT administered with basic nutrition care ( BC ) . DESIGN A prospect i ve , r and omized , controlled clinical trial of two levels of MNT on metabolic control in persons newly diagnosed with or currently under treatment for NIDDM was conducted at diabetes centers in three states ( Minnesota , Florida , and Colorado ) .  BC consisted of a single visit with a dietitian ; PGC involved an initial visit with a dietitian followed by two visits during the first 6 weeks of the study period . Data were collected at entry to the study and at 3 and 6 months . SUBJECTS Results are reported for 179 men and women aged 38 to 76 years : 85 assigned r and omly to BC and 94 to PGC . This represents 72 % of the 247 subjects enrolled . An additional 62 adults with NIDDM at one site who had no contact with a dietitian were identified as a nonr and om comparison group . OUTCOMES Medical outcome measures included fasting plasma glucose ( FPG ) , glycated hemoglobin ( HbA1c ) , and serum lipid levels . Clinical outcomes included weight , body mass index , waist-to-hip ratio , and changes in medical therapy . STATISTICAL ANALYSES Initial analysis of the discrete variables was done using the chi 2 statistic with Yates ' correction . Initial analysis of continuous variables was done by analysis of variance . The changes in variables between time periods were analyzed by paired t test , and comparisons between groups were analyzed using a t test for independent groups . RESULTS At 6 months , PGC result ed in significant improvements in blood glucose control as indicated by FPG and HbA1c levels and BC result ed in significant improvements in HbA1c level . Participants assigned to the PGC group had a mean FPG level at 6 months that was 10.5 % lower than the level at entry , and those in the BC group had a 5.3 % lower value . Among subjects who had diabetes for longer than 6 months , those who received PGC had a significantly better HbA1c level at 3 months compared with those receiving BC . The comparison group showed no improvement in glycemic control over a comparable 6 months . PGC subjects had significant improvements in cholesterol values at 6 months , and subjects in both the PGC and the BC groups had significant weight loss . CONCLUSIONS MNT provided by dietitians result ed in significant improvements in medical and clinical outcomes in both the BC and PGC groups and is beneficial to persons with NIDDM . Persons with a duration of diabetes longer than 6 months tended to do better with PGC than with BC . Because of the upward trend in glucose levels after 3 months , ongoing MNT by dietitians is important for long-term metabolic control BACKGROUND Acute hospitalizations represent substantial financial liability to closed health care systems . Among hospitalized patients , those with repeated admissions are high-cost users . Most managed care plans employ case management to control hospital use . This technique attempts to detect and fulfill unmet medical and social needs , intensify postdischarge care , identify and mobilize effective community services , and enhance primary care access . Despite the popularity of case management to control hospital use , few trials have examined its efficacy . METHODS We conducted a r and omized controlled trial of an intervention of  case managers at a university-affiliated Veterans Affairs medical center . Six hundred sixty-eight patients aged 45 years or older who were discharged from the general medicine inpatient service , who had access to a telephone , and who received primary care at the hospital 's clinics were r and omized to the intervention ( N = 333 ) and control ( N = 335 ) groups . Within 24 hours of discharge , case managers mailed educational material s and access information to intervention patients , and within 5 days they called to review and resolve unmet needs , early warning signs , barriers to keeping appointments , and any readmissions . Case managers contacted intervention patients if they made no visits for 30 days . This result ed in a total of 6260 patient-case manager contacts . Control and intervention patients were followed up for 12 months . RESULTS Intervention patients had more frequent visits per patient per month to the general medicine clinic ( 0.30 + /- 0.23 vs 0.26 + /- 0.22 , P = .008 ) , but we detected no significant differences between groups in nonelective readmissions , readmission days , or total readmissions . CONCLUSIONS Frequent contacts for education , care , and accessibility by case managers using protocol s were ineffective in reducing nonelective readmissions Latinas with type 2 diabetes are in need of culturally sensitive interventions to make recommended long-term lifestyle changes and reduce heart disease risk . To test the longer-term ( 24-month ) effects of a previously successful , culturally adapted , multiple-health-behavior-change program , ¡ Viva Bien ! , 280 Latinas were r and omly assigned to usual care or ¡ Viva Bien!.  Treatment included group meetings to promote a culturally adapted Mediterranean diet , physical activity , supportive re sources , problem solving , stress-management practice s , and smoking cessation . ¡ Viva Bien ! participants achieved and maintained some lifestyle improvements from baseline through 24 months , including significant improvements for psychosocial outcomes , fat intake , social – environmental support , body mass index , and hemoglobin A1c . Effects tended to diminish over time . The ¡ Viva Bien ! multiple-behavior program was effective in improving and maintaining some psychosocial , behavioral , and biological outcomes related to heart health across 24 months for Latinas with type 2 diabetes , a high-risk , underserved population ( Clinical Trials.gov number , NCT00233259 ) Innovative , culturally tailored strategies are needed to extend diabetes education and support efforts in lower-re source d primary care practice s serving racial/ethnic minority groups . A r and omized controlled trial ( RCT ) examined the effect of a diabetes self-care coaching intervention delivered by medical assistants and the joint effect of intervention and ethnicity over time . The r and omized repeated- measures design included 270 low-income African American and Hispanic/Latino patients with type 2 diabetes . The 1-year clinic- and telephone-based medical assistant coaching intervention was culturally tailored and guided by theoretical frameworks . A1C was obtained , and a self-care measure was completed at baseline , 6 months , and 12 months . Data were analyzed using mixed-effects models with and without adjustment for covariates . There was a significant overall improvement in mean self-care scores across time , but no intervention effect . Results revealed differences in self-care patterns across racial/ethnic subgroups . No differences were found for A1C levels across time or group Practical lifestyle interventions are needed to help people with type 2 diabetes increase their physical activity and follow nutrition therapy guidelines . This study examined whether combining instructions to walk more and to eat more low-glycemic index ( GI ) foods ( First Step First Bite Program ) improved hemoglobin A1c and anthropometric and cardiovascular health outcomes in people with type 2 diabetes vs the First Step Program ( instruction only on walking ) . Subjects were r and omly assigned to the First Step Program or First Step First Bite Program ( n=22 in each group ) and attended four weekly group meetings with minimal follow-up during weeks 5 to 16 . All subjects monitored steps per day throughout the study ; First Step First Bite Program subjects also monitored daily intake of low-GI foods . At week 16 ( n=19 per group ) , both groups had increased steps per day by approximately 3,000 compared with baseline ( P<0.01 ) . In the First Step Program vs First Step First Bite Program groups , respectively , waist girth decreased by 5.9+/-0.9 cm vs 3.7+/-0.5 cm and hip decreased by 3.7+/-0.6 cm vs 2.2+/-0.5 cm ( P<0.01 over time , both groups ) . There was no significant difference between groups at week 16 for anthropometric or metabolic variables measured , including hemoglobin A1c . Both the First Step First Bite Program and First Step Program result ed in increased physical activity ;  First Step First Bite Program also increased daily intake of low-GI foods . Both groups experienced similar significant reductions in waist and hip girth . Thus , adding a low-GI component to a walking program in people with type 2 diabetes in good glycemic control did not improve anthropometric or metabolic outcomes . A great number and /or longer duration of low-GI foods may be required to observe improved clinical outcomes Background The prevalence of diabetes mellitus is ubiquitous . Complications and costs of diabetes are rising and are depleting limited re sources . It is imperative for healthcare professionals and patients alike to confront this chronic condition by exploring new interventions . An innovative health care delivery model has emerged in the last 25 years in the form of the group medical visit . Group medical visits can range from of six to twenty patients scheduled together with time allotted for individual care as well as in the group setting . Objectives The review objective was to conduct a systematic review and meta‐ analysis to synthesize the best available evidence related to effectiveness of group medical visits on HbA1c , blood pressure and cholesterol measurements /levels for adult patients with type II diabetes in outpatient setting s. Search strategy A three‐step literature search for studies in English language from 1990 to 2010 was conducted utilising ( a ) a primary search of Medline , CINAHL , PsycINFO and Cochrane Central Register of Controlled Trials , ( b ) a secondary search of non‐indexed data bases , and ( c ) a search of the grey literature . In addition , a manual review of the reference lists of all identified reports and articles was performed to identify additional studies . Inclusion criteria All r and omised and quasi‐experimental studies of adult patients ( > 18 ) with type II diabetes mellitus seen in outpatient health setting s were considered if they met one or more of the following diagnostic outcome measurements : haemoglobin A1c , systolic and diastolic blood pressure , and low density lipoprotein cholesterol . Critical appraisal , data collection and analysis Each of the eligible articles was review ed by two independent review ers . Disagreements between the review ers were resolved through discussion , or with a third review er . Studies that met the inclusion criteria were assessed for method ological quality using the JBI st and ardized critical appraisal tools . Data extraction was undertaken using the st and ardised data extraction tool from JBI‐MAStARI . Main results The search strategy identified 2,040 articles in the published and unpublished literature . Of these , 11 r and omised controlled trials and 4 quasi‐experimental trials met the inclusion criteria and represented 2240 patients included in the final review . There are clear benefits of group medical visits for patients ' HbA1c levels which are consistent in the post‐intervention and change from baseline effect sizes . The most significant effect observed is with the change from baseline results . Some evidence suggests post‐intervention and change from baseline systolic blood pressure improvement at the nine to twelve month interval and change from baseline improvement at the 4 year timeframe . There is no evidence that group visits improve LDL cholesterol values of the group visit participants . Conclusions Group medical visits should be considered by clinicians as an effective non‐pharmacologic intervention that can have a positive impact on biologic markers such as haemoglobin A1c and systolic blood pressure . Implication s for practice The evidence suggests that the most powerful model of Group medical visits ( GMV ) is when a clinician prescriber is present during or immediately after GMV sessions for medication reconciliation or individual patient needs . Implication s for research Future research should include this GMV intervention in r and omised controlled trials across different health systems and socio‐economic and ethnic groups AIM Previous studies have reported lifestyle and risk factor deterioration following completion of a cardiac rehabilitation program ( CRP ) . We report the results of a one-year Extensive Lifestyle Management Intervention ( ELMI ) aim ed at preventing these adverse changes . METHODS AND RESULTS A total of 302 men and women with ischaemic heart disease were recruited following completion of a CRP and r and omized to either the  ELMI  ( consisting of exercise sessions , telephone follow-ups and risk factor and lifestyle counselling ) or  usual care . The primary outcome was global cardiovascular risk using the Framingham and Procam risk scores . Secondary outcomes included risk factors and lifestyle behaviours . Baseline characteristics were similar between the two groups . Adherence to the ELMI was high . There was a non-significant trend in favour of the ELMI between for both the Framingham ( 6.6+/-3.1 to 6.2+/-2.9 vs 6.6+/-3.2 to 6.7+/-3.2 , P=0.138 ) and Procam ( 20.0+/-20.0 to 20.6+/-19.5 vs 19.1+/-18.7 to 21.8+/-19.1 , P=0.089 ) scores . There were no differences in secondary outcomes . CONCLUSIONS A one-year multi-factorial post-CRP intervention results in modest , non-significant benefits to global risk compared to usual care . The absence of deterioration in the usual care group may be due to improved practice s in usual care Hmong refugees with type 2 diabetes mellitus ( DM2 ) have poor glycemic control . For Hmong adults with DM2 , group visits were instituted at a community health center and evaluated for their influence on diabetes management . Pre- and postintervention measures of physical health , mental health , and behavior were collected on 39 participants ( 64 % participation rate ) . Baseline characteristics and clinical outcomes of 39 group visit participants were compared with 22 Hmong DM2 adults who refused to participate and 216 nonparticipating Hmong DM2 adults from a local diabetes registry . Baseline characteristics were similar among the three groups . Although participants received good medical services and their mental health improved ( p < 0.05 ) , clinical outcomes did not significantly improve . Although group visits are feasible for providing medical services for Hmong adults with DM2 , clinical outcomes remain outside of recommended targets . Addressing mental health in this population may be necessary before people can institute behavioral changes that improve diabetes management Executive summary Background As a chronic condition , the prevalence of Type 2 diabetes is increasing worldwide and adherence to oral medications , an essential component of self‐management , has been shown to improve glycaemic control . However compliance with oral medication adherence remains poor . Educating people with Type 2 diabetes is an important strategy to enhance self‐management ability , including medication‐taking behaviour . Objectives The overall objective of the review was to determine the effectiveness of educational interventions to promote oral hypoglycaemic adherence in adults with Type 2 diabetes . Inclusion criteria Types of participants Studies involving adults over 18 years old with Type 2 diabetes , with or without co‐morbidities , currently taking oral hypoglycaemic medication without insulin treatment , and with aglycated haemoglobin ( HbA1c ) > 7.0 % prior to the intervention were considered . Aglycated haemoglobin ( HbA1c ) concentration of less than 7.0 % , is important in order to delay or prevent diabetes‐related complications . Participants could be from the primary , tertiary or acute care setting . Types of intervention The review focused on various forms of educational interventions delivered by healthcare professionals aim ed at improving participants ’ knowledge . Types of outcomes The review evaluated outcomes measuring oral hypoglycaemic adherence including HbA1c , fasting blood glucose levels and other relevant indicators . Types of studies Studies that were r and omized controlled trials ( RCTs ) or case‐control studies were considered . Search strategy A three‐stage search strategy was employed . Papers in English and between the years 1990‐2009 were search ed in the following data bases : CINAHL , Medline , Mosby 's Nursing Consult , PsycINFO , PubMed , ScienceDirect , Scopus , TRIP and Web of Science . Full text was retrieved when the titles and abstract s of studies fulfilled the inclusion criteria . Method ological quality Full papers were assessed for method ological quality independently by two review ers using critical appraisal checklists from the Joanna Briggs Institute ( JBI ) . A third review er was consulted whenever there were disagreements between the two review ers . Data collection / extraction Details of each study included in the review were extracted using st and ardized data extraction forms developed by JBI . Extraction was conducted independently by two review ers . Data synthesis Meta‐ analysis was not possible due to method ological and statistical heterogeneity of the included studies . Hence study findings are presented in narrative form . Results Seven studies included in the final review consisted of seven RCTs . Five studies concluded that the educational intervention was effective in promoting oral hypoglycaemic adherence compared to usual care . These included pharmacist‐led interventions , individual diabetes education provided by nurses and diabetes group education based on a self‐management approach . Similarities among these interventions were provision of information on oral hypoglycaemic medication and the need for regular education sessions . However , small sample s in some studies limited generalization of results . Conclusions Implication s for practice Increased knowledge of oral hypoglycaemic issues and reinforcement of the importance of medication adherence were useful in promoting adherence . Regular education sessions allow individuals to reinforce information and educators to identify barriers to medication adherence . Educational interventions focusing on self‐management strategies appear more likely to achieve positive outcomes . Implication s for research Further trials involving larger sample s and population s with poor glycaemic control are needed . The effects of educational interventions , influence of additional take‐home written material , the optimal interval length of follow‐up and duration of education sessions , and specific processes of individual or group education which have been identified as effective need further exploration To maximize disease control , patients must participate effectively in their medical care . The authors developed an intervention design ed to increase the involvement of  patients  in medical decision making . In a 20-minute session just before the regular visit to a physician , a clinic assistant review ed the medical record of each experimental patient with him/her , guided by a diabetes algorithm . Using systematic prompts , the assistant encouraged patients to use the information gained to negotiate medical decisions with the doctor . A r and omized trial was conducted in two university hospital clinics to compare this intervention with st and ard educational material s in sessions of equal length . The mean pre-intervention glycosylated hemoglobin ( HbA1 ) values were 10.6 + /- 2.1 % for 33 experimental patients and 10.3 + /- 2.0 % for 26 controls . After the intervention the mean levels were 9.1 + /- 1.9 % in the experimental group ( p less than 0.01 ) and 10.6 + /- 2.22 % for controls . Analysis of audiotapes of the visits to the physician showed the experimental patients were twice as effective as controls in eliciting information from the physician . Experimental patients reported significantly fewer function limitations . The authors conclude that the intervention is feasible and that it changes patient behavior , improves blood sugar control , and decreases functional limitations OBJECTIVE To evaluate whether plasma fibrinogen concentration is correlated with the level of physical activity and aerobic power in patients with newly diagnosed non-insulin-dependent diabetes mellitus ( NIDDM ) . RESEARCH DESIGN AND METHODS We studied 78 middle-aged ( 54 ± 6 years , mean ± SD ) , obese ( body mass index [ BMI ] 32 ± 5 kg/m2 ) patients ( 45 men and 33 women ) before and after a 12-month treatment period consisting of either conventional treatment given by community health centers or intensified dietary and exercise education given by a university outpatient clinic . Plasma fibrinogen concentration was measured by using a coagulometer . Physical activity  was assessed by a question naire , and the patients were classified into a sedentary group or moderately or intensively exercising groups . Aerobic power ( maximum oxygen uptake [ ] , anaerobic threshold [ ] ) was measured by direct breath-by-breath technique . RESULTS At baseline , the sedentary patients had higher fibrinogen concentration than those with moderate or high physical activities ( 3.8 ± 0.8 vs. 3.3 ± 0.7 g/I , P < 0.01 ) . Both and ( ml · min−1 · kg−1 ) showed an inverse linear correlation with fibrinogen ( r = -0.38 , P < 0.001 , and r = -0.29 , P < 0.01 , respectively ) . In the step wise multiple regression analysis , BMI , Vo2 max ( ml/min ) , and smoking were the only significant independent factors explaining 23 % of the variance in fibrinogen concentration . In sedentary patients , poor glycemie control was related with high fibrinogen concentration . During the follow-up period , patients maintained , on the average , good to moderate glycemie control . The originally sedentary group showed a decrease in fibrinogen concentration ( to 3.3 ± 0.7 g/I , P < 0.001 ) that reached the same level that the physically more active groups had at baseline . This change was associated with improved glycemie control , but not with any of the other assessed factors , including fatty acid composition of serum lipids reflecting dietary intake of fats . CONCLUSIONS In addition to BMI and smoking , low reported physical activity and low aerobic power are independently associated with high plasma fibrinogen concentration in newly diagnosed NIDDM OBJECTIVE A trial was performed to establish whether our group care model for lifestyle intervention in type 2 diabetes can be exported to other clinics . RESEARCH DESIGN AND METHODS This study was a 4-year , two-armed , multicenter controlled trial in 13 hospital-based diabetes clinics in Italy ( current controlled trials no. IS RCT N19509463 ) . A total of 815 non – insulin-treated patients aged < 80 years with ≥1 year known diabetes duration were r and omized to either group or individual care . RESULTS After 4 years , patients in group care had lower A1C , total cholesterol , LDL cholesterol , triglycerides , systolic and diastolic blood pressure , BMI , and serum creatinine and higher HDL cholesterol ( P < 0.001 , for all ) than control subjects receiving individual care , despite similar pharmacological prescriptions . Health behaviors , quality of life , and knowledge of diabetes had become better in group care patients than in control subjects ( P < 0.001 , for all ) . CONCLUSIONS The favorable clinical , cognitive , and psychological outcomes of group care can be reproduced in different clinical setting A population -based study on the therapeutic effects of a diabetes teaching programme ( DTP ) based on problem oriented participatory education (POPE)--a method based on learner activity in group meetings -- was undertaken at the Primary Health Care Centre , Kisa , Sweden , in collaboration with educationalists . A control group was given conventional classroom teaching . To be included a patient had to be aged 55 - 73 years , to live in his own home , and to have non-insulin-treated type II diabetes mellitus . The therapeutic effects of the DTP were studied before , during , and after POPE with regard to three factors , diabetes related knowledge , behaviour assessed by dietary and exercise habits , and the quality of the anti-diabetic therapy as assessed by metabolic profile including Hb-A1 . Significant improvement in knowledge and transient improvement in Hb-A1 concentration were recorded among patients taking part in a DTP adjusted to their individual problems and needs . When improvement in metabolic control does not last , group meetings should be continued for more than the three months used in the present study . We believe that such improvement is intimately bound up with the psycho-social process that is involved in the group meetings and that helps the patient to cope with the disease in particular and life in general OBJECTIVE This study compared diabetes Treatment As Usual ( TAU ) with Pathways To Change ( PTC ) , an intervention developed from the Transtheoretical Model of Change ( TTM ) , to determine whether the PTC intervention would result in greater readiness to change , greater increases in self-care , and improved diabetes control . RESEARCH DESIGN AND METHODS Participants were stratified by diabetes treatment and r and omized to treatment with PTC or TAU as well as being r and omized regarding receipt of free blood testing strips . The PTC consisted of stage-matched personalized assessment reports , self-help manuals , newsletters , and individual phone counseling design ed to improve readiness for self-monitoring of blood glucose ( SMBG ) , healthy eating , and /or smoking cessation .  A total of 1029 individuals with type 1 and type 2 diabetes who were in one of three pre-action stages for either SMBG , healthy eating , or smoking were recruited . RESULTS For the SMBG intervention , 43.4 % of those receiving PTC plus strips moved to an action stage , as well as 30.5 % of those receiving PTC alone , 27.0 % of those receiving TAU plus strips , and 18.4 % of those receiving TAU alone ( P < 0.001 ) . For the healthy eating intervention , more participants who received PTC than TAU ( 32.5 vs. 25.8 % ) moved to action or maintenance ( P < 0.001 ) . For the smoking intervention , more participants receiving PTC ( 24.3 % ) than TAU ( 13.4 % ) moved to an action stage ( P < 0.03 ) . In intention-to-treat ( ITT ) analysis of those receiving the SMBG intervention , PTC result ed in a greater reduction of HbA(1c ) than TAU , but this did not reach statistical significance . However , in those who moved to an action stage for the SMBG and healthy eating interventions , HbA(1c ) was significantly reduced ( P < 0 0.001 ) . Individuals who received the healthy eating intervention decreased their percentage of calories from fat to a greater extent ( 35.2 vs. 36.1 % , P = 0.004 ) , increased servings of fruit per day ( 1.89 vs. 1.68 , P = 0.016 ) , and increased vegetable servings ( 2.24 vs. 2.06 , P = 0.011 ) but did not decrease weight . However , weight loss for individuals who received the healthy eating intervention and who increased SMBG frequency as recommended was significantly greater , with a 0.26-kg loss in those who remained in a pre-action SMBG stage but a 1.78-kg loss in those performed SMBG as recommended ( P < or= 0 . 01 ) . CONCLUSIONS This study demonstrates that this intervention has the potential of positively impacting the health of broad population s of individuals with diabetes , not just the minority who are ready for change OBJECTIVE To determine how frequently the National Cholesterol Education Program ( NCEP ) goal of a low-density lipoprotein ( LDL ) cholesterol level of 100 mg/dL or less is achieved in clinical practice in patients with coronary artery disease and what fraction of patients can achieve this goal without drug therapy . DESIGN We examined the results of lipid management in 152 consecutive patients who had completed cardiac rehabilitation after an acute coronary event . Patients were r and omized to follow-up by specially trained nurses or by preventive cardiologists , and they were not receiving  lipid-lowering drugs at the start of the study . MATERIAL AND METHODS Patients were given aggressive diet and exercise recommendations and lipid-lowering drugs in accordance with NCEP guidelines . Follow-up was continued for a mean of 526 days after the first lipid assessment subsequent to the coronary event . Multiple logistic regression analysis was used to identify independent predictors of a final LDL cholesterol level of 100 mg/dL or less . RESULTS Of the study group , 39 % achieved the NCEP goal LDL cholesterol level of 100 mg/dL or less . Characteristics of the patients with LDL cholesterol levels of 100 mg/dL or less in comparison with those with LDL cholesterol levels of more than 100 mg/dL included a greater frequency of drug therapy ( 65 % versus 38 % ) , more rigorous dietary compliance , longer follow-up ( 586 + /- 317 days versus 493 + /- 264 days ) , more favorable weight change ( -0.3 + /- 4.9 kg versus + 1.7 + /- 5.0 kg ) , and more extensive weekly exercise ( 183 + /- 118 minutes versus 127 + /- 107 minutes ) . CONCLUSION The registered nurses managed the lipids of these patients as effectively as did the preventive cardiologists . Appropriate drug therapy was the most important factor in achieving an LDL cholesterol level of 100 mg/dL or less , but 35 % of patients attaining this NCEP goal were not receiving drug therapy . Exercise , dietary compliance , and weight loss were also important factors The Diabetes Education Study ( DIABEDS ) was a r and omized , controlled trial of the effects of patient and physician education . This article describes a systematic education program for diabetes patients and its effects on patient knowledge , skills , self-care behaviors , and relevant physiologic outcomes . The original sample consisted of 532 diabetes patients from the general medicine clinic at an urban medical center . Patients were predominantly elderly , black women with non-insulin-dependent diabetes mellitus of long duration . Patients r and omly assigned to experimental groups ( N = 263 ) were offered up to seven modules of patient education . Each content area module contained didactic instruction ( lecture , discussion , audio-visual presentation ) , skill exercises ( demonstration , practice , feedback ) , and behavioral modification techniques ( goal setting , contracting , regular follow-up ) .  Two hundred seventy-five patients remained in the study throughout baseline , intervention , and postintervention periods ( August 1978 to July 1982 ) . Despite the requirement that patients demonstrate mastery of educational objectives for each module , postintervention assessment 11–14 mo after instruction showed only rare differences between experimental and control patients in diabetes knowledge . However , statistically significant group differences in self-care skills and compliance behaviors were relatively more numerous . Experimental group patients experienced significantly greater reductions in fasting blood glucose ( −27.5 mg/dl versus −2.8 mg/dl , P < 0.05 ) and glycosylated hemoglobin ( −0.43 % versus + 0.35 % , P < 0.05 ) as compared with control subjects . Patient education also had similar effects on body weight , blood pressure , and serum creatinine . Continued follow-up is planned for DIABEDS patients to determine the longevity of effects and subsequent impact on emergency room visits and hospitalization In this study we assessed the short- and long-term effects of 4-weeks of exercise training ( MI ) soon after myocardial infa rct ion in patients on beta-blocker treatment . Thirty-seven male patients < or = 65 years of age were included in the study , 19 of them r and omized to exercise training ( ET ) and 18 to a control group ( Ctr ) .  Cumulated work ( CW ) , calculated in kiloJoules ( kJ ) , was recorded before immediately after the intervention period and again six months after the MI . In the short term the mean ( SD ) CW increased by 22 % ( from 65(20 ) to 79(25 ) kJ ) in the ET group , compared with no change in the Ctr patients ( 65(24 ) vs 65(21 ) kJ ) ( p = 0.009 ) . At late follow-up CW was 14 % above baseline in the ET patients ( 65(20 ) vs 74(20 ) kJ ) p = 0.036 , compared with only 6 % in the 15 Ctr patients who were still available for follow-up ( 68(24 ) vs 72(29 ) kJ ) , but without a significant between-group difference . In post-MI patients on beta-blocker treatment , and with a high baseline exercise capacity , physical training improved exercise capacity in the short term , but there was no significant between-group difference at long-term follow-up We examine whether one-to-one lifestyle counseling for non-insulin-treated diabetic out patients by a Certified Expert Nurse ( CEN ) can improve patients ' health outcomes . Participants were r and omly assigned to a 1-year lifestyle intervention ( n=67 ) or to a usual care group ( n=67 ) . Main outcome measures were changes from baseline in : HbA(1C ) and score of health related quality of life scales ( SF-36 and Problem Areas in Diabetes Scale ) . Cognitive/behavioral modification for 1 year and satisfaction in CEN counseling was also measured by self-produced items . We found no significant differences in HbA(1C ) , BMI , blood pressure , serum lipids , or health related quality of life over 1 year between the two groups . Patients in the intervention group , however , showed modest but more favorable modification of cognition ( p=0.004 ) and behavior ( p<0.001 ) than subjects in usual care group . The low attrition rate ( 9 % ) , more frequent hospital visit ( 12+/-2 times versus 11+/-3 times ; p=0.03 ) and high degree of satisfaction ( 95 % ) in the intervention group indicate feasibility of the monthly CEN counseling in the outpatient setting s of Japanese hospitals . Future research should confirm the long-term effectiveness of the CEN counseling on clinical outcomes and the cost effectiveness of a possibly time-consuming intervention Abstract The purpose of the trial was to analyze whether supervised physical training could reduce death and nonfatal reinfa rct ion in a nonselected series of postinfa rct patients . All patients born in 1913 and later , who were hospitalized for a myocardial infa rct ion during 1968–1970 in Goteborg Sweden , were r and omized to a training group ( 158 patients ) and a control group ( 157 patients ) . Other treatment was exactly the same and st and ardized for the two groups . Twenty-seven percent were excluded from training . Training started 3 months after the infa rct and was scheduled for three times a week . The training group had higher physical working capacity after 1 yr than the control group . Blood pressure was lower , but there was no differences in blood lipids . During 4 yr of follow-up , 28 patients died in the training group and 35 in the control group . The numbers of nonfatal reinfa rcts were 25 and 28 , respectively . Within the training group patients adhering to the program had lower mortality than those who did not , but the former also had lower initially predicted risk of dying . A special analysis of patients who attended the training program in comparison to matched controls also showed a lower mortality . No differences in mortality between the training group and the control group were statistically significant , however OBJECTIVE To determine the effect of a bicultural community health worker ( CHW ) on completion of diabetes education in an inner-city Hispanic patient population and to evaluate the impact of completion of the education program on patient knowledge , self-care behaviors , and glycemic control . RESEARCH DESIGN AND METHODS Patients were r and omized into CHW intervention and non-CHW intervention groups . All patients received individualized , comprehensive diabetes education from a certified diabetes nurse educator after baseline demographic information , diabetes knowledge , diabetes self-care practice s , and glycohemoglobin levels were assessed . Rates of education program completion were determined . Diabetes knowledge , self-care practice s , and glycohemoglobin levels were reassessed at program completion and at a later postprogram follow-up medical appointment and compared to baseline . Logistic regression analysis and the Mantel-Haenszel χ2 statistic were used to determine the effect of the CHW assignment on program completion . Analyses of covariance were performed with end-of-treatment behavior scores , knowledge scores , and glycohemoglobin levels as outcome variables , controlling for baseline values and testing for the effect of CHW assignment . RESULTS Of 64 patients enrolled in the study , 40 ( 63 % ) completed and 24 ( 37 % ) dropped out before completing the diabetes education program . Of the patients having CHW intervention , 80 % completed the education program , compared with 47 % of patients without CHW intervention ( P = 0.01 ) . “ Dropouts ” were younger ( age 47.5 ± 12.5 years [ mean ± SD ] ) compared with patients who completed the program ( 55.9 ± 9.9 years ) ( P = 0.004 ) . Dropout status showed no significant relationship to educational level achieved or literacy level . For the program “ completers , ” knowledge levels and selected self-care practice s significantly improved , and glycohemoglobin levels improved from a baseline level of 11.7 % to 9.9 % at program completion ( P = 0.004 ) and 9.5 % at the postprogram follow-up ( P < 0.001 ) . The effect of the CHW assignment on program completion , controlling for financial status and language spoken , was extremely robust ( P = 0.007 ) . The effect of the CHW on knowledge , self-care behavior , or glycohemoglobin outcome variables was not statistically significant . CONCLUSIONS These findings suggest that intervention with a bicultural CHW improved rates of completion of a diabetes education program in an inner-city Hispanic patient population irrespective of literacy or educational levels attained . Our data further suggests that completion of individualized diabetes educational strategies leads to improved patient knowledge , self-care behaviors , and glycemic control OBJECTIVES To evaluate the efficacy of a structured behaviour therapy programme on smoking cessation in diabetic patients . DESIGN Prospect i ve , r and omized , controlled intervention study . SETTING University out-patient diabetes clinic . SUBJECTS A total of 794 consecutive insulin-treated smoking diabetic patients were invited to participate in a smoking cessation programme . Eighty-nine patients agreed to participate and were r and omized in two groups . INTERVENTIONS Forty-four patients were r and omized to a structured extensive behaviour therapy anti-smoking intervention and 45 patients to a  control group that received a single unstructured anti-smoking advice session given by a physician . MAIN OUTCOME MEASURES After 6 months , nine patients were confirmed not to be smoking ( i.e. urine cotinine concentration below 20 ng ml-1 , 2 [ 5 % ] in the behaviour therapy intervention group and 7 [ 16 % ] in the control group . CONCLUSIONS In diabetic patients an extensive behaviour therapy intervention for smoking cessation is no more successful than an unstructured physician 's advice A nurse rehabilitator , supplementing routine physician/nursing coronary care unit ( CCU ) care , was found to be effective in increasing the return to work rate ( p < .05 ) and decreasing smoking ( p < .05 ) in a r and omized trial of 102 patients with acute myocardial infa rct ion ( MI ) . These outcomes were thought to be due to the nurse rehabilitator 's efforts in increasing patient knowledge of heart disease ( p < .01 ) and individual counseling Purpose The purpose of this comparative effectiveness study is to compare diabetes self-management support ( DSMS ) approaches and determine who can be most effective in helping patients maintain/improve clinical  outcomes  ,  self-care behaviors , distress , and satisfaction following  diabetes self-management education ( DSME )  delivered in primary care . Methods After receiving DSME , 141 participants were r and omized to receive DSMS delivered by a trained supporter :  educator , peer , practice staff , or usual education during a 6-month follow-up period . DSMS groups were compared to determine which supporter helped participants to maintain/improve A1C , blood pressure , lipids , weight , self-care , and distress . DSMS satisfaction was also examined . Results There was a significant improvement in A1C , empowerment , aspects of self-care , and distress following DSME at 6 weeks . Those in the educator DSMS group best sustained improved A1C while those in the other DSMS groups maintained glycemic improvements but began to show trends toward worsening . No significant differences or clear trends were seen in other clinical , behavioral , or psychosocial outcomes . The Program Reinforcement Impacts Self-Management ( PRISM ) study demonstrates that following DSME , participants maintained improved glycemia , lipid , weight , and self-care behaviors and reductions in distress throughout the delivery of DSMS interventions regardless of DSMS supporter . All of the participants reported satisfaction with DSMS . Conclusions These findings reaffirm the critical role of educators but suggest that others may serve as DSMS supporters . Results suggest that DSME delivered in primary care is effective and multiple DSMS agents are reasonable . As patient-centered self-management approaches are being explored in primary care , delivery of DSME and DSMS becomes paramount BACKGROUND Although maintaining nearly normal glycemia delays onset and slows progression of diabetes complications , many patients with diabetes and their physicians struggle to achieve glycemic targets . The best methods to support patients as they follow diabetes prescriptions and recommendations are unclear . METHODS To test the efficacy of a behavioral diabetes intervention in improving glycemia in long- duration , poorly controlled diabetes , we r and omized 222 adults with diabetes ( 49 % type 1 ) ( mean [ SD ] age , 53 [ 12 ] years ; mean [ SD ] disease duration 18 [ 12 ] years ; mean [ SD ] hemoglobin A(1c ) [ HbA(1c ) ] concentration , 9.0 % [ 1.1 % ] ) to attend ( 1 ) a 5-session manual-based , educator-led structured group intervention with cognitive behavioral strategies ( structured behavioral arm ) ; ( 2 ) an educator-led attention control group education program ( group attention control ) ; or ( 3 ) unlimited individual nurse and dietitian education sessions for 6 months ( individual control ) . Outcomes were baseline and 3- , 6- , and 12-month postintervention HbA(1c ) levels ( primary ) and frequency of diabetes self-care , 3-day pedometer readings , 24-hour diet recalls , average number of glucose checks , physical fitness , depression , coping style , self-efficacy , and quality of life ( secondary ) . RESULTS Linear mixed modeling found that all groups showed improved HbA(1c ) levels ( P < .001 ) . However , the structured behavioral arm showed greater improvements than the group and individual control arms ( 3-month HbA(1c ) concentration changes : -0.8 % vs -0.4 % and -0.4 % , respectively ( P = .04 for group × time interaction ) . Furthermore , participants with type 2 disease showed greater improvement than those with type 1 ( P = .04 for type of diabetes × time interaction ) . Quality of life , glucose monitoring , and frequency of diabetes self-care did not differ by intervention over time . CONCLUSIONS A structured , cognitive behavioral program is more effective than 2 control interventions in improving glycemia in adults with long- duration diabetes . Educators can successfully use modified psychological and behavioral strategies . TRIAL REGISTRATION clinical trials.gov Identifier : NCT000142922
target: Nurses only and multidisciplinary teams were the most frequent professionals to provide education , and most educational interventions were delivered postdischarge .
  Psychoeducational interventions were generally effective at reducing smoking and admissions for patients with ACS .
  Culturally appropriate health education , self-management educational interventions , group medical visits and psychoeducational interventions were generally effective for patients with T2DM .
  Results indicate that there is a body of current evidence about the efficacy of health education , its content and delivery methods for patients with ACS or T2DM .
background: OBJECTIVES This umbrella review aim ed to identify the current evidence on health education-related interventions for patients with acute coronary syndrome ( ACS ) or type two diabetes mellitus ( T2DM ) ; identify the educational content , delivery methods , intensity , duration and setting required .
  The purpose was to provide recommendations for educational interventions for high-risk patients with both ACS and T2DM .