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date: 29 November 2022

• Wendy AuslanderWendy AuslanderBarbara A. Baily Professor of Social Work, George Warren Brown School of Social Work, Washington University in St. Louis
•  and Elizabeth BuddElizabeth BuddElizabeth Budd, MPH, is a doctoral student at the George Warren Brown School at Washington University in St. Louis studying physical activity and chronic disease prevention. She received her Bachelor’s degree in Sociology and Spanish Studies from Santa Clara University, and her Master’s of Public Health from St. Louis University.

### Summary

The purpose of this article is to provide an overview of: diabetes and its significance, the differences in types of diabetes, and landmark clinical trials that have resulted in changes in philosophy and treatment of diabetes. Second, a review of the various types of evidence-based and promising behavioral interventions in the literature that have targeted children and adults are presented. Social workers and other helping professionals are uniquely positioned to work collaboratively to improve psychosocial functioning, disease management, and prevent or delay complications through behavioral interventions for children and adults with diabetes.

### Subjects

• Health Care and Illness

### Overview of Diabetes Mellitus

Diabetes mellitus is a disease that is characterized by high levels of blood glucose resulting from problems with the production of insulin from the pancreas or failure to use the insulin properly (Centers for Disease Control and Prevention [CDC], 2011). Insulin moves glucose (dietary sugar) from the bloodstream into cells for energy or storage. Without insulin, glucose remains in the blood, causing high blood sugar. Persistent high blood sugar levels can ultimately lead to complications and conditions (see Table 1) including damage to the kidneys, nerves, eyes, feet, and heart (CDC, 2011). According to the CDC, diabetes is the seventh leading cause of death in the United States (CDC, 2011). The World Health Organization (WHO, 2013) states diabetes is predicted to become the seventh leading cause of death in the world by the year 2030. Furthermore, approximately 347 million people worldwide suffer from diabetes. It is believed that an emerging global epidemic of diabetes can be traced back to rapid increases in physical inactivity, consumption of refined sugars, and obesity.

Physicians test for diabetes by measuring blood glucose. An average fasting glucose ranges from 70 to 130 milligrams/deciliter (American Diabetes Association, 2013a). Blood glucose rises after eating but should remain less than 180 milligrams/deciliter (American Diabetes Association, 2013a). In healthy individuals blood sugar returns to normal limits within two hours of eating.

#### The Finnish Diabetes Prevention Study

The Finnish Diabetes Prevention Study compared the impact of a lifestyle intervention with usual care on preventing type 2 diabetes among 522 Finnish adults with pre-diabetes (Lindstrom et al., 2003). The Diabetes Prevention Study lifestyle intervention was similar to the intervention in the Diabetes Prevention Program, although contact with a nutritionist was less frequent. Intervention participants met individually with a nutritionist seven times in the first year and once every three months for the remaining two years of the study. Participants voluntarily attended group support meetings and various educational demonstrations throughout the study as well. Goals of the lifestyle intervention included: a weight loss of 5% of one’s baseline body weight, a decrease in overall dietary fat intake (that is, to less than 30% of total energy intake), a decrease in saturated fat intake (that is, to less than 10% of total energy), an increase in fiber intake, and at least 30 min of physical activity a day (Lindstrom et al.). The researchers found the lifestyle intervention was significantly more effective at preventing type 2 diabetes, lowering blood glucose levels, improving dietary intake, and increasing physical activity compared to the usual care delivered to the control group. Nine percent of the participants in the intervention group progressed to type 2 diabetes by year three of the study compared with 20% of participants in the control group. Comparable to Diabetes Prevention Program findings, 46% of intervention participants in the Diabetes Prevention Study met or exceeded the goal of 5% weight loss in the first year compared to only 14% of their control group counterparts.

#### Treatment Options for Type 2 Diabetes in Adolescents and Youth

In response to the increasing incidence of type 2 diabetes in American youth due to the increase of obesity, the National Institutes of Health conducted the Treatment Options for Type 2 Diabetes in Adolescents and Youth (TODAY) study. The purpose of the study was to determine the most effective treatment for type 2 diabetes among adolescents, since it is not known whether the clinical course of diabetes would be the same for children as it is for adults. For the Treatment Options for Type 2 Diabetes Study, the efficacy of three treatment interventions specifically for adolescents were evaluated through a randomized clinical trial comparing three arms: metformin-only treatment, metformin combined with rosiglitazone treatment, and metformin combined with an intensive lifestyle program (TODAY Study Group, 2007). Similar to the Diabetes Prevention Program and the Diabetes Prevention Study, the lifestyle program focused on individualized diet and physical activity counseling and a goal weight loss of 7 to 10% of one’s baseline body weight. Contact with a personal health coach included weekly in-person meetings for the first six months, biweekly in-person or telephone meetings for the second six months, and monthly in-person and telephone meetings for the rest of the participant’s time in the study (TODAY Study Group). A portion of the meetings also involved the participant’s parent or caregiver. The results of the study indicated that of the 699 participants, rates of failure to reach the desired outcome of glycated hemoglobin of less than 8% at follow-up were 51.7% for metformin alone, 38.6% for metformin plus rosiglitazone, and 46.6% for metformin plus lifestyle intervention. Thus, the addition of rosiglitazone (not a lifestyle intervention) was superior to metformin alone (TODAY Study Group, 2012). The findings indicate that type 2 diabetes may be more aggressive in adolescents than adults because only approximately half of the participants were able to maintain good metabolic control despite adhering to the medication regimen. Because type 2 diabetes in youths disproportionately affects minority groups such as African Americans, Hispanics, and American Indians, economic and other psychosocial stressors may also pose barriers to diabetes management in this population (Linder, Fradkin, & Rodgers, 2013).

### Behavioral Interventions for Children and Adolescents

For over three decades, there has been a growing literature on factors that are associated with good adherence and metabolic control among children and adolescents with type 1 diabetes. These include family factors (Anderson & Auslander, 1980; Anderson, Auslander, Jung, Miller, & Santiago, 1990; Auslander, Bubb, Rogge, & Santiago, 1993), psychological factors (Johnson, 1980; Gonder-Frederick, Cox, & Ritterband, 2002), and demographic factors such as socioeconomic status, single-parenthood, and ethnicity (Auslander, Anderson, Bubb, Jung, & Santiago, 1990; Auslander, Thompson, Dreitzer, White, & Santiago, 1997; Thompson, Auslander, & White, 2001). Some of these factors represent modifiable risk and protective factors and have been the targets of intervention research in the last 20 years. Although most of these intervention studies were aimed at improving behavioral and psychosocial outcomes, almost all of them included hemoglobin A1c, which is the gold standard for measuring the child’s level of metabolic control or control of their blood glucose levels over a two month period.

Successful management of diabetes is due in part to the patient’s ability to adhere to a complex treatment regimen. The majority of children and adolescents who are diagnosed with diabetes have type 1 diabetes and the treatment regimen is complex. The regimen involves daily injections of insulin or use of an insulin pump, frequent blood glucose monitoring, regular meals, dietary restrictions, and physical activity. This poses demands and stress on parents and even siblings for supervising and/or sharing the responsibilities for carrying out the treatment regimen, depending on the age of the child. Thus, many of the behavioral interventions for children and adolescents with diabetes have included parents, other family members, and family-related outcomes.

#### Family-Based Interventions

Knowledge gained from cross-sectional studies has identified several dimensions of family life that are associated with successful management of type 1 diabetes in children and adolescents, such as family support, family communication patterns, and family responsibility sharing and monitoring of the disease. The family-based interventions in this group were delivered in the home, the clinic, or other facility, but all focus on changing family (parent, child, sibling) knowledge, behaviors, and cognitions related to diabetes management. The assumption behind these interventions is that the family has a strong influence on the child’s self-management behaviors, even among adolescents, and that changing the family context and patterns that overlap with diabetes-related behaviors are necessary for improvements in disease management.

##### Family Teamwork.

A clinic-based intervention named Encouraging Parent–Child Teamwork was based on meetings with family members to discuss sharing of diabetes-related responsibilities and emotional support for the adolescent during the child’s routine ambulatory office visits (Anderson, Ho, Brackett, & Laffel, 1999). The intervention was designed to be brief, family focused, and low cost using written materials and four sessions focusing on (1) the need for parental involvement and support during adolescence, (2) coping with conflicts about blood glucose monitoring, (3) preventing conflicts around food, and (4) parental support for exercise. Using a randomized control group design, the parent–child teamwork condition was compared with an attention control group and a standard care group and followed for 2 years. Findings indicated that the teamwork families reported significantly less diabetes-related family conflict and a trend for more adolescents to improve their glycemic control than the control and standard care groups (Anderson et al., 1999). A second evaluation study of the Teamwork intervention showed that the teamwork condition maintained or increased family involvement and demonstrated a significant improvement in glycemic control when compared with the adolescents in the standard care condition. However, in this trial no significant differences between groups were found in diabetes-related family conflict (Laffel et al., 2003). One of the major benefits of this intervention is that it is delivered during the child’s routine medical visits, and that social workers on the treatment team can easily be trained to conduct the sessions. This is more cost-effective than a home-based intervention and is a good alternative to families that are not interested or do not have the time for group or individual sessions. This may not be a feasible strategy for families that routinely miss their appointments, and it is often these families who are most in need of psychosocial and family services.

A second family-based, clinic-integrated behavioral intervention for adolescents with type 1 diabetes was conducted in four large pediatric endocrine clinics in Boston, Chicago, Jacksonville, and Houston. The WE-CAN Manage Diabetes Intervention was developed to improve diabetes management by increasing family communication skills, problem-solving skills, and responsibility sharing through telephone and one-on-one contacts during clinic visits with health advisors (Nansel, Iannotti, & Liu, 2012). Results of the randomized clinical trial indicated a differential effect of the intervention by age in the experimental group; adolescents ages 12 to 14 significantly improved glycemic control compared with their counterparts ages 9 to 11. Findings of this study suggest that the WE-CAN approach may be a promising intervention for adolescents as they assume greater responsibility for diabetes-related problem solving and independence from their parents. It was unclear what the pathways or mechanisms were that led to the improvements in glycemic control, since the intervention did not influence adherence as it was measured in the study.

##### Diabetes Behavioral Family Systems Therapy.

Behavioral Family Systems Therapy (BFST) is defined as a flexible, multi-component intervention that focuses on improving family communication and problem-solving (Robin & Foster, 1989). The focus of this therapy is to reduce parent–child conflict during adolescence when children strive for autonomy and parents desire stability and the status quo. The underlying assumption of BFST is that parent-adolescent conflict can be reduced by four intervention components: problem-solving training, communication training, cognitive restructuring, and functional–structural family therapy. The first evaluation of this intervention was a randomized control trial that compared BFST with education and support and current therapy and included ten sessions over a 3 month period (Wysocki et al., 2000). Results indicated a delayed improvement in treatment adherence in the BFST group but no significant differences between groups for metabolic control (Wysocki et al., 2000; 2001)

A second test of BFST (Wysocki et al., 2007) was conducted using a modified version of the intervention for diabetes-specific management-related problems and communication called BFST for Diabetes (BFST-D). The modified BFST-D intervention added the following components: a focus on diabetes-specific behavioral problems, training in behavioral contracting, a one week simulation of living with diabetes for the parents, and extending the treatment from three to six months. Results indicated that a significantly higher percentage of EFST-D adolescents improved their adherence to treatment compared with the standard care group at each follow-up (6, 12, 18 months), and the education and support group at 6 and 18 months. Although adolescents in all three groups showed improvements in metabolic control at the posttest, levels of metabolic control for the BFST-D group were significantly lower than the other two groups at follow-up. The authors suggest that the initial improvement in the comparison groups were due to a nonspecific effect of participating in the study (for example, time and attention), and that these improvements did not last after the intervention ended. These sustained improvements in the BFST-D group also suggest that a diabetes-specific, modified family intervention shows more promise than a general family systems approach for improving diabetes adherence and diabetes control in adolescents who have less than optimal control. Moreover, because there were no significant group-by-time interaction effects in family conflict, the role of family conflict in improving metabolic control is unclear.

##### Multisystemic Therapy.

Multisystemic therapy (MST) was developed as an intensive family-centered, community-based treatment for adolescents who have serious antisocial behaviors (Henggeler, 1999; Henggeler, Pickrel, & Brondino, 1999; Henggeler, Schoenwalk, Borduin, Rowland, & Cunningham, 1998). It has been considered a good approach for treating youths with poorly controlled type 1 diabetes because MST targets the adolescent within the broader context of the family system, the school, and the community, such as the health care system (Ellis et al., 2007). The treatment does not consist of specific sessions but instead blends cognitive behavioral therapy, behavior management training, family therapies, and community psychology to change behaviors.

#### Information and Communication Technology Interventions

Information and Communication Technology (ICT) interventions are those that use technology-based environments to enhance knowledge and support for diabetes management (Cooper, Cooper, & Milton, 2009), which include mobile telephones and text messaging, telephone support, video and tele-conferencing, electronic communication devices for transferring clinical information, web-based discussion boards, and skill building. The common themes across ICT interventions are to allow remote access to services and to promote communication, education, and support for diabetes self-management (Sutcliffe et al., 2011).

One knowledge and skill-building pilot study reported the feasibility of an internet program to improve self-management problem-solving skills (Mulvaney et al., 2011). The YourWay Internet intervention consisted of multimedia problem-based stories of psychosocial barriers to self-management that adolescents might experience such as time pressure and embarrassment. Adolescents were prompted to relate their own experiences to those in the story and to use problem-solving techniques to solve the problems. Accompanying the problem vignettes were multimedia presentations on the steps of problem solving, social networking with peer forums, and comparisons of responses with other adolescents. Although the sample size was small (N = 41), the results were promising; there were improvements in self-management problem-solving skills indicating that an internet-based interactive program may be a feasible approach for adolescents to reduce barriers to diabetes care (Mulvaney et al., 2011). In a second study (N = 72) that tested the intervention in comparison with a usual care group, after 12 weeks adolescents in the YourWay Internet group showed significant improvements in self-management and problem solving (Mulvaney, Rothman, Wallston, Lybarger, & Dietrich, 2010). This intervention is promising and warrants further testing with a larger sample size to test the maintenance of improvements and further development on how parents and clinicians could be integrated into the intervention.

A study that used videophone (for example, Skype) or telephone therapy to increase family access to a psychologist was conducted with 27 youths to improve adherence behaviors and diabetes-specific family processes (telehealth; Heidgerken et al., 2006). Sessions lasted approximately 15 to 20 minutes, with 3 to 4 sessions per week over six months. For young children and children who were not receptive to participating, more time was spent with the parent. Findings from the one group, pre-post evaluation showed significant improvements in metabolic control, yet the study was limited by the absence of follow-up assessments to determine if the improvements maintained. Moreover, there were no measures of intermediate outcomes such as adherence and family functioning. The advantages to videophone and telephone therapy are the reduction in cost and time and the increase in flexibility and access to treatment. Telemedicine (internet therapy, Theraskype) is a growing phenomenon and currently whether or not the therapy is reimbursable by insurance depends on the state, type of insurance, type of session, and location of the therapist.

Other studies have evaluated the use of telephone calls to provide support for young people who have type 1diabetes, but results have been inconsistent. One such study involved having a diabetes specialist deliver negotiated telephone calls (at mutually agreed upon times and frequency) that used problem-solving and counseling techniques with the adolescent (Howells et al., 2002). A randomized clinical trial tested the impact of this intervention called Negotiated Telephone Support (NTS) that compared three groups: NTS plus routine care (clinic visits every three months), NTS plus an annual clinic visit, and a control group of routine care only. The youths received an average of 16 telephone calls per year. A one year follow-up evaluation indicated that both NTS groups showed significant improvements in self-efficacy compared with the control group, but no improvements were found in metabolic control. Another randomized controlled trial tested the effects of bi-monthly supportive telephone discussions from a diabetes educator (Nunn, King, Smart, & Anderson, 2006). Results were not favorable; there were no differences between the youths who received the telephone calls and those in the control group in metabolic control, hospital admissions, diabetes knowledge, adherence, or psychological functioning.

Mobile phones are increasingly being used as a cost-effective approach to provide support, motivation, and feedback through text messaging for people with diabetes. Sweet Talk is a text-message motivational support network that was developed to increase self-efficacy related to intensive insulin therapy for young people with type 1 diabetes (Franklin, Waller, Pagliari, & Greene, 2006). The study used tailored text messages (feedback, information, and reminders) to reinforce personal self-management goals delivered from the Sweet Talk software. A randomized controlled trial showed that youths in the Sweet Talk plus conventional therapy group showed significant improvements in diabetes self-efficacy and self-reported adherence compared with conventional therapy alone, but no corresponding improvements in metabolic control.

One promising aspect of ICT interventions is the potential of social networking to provide peer social and psychological support. Diabetes can be an isolating disease for adolescents, particularly those who have little or no contact with others who have the disease. Facebook has become an important online social networking site and used by people with diabetes for information sharing about diabetes management, particularly about sensitive issues, interpersonal support, and identification of resources (Greene, Choudhry, Kilabuk, & Shrank, 2011). In one of a few studies to examine online messages among adolescents with type 1 diabetes, half of the requests were social support-related messages (Ravert, Hancock, & Ingersoll, 2003).

In summary, there are several promising ICT interventions that promote access, communication, and engagement of adolescents with service providers and peers, and web-based, internet education and social support for adolescents with type 1 diabetes. It remains to be seen whether ICT interventions will have an impact on metabolic control and self-management behaviors because there are few larger scale, rigorous effectiveness studies and cost-effectiveness analyses with this population (Cooper et al., 2009).

### Behavioral Interventions for Adults with Diabetes

Among adults with diabetes, effective management of diabetes involves many life-long behavior changes in several areas such as diet, physical activity, blood glucose monitoring, medication, and sometimes insulin injections. After initiating new behaviors, maintaining these behaviors is challenging even among conscientious and motivated individuals (Barlow, Wright, Sheasby, Turner, & Hainsworth, 2002; Norris, Engelgau, & Narayan, 2001). As with children and adolescents, psychosocial factors play an important role in managing the disease and preventing and delaying the onset of complications.

Most of the behavioral interventions that have been delivered and evaluated among adults contain some components of what is termed self-management education, which includes information, education, cognitive behavioral skills, and support for improving adherence and metabolic control as the desired medical outcomes, in addition to psychosocial outcomes. Self-management requires the active and central role of the person with the disease in his/her management of the disease (Creer et al., 1988). In 2003, Lorig and Holman defined self-management education as the teaching and practice of a set of three tasks and six skills. The tasks are included in self-management education with a person’s psychological health in mind, in addition to physical health. The tasks include: medical or behavioral management, role management, and emotional management. The skills include problem solving, decision making, resource utilization, creating a patient–provider partnership, action planning, and self-tailoring (Lorig & Holman, 2003). Table 3 provides descriptions of the self-management education tasks and skills as well as examples of how they could be applied to an adult with diabetes.

In addition to tasks and skills, Lorig and Holman (2003) and others (National Institute for Clinical Excellence, 2003; Wangberg, 2008) have identified high self-efficacy to be an important mechanism through which self-management education interventions are most effective at behavior change for people living with a chronic disease. Self-efficacy is the belief in one’s capabilities to organize and execute the courses of actions required to produce a given attainment (Bandura, 1997). It is also often referred to as one’s confidence to perform a behavior (Lorig & Holman, 2003). Researchers agree that self-efficacy is important, but there are inconsistencies in the literature as to whether self-efficacy acts as a moderator, mediator, or both in influencing the effectiveness of self-management education interventions.

#### Table 3 Self-Management Education Tasks and Skills (Lorig & Holman, 2003)

Self-Management Education Component

Description

Examples for an Adult with Diabetes

Medical/behavioral management

Taking care of one’s physical health with medication and healthy behaviors

• Monitor blood glucose levels

• Take the proper dosage of insulin

• Eat a healthy, balanced diet

• Be physically active at least 30 minutes each day

Role management

Finding and/or modifying behaviors that are meaningful

• A mother, who is known for baking cookies and sharing them with her family, learns how to bake healthier foods to share instead

• A person, who unwinds from work by watching TV, begins to go for a walk around the neighborhood instead

Emotional management

Coping with stress, anger, depression, and other difficult emotions in healthy ways

• Talk with a therapist or spiritual advisor about one’s thoughts and feelings

• Keep a journal of one’s thoughts and feelings

• Meditate

• Talk with family and friends about one’s thoughts and feelings

Skill

Problem solving

Defining problems, exploring solutions, taking action, and evaluating the results (D’Zurilla, 1986)

• Brainstorm by writing down all possible solutions to a problem

• Consult family, friends, and one’s physician on possible solutions

• Make a plan for enacting the solution

• Reflect on the effectiveness of the solution on alleviating the problem

Decision making

Gathering the proper information to respond in an informed manner as changes or problems occur (D’Zurilla, 1986)

• Learn how to identify symptoms of low blood sugar

• Learn which foods are best for glucose control

• Learn what sensations are normal and abnormal when getting back into an exercise routine

Resource utilization

Knowing how and where to find information or access services

• Learn where to look on the internet to find credible information on diabetes self-management

• Learn what services are covered by your health insurance by calling a service representative

Creating a patient–provider partnership

Including one’s doctor in the decisions, barriers, and successes related to one’s disease management

• Schedule regular check-ups with one’s physician

• Bring a list of questions and concerns to the check-up relating to one’s diabetes management

• The physician listens to the patient and helps to problem-solve

Action planning

Mapping out specific, accomplishable steps that are a part of a solution to a problem or progress toward a long-term goal, then implementing them

• Make a plan to bring athletic shoes to work and take a 30 minute walk immediately before lunch on Monday, Wednesday, and Friday this week

• Place healthy snacks in one’s car or purse for easy access throughout the day

Self-tailoring

Modifying recommendations, tasks, and skills to fit one’s personal situation or respond to problems that arise

• A person who finds exercise boring could look for a new physical activity that sounds fun (for example, dance class, water aerobics) and invite a friend

• A person who drinks soda on a daily basis could begin cutting down on soda consumption by replacing soda with water three days a week; then revise goals after they are accomplished

#### Diabetes Self-Management Education Interventions

Specific to adults with diabetes, there is abundant evidence to support the efficacy of self-management education. Norris, Engelgau, and Narayan’s (2001) systematic review of diabetes self-management education interventions found them to be effective in increasing knowledge and improving blood glucose monitoring, blood glucose control, and dietary behaviors within six months after the conclusion of the intervention. However, the impact of diabetes self-management education interventions on other behavioral and medical outcomes (for example, physical activity, blood pressure) and quality of life was variable (Norris et al.). Norris and colleagues (2002) confirmed that participants in diabetes self-management education interventions had lower blood-glucose levels than control participants up to at least four months following the conclusion of the intervention. Ellis et al. (2004) conducted a study to test which intervention components of self-management education contributed most to the effects on improving glycemic control. They found three components accountable for most of the intervention effect: face-to-face or in-person delivery, physical activity, and cognitive reframing (that is, a behavioral skill of changing one’s perception from negative or less advantageous to positive or more advantageous) (Ellis et al.; Miller & Rollnick, 2002).

Group delivered diabetes self-management education sessions are more cost-effective than individually based interventions, and they have the additional benefit of providing peer support to participants. Deakin, McShane, Cade, and Williams (2005) conducted a meta-analysis of 11 randomized, controlled, group-based, self-management education clinical trials of adults with diabetes. The interventions took place in primary care or hospital diabetes centers in the United States and developed European countries and included a minimum of one, one-hour session. The results showed strong support for the effectiveness of group-based diabetes education including improved glycemic control and diabetes knowledge up to 14 months after the conclusion of the intervention compared with the usual care control group. Further, the study found that participants in group-based interventions had lower blood glucose levels, body weight, and systolic blood pressure; needed less medication; had a higher quality of life (for example, enjoyment of food, freedom to eat), self-management skills (for example, dietary and physical activity behaviors), and self-empowerment/self-efficacy compared with control group participants (Deakin et al.). There were no significant differences in the study results based on length of the intervention (3 to 52 h in the first year) or size of the group (6 to 18 members). Participants in the included studies were primarily white; however, also included in the studies were participants of primarily Mexican American and South Asian descent.

#### Diabetes Self-Management Education in Diverse Populations

Diabetes self-management education interventions have been modified in several ways to better serve diverse populations. As previously mentioned, adults in the United States of a minority race/ethnicity or low socioeconomic status have an increased risk for diabetes as well as more barriers to successful disease management compared to white adults and those of higher socioeconomic status (Hill-Briggs et al., 2011; Melkus et al., 2010). The three following studies found positive effects of varying degrees from culturally tailored self-management education interventions among three populations at high risk for poorly managed diabetes.

In 2011, Hill-Briggs et al. conducted a self-management education intervention study among low income, African Americans with diabetes (N = 56). The study intervention was based on a systematic review that found consistent positive associations among glycemic control, healthy dietary behaviors, and interventions that teach problem-solving skills (Hill-Briggs & Gemmell, 2007). The study intervention focused on problem-solving skills and was designed for low literacy. Participants were randomized to either the intensive (one diabetes and cardio vascular disease self-management education session and eight problem-solving sessions) or condensed intervention (one diabetes and cardio vascular disease self-management education session and one problem-solving session). At three months post-intervention, participants of the intensive intervention showed significantly more improved glycemic control, knowledge, problem-solving skills, and self-management behaviors compared with participants in the condensed intervention (Hill-Briggs et al., 2011). Likewise, there were clinically significant improvements in systolic and diastolic blood pressure and low-density lipoprotein cholesterol among a subset of intensive intervention participants with high blood pressure and/or high lipid levels at the beginning of the study (Hill-Briggs et al.).

Brown, Garcia, Kouzekanani, and Hanis (2002) tested a culturally specific self-management education intervention for Mexican Americans with diabetes (N = 256). The intervention consisted of three months of weekly sessions and six months of biweekly support group sessions led by bilingual Mexican American dieticians, nurses, and trained community lay workers, while the waitlisted control group received usual care. The intervention was tailored to the language and diet of the local Mexican American culture and particular attention was paid to cultural health beliefs and family participation (Brown et al.). Among the intervention group, diabetes-related knowledge and health beliefs and glycemic control were significantly improved compared with the control group.

In 2002, Gilliland, Azen, Perez, and Carter conducted a nonrandomized diabetes self-management education intervention in three Native American communities in New Mexico. Participants (N = 104) were assigned to an intervention group that attended sessions with family and friends, an intervention group that attended sessions individually, or a usual care control group. The intervention was tailored to the local Native American culture including traditional Native American values, foods, videos featuring Native Americans, and storytelling as a learning method. The study did not find a statistically significant change in blood glucose levels between the group and individual intervention groups, but did find a significant increase in blood glucose levels in the usual care group (Gilliland et al., 2002).

#### Peer Support and Diabetes Self-Management Education

Multiple studies have tested the efficacy of providing peer support as an additional component to diabetes self-management education interventions. Peer supporters are typically lay people who have relevant experiential knowledge of diabetes and the population of interest (Dennis, 2003). A peer supporter may provide emotional support, appraisal (that is, encouragement), and/or informational support for diabetes management (Dennis). In general, peer support has been shown to facilitate self-management tasks and skills including self-efficacy, emotional exploration, problem-solving, goal-setting, and social support (Funnell, 2010). Peer support has been delivered in a variety of ways including by telephone, internet, and e-mail, in-person, and with a group or individually (Dale, Caramlau, Sturt, Friede, & Walker, 2009).

Dale, Williams, and Bowyer (2011) conducted a systematic review of self-management education interventions with a peer support component for adults with diabetes. The study found peer support, regardless of the delivery method, is associated with significant improvements in glycemic control, body mass index, weight, cholesterol, blood pressure, physical activity, depression, perceived social support, and self-efficacy among adults with diabetes (Dale et al.). However, there are inconsistencies in the literature on the effectiveness of peer support in diabetes self-management education. For example, Smith and colleagues (2011) compared the outcomes of participants (N = 395) who received diabetes self-management education to participants who received diabetes self-management education plus nine group meetings led by peer supporters. The study found no significant differences in glycemic control, cholesterol, systolic blood pressure, or well-being among all participants. Likewise, Tang, Ayala, Cherrington, and Rana (2011) conducted a systematic review of diabetes self-management education interventions specifically with peer supporters who were volunteers, instead of paid peer supporters. The review found little support for the effects of peer support at improving diabetes-related clinical, behavioral, or psychosocial outcomes.

#### Motivational Interviewing and Diabetes Self-Management Education

Motivational interviewing has also been added to diabetes self-management education interventions. Motivational interviewing was introduced as a counseling method for facilitating behavior change in the 1980s (Miller, 1983). Since then, motivational interviewing has been an effective strategy in treating alcohol and tobacco use disorders (Lai, Cahill, Qin, & Tang, 2010; Miller) and weight loss (Wong & Cheng, 2013) among other areas (Rubak, Sandbaek, Lauritzen, & Christensen, 2005). Motivational interviewing aims to foster self-efficacy and support behavior change. This is done through collaborative, one-on-one conversations between practitioner and client about normal, mixed feelings that accompany behavior change (that is, ambivalence) (Miller & Rollnick, 2002). Motivational interviewing is based on four principles: express empathy, develop discrepancy, roll with resistance, and support self-efficacy (Miller & Rollnick). Table 4 provides descriptions and examples of these principles.

#### Table 4 Four Principles of Motivational Interviewing (Miller & Rollnick, 2002)

Studies have evaluated the effectiveness of motivational interviewing as a strategy to aid in diabetes self-management in several ways. Two studies compared the impact of a group weight control intervention versus a group weight control intervention plus individualized motivational interviewing among different populations (Smith, Heckemeyer, Kratt, & Mason, 1997; West, DiLillo, Bursac, Gore, & Greene, 2007). In the forty-two session intervention study among older (≥50 years) obese women with diabetes, Smith and colleagues (1997) found that women in both groups experienced significant weight loss, but the women in the weight control plus motivational interviewing group had significantly improved glycemic control compared to the women in the weight control only group. This study also found that the weight control plus motivational interviewing group demonstrated higher participation rates in weight control and blood glucose monitoring than the weight control only group. A larger study by West and colleagues (2007) among overweight women with diabetes (N = 217) produced consistent findings. The women in the weight control plus motivational interviewing group lost more weight and had better glycemic control at the conclusion of the intervention compared to women in the weight control only group. West et al. found that the differential weight loss among the weight control plus motivational interviewing group was mediated by better adherence to the weight control intervention. However, motivational interviewing was shown to be less effective among African American women compared to white women. African American women lost less weight on average than the white women.

In 2009, Rubak, Sandbaek, Lauritzen, Borch-Johnsen, and Christensen reported the results of a randomized controlled trial in Denmark to determine if training general practitioners (N = 65) in motivational interviewing could improve diabetes knowledge and beliefs regarding diabetes prevention and treatment, and motivation for behavior change among adults with diabetes (N = 265). Both the intervention and control groups of doctors received training in intensive treatment of adults with diabetes. The intervention doctors received training in motivational interviewing during a one and a half day course with a half day follow-up course twice during the first year. The study found that patients of the intervention doctors were significantly more autonomous and motivated in their behavior change, more aware of the importance of managing their diabetes, and more knowledgeable of the possibility of preventing complications than the patients of the control doctors (Rubak et al., 2009). Welch, Zagarins, Feinberg, and Garb (2011) conducted a randomized clinical trial to compare the relative effectiveness of diabetes self-management education, motivational interviewing, and diabetes self-management education plus motivational interviewing among people with poorly controlled diabetes (N = 234). All of the interventions included four sessions over six months and were delivered by certified diabetes educators. Consistent with the literature, all three intervention groups experienced an overall significant improvement in glycemic control. Inconsistent with the aforementioned supportive findings on motivational interviewing and diabetes self-management outcomes, this study found that diabetes self-management education alone was more effective than diabetes self-management education plus motivational interviewing in glycemic control (Welch et al.).

#### Diabetes Self-Management Education and Mental Health

People with type 1 and type 2 diabetes have an increased risk of mental health problems (for example, depression, anxiety) compared to the general population (Katon et al., 2008). Studies have shown a dangerous interaction between diabetes and mental health problems, each negatively affecting the other (Golden et al., 2008). Those with both diabetes and mental health problems tend to have poorer glycemic control and experience more negative repercussions of diabetes than people with diabetes without mental health problems (Anderson et al., 2007). Cognitive behavioral therapy interventions that focus primarily on addressing mental health problems in the context of diabetes management are discussed.

##### Cognitive Behavioral Interventions.

Cognitive behavioral therapy (CBT) is a therapeutic approach that is used to help clients become aware of the thoughts and feelings that contribute to their behaviors, evaluate those thoughts and feelings, and adjust them to support their desired behavior change (Rachman, 1997). Like motivational interviewing, cognitive behavioral therapy has been effective in treating a variety of addictions (Maude-Griffin et al., 1998) and mental health problems (Beck & Emery, 2005; Beck, Rush, Shaw, & Emery, 1987). Table 5 provides a description of cognitive behavioral therapy strategies that are commonly used.

#### Table 5 Cognitive Behavioral Therapy Strategies (Craske, 2010)

Strategies

Description

Skill and Reinforcement Based

Self-monitoring

Observing and tracking behaviors, thoughts, and emotions to increase awareness and identify patterns of maladaptive thought processes

Relaxation

Calming oneself through: meditation, progressive muscle tightening and releasing, deep breathing, or yoga

Behavioral rehearsal of social skills and assertiveness

Role playing scenarios between practitioner and client to practice communication and negotiation skills

Problem-solving training

Defining the problem, brainstorming solutions, choosing the best solution based on a cost benefit analysis of the options, taking action, and evaluating the outcome

Behavioral activation

Observing and tracking one’s mood respective to incidents when one engages in or avoids activities

Behavioral contracting

Planning for and committing to small behaviors or goals that contribute to one’s progress toward a long-term goal

Habit reversal

Becoming aware of the chain of events or emotions that lead to a behavior and interrupting the chain of events with a replacement behavior

Exposure Based

Exposure therapy

Presenting the experience that incites discomfort in a progressive systematic way

Response prevention

Presenting the experience that incites discomfort in a progressive systematic way, while also disallowing the coping response/behavior

Cognitively Based

Rational-Emotive Behavior therapy

Observing and tracking thoughts and analyzing their rational or irrational (for example, extreme thinking) nature

Cognitive therapy

Observing and tracking thoughts and treating them as hypotheses to be tested and challenged with alternative hypotheses

Self-instruction training

Talking oneself through performing a behavior including: preparing (that is, describing what is required to perform the behavior), confronting (that is, explaining the steps of performing the behavior), coping (that is, providing encouragement and assurance of one’s competence), and reinforcing (that is, providing positive feedback for accomplishing the behavior)

Lustman, Griffith, Freedland, Kissel, and Clouse (1998) conducted one of the first randomized controlled trials on CBT for depression in adults with diabetes. Participants (N = 51) received 10 weeks of diabetes education plus individual CBT or diabetes education only. A significantly greater proportion of participants in the CBT group experienced remission from depression compared to the diabetes education only group at 10 weeks and 6 months after the conclusion of the intervention (Lustman et al., 1998). Furthermore, participants in the CBT group had significantly better glycemic control compared to participants in the diabetes education only group at six month follow-up.

Years later, Harkness et al. (2010) conducted a systematic review and meta-analysis of randomized controlled trials of psychosocial interventions with objectives to improve the physical and mental health of people with diabetes. Although the inclusion criteria accepted people of all ages with type 1 and type 2 diabetes, most of the studies in the review involved adult participants with type 2 diabetes. Of the 73 included psychosocial intervention studies, 53% were lifestyle interventions (for example, diabetes education plus CBT), 29% were mental health interventions (for example, CBT, relaxation techniques, social support), and 18% included both lifestyle and mental health intervention components (Harkness et al., 2010). These psychosocial intervention groups were compared to no treatment or usual care control groups. Harkness et al. found small improvements in glycemic control and mental health (for example, depression, anxiety) among participants in the psychosocial intervention groups compared to control groups. Interventions with a lifestyle and mental health focus had significantly greater positive effects on mental health compared to interventions with only a lifestyle focus. A meta-regression found that the positive effects of psychosocial interventions on glycemic control were significantly greater among participants with poor glycemic control at the start of the study and weaker among older adults (>50 years) compared to participants who began the study with acceptable glycemic control and younger participants (Harkness et al.).

#### Empowerment Interventions

Empowerment as an approach is well engrained in self-management diabetes education interventions (Funnell, Tang, & Anderson, 2007). Empowering adults with diabetes is to provide them with accurate information on which to base their decisions and increase their self-efficacy for making healthy decisions and performing healthy behaviors through skill-building, social support, and goal setting. The premise of Empowerment Theory is that everyone has strengths and that together (that is, patients, medical providers, family members, community members) people have more influence on creating the changes they desire (Rappaport, 1981, 1984).

In 1995, Anderson and associates conducted a randomized, waitlist-controlled trial of a patient empowerment intervention for adults with diabetes (N = 46). Participants received six empowerment sessions over six weeks or were placed in the waitlist control group. The empowerment sessions included goal setting, problem-solving, stress management, and eliciting social support (Anderson et al., 1995; Feste, 1991). Participants in the empowerment group had significantly increased self-efficacy and diabetes attitudes and significantly improved glycemic control compared to control group participants.

Anderson et al. (2005) later scaled up their earlier empowerment-based intervention study (Anderson et al., 1995). This randomized controlled trial evaluated the effectiveness of a problem-solving focused, culturally tailored empowerment intervention for African American adults with diabetes (N = 239). Participants received six group-based empowerment sessions over six weeks, while control participants were on a waitlist until they also received the intervention six weeks later. Empowerment participants could choose to participate in monthly telephone calls from a nurse or monthly support group meetings during a follow-up period of up to one year after the intervention. The results showed a significant between-group difference with greater weight loss among the empowerment participants compared to the waitlist participants.

In 2007, Adolfsson, Walker-Engstrom, Smide, and Wikblad applied the empowerment program used by Anderson et al. (1995; 2005) to seven primary care settings in Sweden and also found variable results. Participants (N = 101) received six empowerment sessions or usual diabetes care. Although confidence in diabetes knowledge was significantly higher among the empowerment participants compared to the control group participants, there were no significant differences between groups for self-efficacy, satisfaction with daily life, body mass index, or glycemic control (Adolfsson et al., 2007).

### Legacy

Diabetes is one of the most common and serious chronic diseases for people in the United States and worldwide, most of whom have the type 2 form of the disease. There are striking racial and ethnic disparities of type 2 diabetes in the United States among adolescents and adults, with higher rates found in American Indians, Mexican Americans, and African Americans. Over the last 3 decades, there have been several landmark multi-site randomized clinical trials that have focused on diabetes management and prevention. Results of the trials have led to an increased emphasis on treatment adherence and patient responsibility for diabetes management. Evidence-based and promising behavioral interventions have emerged for children, adolescents, and adults. The behavioral interventions fall within the skill set and expertise of social workers and other helping professionals, such as family-based interventions, cognitive behavioral therapy, motivational interviewing, and empowerment strategies. As members of health care teams, social workers can effectively integrate and coordinate behavioral interventions to improve patient outcomes and quality of life.

### Acknowledgment

This chapter was funded by Grant Number 1P30DK092950 from the NIDDK, and its contents are solely the responsibility of the authors and do not necessarily represent the official views of the NIDDK.

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