InSight: Structured education for people with type 1 diabetes

Education programmes addressing carbohydrate counting and insulin adjustment in type 1 diabetes have been shown to yield benefits both in quality of life and glycaemic control (DAFNE [Dose Adjustment For Normal Eating and Exercise] Study Group, 2002). However, although the importance of such education is widely accepted – and recommended by the Department of Health and Diabetes UK (2005) – there is little evidence for its effectiveness in clinical practice.

InSight
In response to this lack of clinical evidence, the authors designed “InSight”, a structured education programme that aimed to facilitate self-management for people with type 1 diabetes. InSight is based on theories of adult education and experiential learning, and runs over 4 weeks with weekly sessions, providing 15 hours total contact time. It is designed to facilitate skills for carbohydrate counting and insulin adjustment, and supports self-management of hypoglycaemia, hyperglycaemia, illness and exercise. InSight meets all the criteria for structured education and is subject to audit and evaluation.

InSight is a multicentre intervention. Here, the authors discuss the Oxfordshire current audit, which investigated the effectiveness of InSight over 2 years follow-up. Over these 2 years, 88 people have completed follow-up and their results are discussed here.

Assessing InSight
The agreed criteria for audit were used, as recommended by the Diabetes Education Network, and biomedical and psychosocial data were collected. Biomedical data included HbA_1c, body weight, BMI and lipid levels, and diabetes-related distress was assessed by the use of the PAID (Problem Areas In Diabetes) questionnaire (Polonsky et al, 1995). PAID comprises 20 questions addressing potential problem areas related to diabetes. Each question scores between 1 and 4 and total scores are expressed as a percentage, with higher scores denoting more of a problem. There is an agreed cut-off point of 40%, with scores above this indicating a significant problem.

Results
Baseline characteristics of the 88 participants are as follows (all values expressed as means): age 44.6 years; diabetes duration 23.6 years; HbA_1c 8.5% (69 mmol/mol); body weight 70.7 kg; BMI 25.5 kg/m²; total cholesterol 4.8 mmol/L; HDL-cholesterol 1.7 mmol/L; LDL-cholesterol 2.59 mmol/L; triglycerides 1.15 mmol/L.

At 2 years, data were collected for 82% of the original cohort, which showed a significant reduction in HbA_1c of –0.2% (P=0.004), and a reduction in lipid levels, including total cholesterol (–0.3 mmol/L; P=0.003), LDL-cholesterol (–0.28 mmol/L; P=0.003) and triglycerides (–0.19 mmol/L; P=0.04). There were no significant changes in body weight, BMI or HDL-cholesterol.

PAID questionnaires were completed at baseline and after 1 year of the study. The results showed a significant decrease in diabetes-related distress. The mean scores at baseline were 32% and these improved to 19% (P<0.001) 1 year after completing the InSight programme.

Conclusion
This audit shows that InSight has produced significant improvements in biomedical outcomes, in particular glycaemic control, and in diabetes-related distress, and that these positive outcomes are maintained at 2 years follow-up.