Evidence Report/Technology Assessment 

Number 166 

Diabetes Education for Children With Type 1 

Diabetes Mellitus and Their Families 

Prepared for: 

Agency for Healthcare Research and Quality 

U.S. Department of Health and Human Services 

540 Gaither Road 

Rockville, MD 20850 

www.ahrq.gov 

Contract No. 290-02-0023 

Prepared by: 

University of Alberta/Capital Health Evidence-based Practice Center, Edmonton, AB, 

Canada 

Investigators 

Robert Couch, M.S., M.D., F.R.C.P.C. 

Mary Jetha, M.D., F.R.C.P.C. 

Donna M. Dryden, Ph.D. 

Nicola Hooton, B.Sc., M.P.H. 

Yuanyuan Liang, Ph.D. 

Tamara Durec, B.Sc. (Pharm.), M.L.I.S. 

Elizabeth Sumamo, B.Sc., M.P.H. 

Carol Spooner, B.Sc.N., M.S. 

Andrea Milne, B.Sc.N. 

Kate O’Gorman, B.Sc. 

Terry P. Klassen, M.D., M.S., F.R.C.P.C. 

AHRQ Publication No. 08-E011 

April 2008
 

This report is based on research conducted by the University of Alberta/Capital Health 

Evidence-based Practice Center (EPC), Edmonton, AB, Canada, under contract to the 

Agency for Healthcare Research and Quality (AHRQ), Rockville, MD (Contract No. 290-02-

0023). The findings and conclusions in this document are those of the author(s), who are 

responsible for its content, and do not necessarily represent the views of AHRQ. No statement 

in this report should be construed as an official position of AHRQ or of the U.S. Department 

of Health and Human Services. 

The information in this report is intended to help clinicians, employers, policymakers, and 

others make informed decisions about the provision of health care services. This report is

intended as a reference and not as a substitute for clinical judgment. 

This report may be used, in whole or in part, as the basis for the development of clinical 

practice guidelines and other quality enhancement tools, or as a basis for reimbursement and 

coverage policies. AHRQ or U.S. Department of Health and Human Services endorsement of 

such derivative products may not be stated or implied. 
ii

This document is in the public domain and may be used and reprinted without permission 

except those copyrighted materials noted for which further reproduction is prohibited without 

the specific permission of copyright holders. 

Suggested Citation: 

Couch R, Jetha M, Dryden DM, Hooton N, Liang Y, Durec T, Sumamo E, Spooner C, Milne 

A, O’Gorman K, Klassen TP. Diabetes Education for Children With Type 1 Diabetes 

Mellitus and Their Families. Evidence Report/Technology Assessment No. 166. (Prepared by 

the University of Alberta/Capital Health Evidence-based Practice Center under Contract No. 

290-02-0023.) AHRQ Publication No. 08-E011. Rockville, MD: Agency for Healthcare 

Research and Quality. April 2008.

No investigators have any affiliations or financial involvement (e.g., employment, 

consultancies, honoraria, stock options, expert testimony, grants or patents received or 

pending, or royalties) that conflict with material presented in this report. 
iii

Preface 

 The Agency for Healthcare Research and Quality (AHRQ), through its Evidence-based 

Practice Centers (EPCs), sponsors the development of evidence reports and technology 

assessments to assist public- and private-sector organizations in their efforts to improve the 

quality of health care in the United States. The reports and assessments provide organizations 

with comprehensive, science-based information on common, costly medical conditions and 

new health care technologies. The EPCs systematically review the relevant scientific 

literature on topics assigned to them by AHRQ and conduct additional analyses when 

appropriate prior to developing their reports and assessments. 

 To bring the broadest range of experts into the development of evidence reports and 

health technology assessments, AHRQ encourages the EPCs to form partnerships and enter 

into collaborations with other medical and research organizations. The EPCs work with these 

partner organizations to ensure that the evidence reports and technology assessments they 

produce will become building blocks for health care quality improvement projects 

throughout the Nation. The reports undergo peer review prior to their release. 

 AHRQ expects that the EPC evidence reports and technology assessments will inform 

individual health plans, providers, and purchasers as well as the health care system as a 

whole by providing important information to help improve health care quality. 

 We welcome comments on this evidence report. They may be sent by mail to the Task 

Order Officer named below at: Agency for Healthcare Research and Quality, 540 Gaither 

Road, Rockville, MD 20850, or by e-mail to epc@ahrq.gov. 

Carolyn M. Clancy, M.D. 

Director 

Agency for Healthcare Research and Quality 

Beth A. Collins Sharp, R.N., Ph.D. 

Director, EPC Program 

Agency for Healthcare Research and Quality 

Jean Slutsky, P.A., M.S.P.H. 

Director, Center for Outcomes and Evidence 

Agency for Healthcare Research and Quality 

Stephanie Chang, M.D., M.P.H. 

EPC Program Task Order Officer 

Agency for Healthcare Research and Quality 
iv

Acknowledgments 

We are grateful to members of the technical expert panel, Dr. Denis Daneman 

(University of Toronto), Alison Evert (University of Washington Medical Center), Dr. 

Jeff Johnson (University of Alberta), Dr. Richard Justman (United HealthCare), Dr. Lori 

Laffel (Joslin Diabetes Center), Dr. Gabriela Ramirez (Nemours Children’s Clinic), Dr. 

Janet Silverstein (University of Florida), Linda Walsh (American Academy of 

Pediatrics), Caryn Davidson (American Academy of Pediatrics) and Stephanie Chang 

(Agency for Healthcare Research and Quality), who provided direction for the scope and 

content of the review. 

We are grateful to Karalee Ratzlaff for collecting potentially relevant studies, Dr. 

Nina Buscemi for providing feedback on the draft of this report, and Ken Bond for 

editing the report. 
v

Structured Abstract

Objectives: To determine the effectiveness of diabetes education on metabolic control, 

diabetes-related hospitalizations, complications, and knowledge, quality of life and other 

psychosocial outcomes for children with type 1 diabetes and their families. 

Data Sources: A systematic and comprehensive literature review was conducted in 21 

electronic databases of medical and health education literature to identify randomized 

controlled trials (RCTs) and observational studies evaluating the effectiveness of diabetes 

education.

Review Methods: Study selection, quality assessment, and data extraction were 

conducted independently by several investigators in duplicate. A descriptive analysis is 

presented. 

Results: From 12,756 citations, 80 studies were identified and included in the review (53 

RCTs or CCTs, 27 observational studies). The methodological quality of studies was 

generally low. 

Most studies (35/52) that examined the effect of educational interventions on HbA1c 

found no evidence of increased effectiveness of the interventions over the education 

provided as part of standard care. Successful interventions were heterogeneous and 

included cognitive behavioral therapy, family therapy, skills training and general diabetes 

education. Most studies reported a positive effect on health service utilization (i.e., 

reduced use), although less than half were statistically significant. There was no clear 

evidence that educational interventions had an effect on short-term complications. 

The effect of educational interventions on diabetes knowledge was unclear with 12/30 

studies reporting a significant improvement. Interventions which had varying effects on 

knowledge scores included diabetes camp, general diabetes education, and cognitive 

behavioral therapy. In the area of self management/regimen adherence, 10/21 studies 

reported improving this outcome significantly. Successful interventions included general 

diabetes education and cognitive behavioral therapy. Educational interventions were 

successful in improving various psychosocial outcomes. 

The results of two studies examining refinements to intensive therapy education 

suggest that educational interventions may enhance the effects of intensive diabetes 

management in reducing HbA1c. 

Conclusions: Due to the heterogeneity of reported diabetes education interventions, 

outcome measures, and duration of followup, there is insufficient evidence to identify a 

particular intervention that is more effective than standard care to improve diabetes 

control or quality of life or to reduce short-term complications. 
vi

Contents 

Executive Summary............................................................................................................ 1 

Evidence Report.............................................................................................................. 15 

Chapter 1. Introduction .................................................................................................... 17 

Type 1 Diabetes Mellitus.............................................................................................. 17 

Current Standards.......................................................................................................... 19 

Objective of this Evidence Report ................................................................................ 21 

The Key Questions........................................................................................................ 21 

Chapter 2. Methods.......................................................................................................... 23

Literature Search and Retrieval .................................................................................... 24 

Study Selection ............................................................................................................. 25 

Assessment of Methodological Quality........................................................................ 25 

Grading the Body of Evidence...................................................................................... 26 

Data Extraction ............................................................................................................. 26 

Data Analysis................................................................................................................ 27 

Peer Review .................................................................................................................. 28

Chapter 3. Results ............................................................................................................ 29 

Literature Search........................................................................................................... 29 

Description of Included Studies.................................................................................... 30 

Methodological Quality of Included Studies ................................................................ 32 

Results of Included Studies........................................................................................... 39 

HbA1c........................................................................................................................... 39 

Health Services Utilization ........................................................................................... 57 

Complications ............................................................................................................... 62 

Knowledge .................................................................................................................... 69 

Skills ............................................................................................................................. 80 

Self-Management/Adherence ....................................................................................... 84 

Psychosocial Outcomes ................................................................................................ 94 

Quality of Life............................................................................................................. 123 

School Performance.................................................................................................... 124 

Chapter 4. Discussion .................................................................................................... 127 

Grading the Body of Evidence.................................................................................... 127 

Discussion of Key Questions...................................................................................... 130 

Limitations .................................................................................................................. 135 

Conclusions................................................................................................................. 136 

Future Research Opportunities ................................................................................... 136 

References and Included Studies .................................................................................... 139 
vii

Tables

Table 1. Summary table for diabetes education for children with type 1 diabetes......... 7 

Table 2. Inclusion and exclusion criteria for studies assessing the effectiveness of 

diabetes education for children and their families .......................................... 25 

Table 3. Methodological quality and source of funding of randomized controlled trials 

assessing the effectiveness of diabetes education for children with type 1 

diabetes and their families .............................................................................. 35 

Table 4. Methodological quality and source of funding for controlled clinical trials 

assessing the effectiveness of diabetes education for children with type 1 

diabetes and their families .............................................................................. 37 

Table 5. Methodological quality of before-and-after studies and cohort studies.......... 38 

Table 6. Summary of results for studies assessing the effect of diabetes education on 

HbA1c............................................................................................................. 53 

Table 7. Summary of results for studies assessing the effect of diabetes education on 

health services utilization................................................................................ 61 

Table 8. Summary of results of studies assessing the effect of diabetes education on 

short-term complications ................................................................................ 68 

Table 9. Summary of results of studies assessing the effect of diabetes education on 

knowledge....................................................................................................... 77 

Table 10. Summary of results of studies assessing the effect of diabetes education on 

skills ................................................................................................................ 83 

Table 11. Summary of results of studies assessing the effect of diabetes education on 

self-management/regimen adherence.............................................................. 92 

Table 12. Summary of results of studies assessing the effect of diabetes education on 

family/social relationships .............................................................................. 99 

Table 13. Summary of results of studies assessing the effect of diabetes education on 

family and social support.............................................................................. 104 

Table 14. Summary of results of studies assessing the effect of diabetes education on 

social skills.................................................................................................... 107 

Table 15. Summary of results of studies assessing the effect of diabetes education on 

coping............................................................................................................ 111 

Table 16. Summary of results of studies assessing the effect of diabetes education on 

 self-perception............................................................................................... 115 

Table 17. Summary of results of studies assessing the effect of diabetes education on 

self-efficacy................................................................................................... 118 

Table 18. Summary of results of studies assessing the effect of diabetes education on 

stress.............................................................................................................. 119 

Table 19. Summary of results of studies assessing the effect of diabetes education on 

anxiety and depression.................................................................................. 122 

Table 20. Summary of results of studies assessing the effect of diabetes education on 

quality of life................................................................................................. 124 

Table 21. Summary of results of studies assessing the effect of diabetes education on 

school performance....................................................................................... 125 

Table 22. Grading the strength of evidence .................................................................. 127 
viii

Figures 

Figure 1. Analytical framework for evidence report on the effectiveness of diabetes 

education......................................................................................................... 23 

Figure 2. Flow-diagram for study retrieval and selection .............................................. 30 

Appendixes and Evidence Tables for this report are provided electronically at 

http://www.ahrq.gov/downloads/pub/evidence/pdf/diabetesed/diabetesed.pdf
1

Executive Summary 

Introduction 

Currently, type 1 diabetes affects 1 in every 400 to 600 children, and more than 13,000 

children are newly diagnosed each year.1,2

Type 1 diabetes is managed by insulin replacement and balancing of diet and exercise in 

order to maintain glycemic control and prevent the occurrence of complications. Glycemic 

control, which is linked directly to complication rates,1 is monitored by the measurement of 

glycosylated hemoglobin (HbA1c), which reflects the mean blood glucose level over the 

previous 2 to 3 months. Lowering HbA1c has been associated with a reduction of 

microvascular complications of diabetes.3

In order to effectively manage diabetes, education about components of management 

such as blood glucose monitoring, insulin replacement, diet, exercise, and problem solving 

strategies must be delivered to the patient. Education is important both at diagnosis, where 

there is usually no knowledge base and patient and family are given the basic skills for 

controlling the disease,4

 and throughout the patient’s lifetime, with ongoing attention to selfmanagement skills, screening and prevention of complications, and to new developments in 

these areas. Since management of diabetes requires lifestyle changes, it is important that 

education be delivered to the whole family. 

Key Questions 

 The American Academy of Pediatrics put forth the following five questions: 

1. What is the evidence that diabetes education on day-to-day management of diabetes 

improves metabolic control (as determined by HbA1c, numbers of diabetes-related 

hospitalizations, frequency of diabetic ketoacidosis [DKA] and numbers of episodes of 

hypoglycemia)? 

2. What is the evidence that medical nutrition therapy education on day-to-day management 

of diabetes improves HbA1c values and results in less variability in blood glucose levels? 

3. What is the evidence that diabetes education results in improved long-term management 

of diabetes, including better adherence to recommendations made in clinic and decreased 

hospitalizations and emergency department (ED) visits for diabetes-related 

complications? 

4. What is the evidence that diabetes education programs improve knowledge about 

diabetes management? 

a. What is the evidence that this knowledge increases the child’s self-confidence in his 

or her ability to handle the disease and has a positive impact on the child’s quality of 

life (QOL) and other psychosocial issues (e.g., school absences, school performance, 

adherence to a medical regimen)? 

b. What is the evidence that this knowledge improves long-term metabolic control (i.e., 

decreases or prevents diabetes-related complications), as shown in the Diabetes 

Control and Complications Trial (DCCT) (as measured by retinal, renal, 

cardiovascular, and neurological evaluations), in children of families who receive 
2

these diabetes education or medical nutrition therapy program services compared to 

children of families who do not receive these services? 

5. What is the evidence that training in intensive diabetes management (consistent with 

DCCT, including blood glucose monitoring at least four times a day, three or more daily 

insulin injections or use of an insulin pump and education on when and how to adjust 

insulin doses) conducted in the practitioner setting yields: 

a. Improved metabolic control, (as determined by HbA1c values, numbers of diabetesrelated hospitalizations, frequency of DKA and numbers of episodes of 

hypoglycemia)? 

b. A decrease in or prevention of diabetes-related complications (as measured by retinal, 

renal, cardiovascular, and neurological evaluations), as demonstrated by DCCT? 

Methods 

Literature Search 

Search terms were adapted for the following electronic databases: MEDLINE® Ovid, 

Ovid MEDLINE® In-Process & Other Non-Indexed Citations, Cochrane Central Register of 

Controlled Trials, Cochrane Database of Systematic Reviews (CDSR), Database of Abstracts 

of Reviews of Effects (DARE), HealthSTAR, EMBASE, CINAHL®, ERIC, PsycINFO®, 

CINAHL Plus with Full Text (EBSCO), Science Citation Index Expanded® and Social 

Sciences Citation Index® (both via ISI Web of KnowledgeSM), PubMed®, LILACS (Latin 

American and Caribbean Health Science Literature), Proquest® Dissertations & Theses, 

CRISP (Computer Retrieval of Information on Scientific Projects), National Library of 

Medicine (NLM) Gateway, OCLC ProceedingsFirst and PapersFirst, and trial registries such 

as The National Research Register, ClinicalTrials.gov, and Current Controlled Trials. We 

also searched websites of relevant professional associations, and reference lists of relevant 

reviews and included studies. Only English-language studies were included. 

Study Selection 

Two reviewers independently screened titles and abstracts to determine if an article met 

general inclusion criteria. The full text of all articles identified as “include” or “unclear” was 

retrieved for formal review. 

Using a priori inclusion criteria, two reviewers independently assessed each full text 

article using a standard form. Disagreements were resolved by consensus or third-party 

adjudication. 

Quality Assessment 

Two reviewers independently assessed the methodological quality of included studies. 

The Jadad Scale and Schulz criteria for allocation concealment were used to assess the 

methodological quality of randomized and nonrandomized controlled clinical trials. In a post 

hoc assessment, trials were given credit if outcome assessors were blinded to outcomes. The 

Thomas Quality Assessment Tool for Quantitative Studies was used to assess studies of other 

designs. In addition, the funding source was recorded. 
3

Data Extraction 

Data were extracted by one reviewer using standardized forms and checked for accuracy 

and completeness by a second reviewer. Extracted data included inclusion/exclusion criteria, 

and the characteristics of participants, interventions, and outcomes. Disagreements were 

resolved by consensus or third-party adjudication. 

Data Analysis 

Due to extreme heterogeneity in study designs, interventions, populations, and outcomes, 

no meta-analyses were performed. Interventions were grouped into nine broad categories: 

general diabetes education (21 studies), interventions based on cognitive behavioral therapy 

(24 studies), family therapy (9 studies), skills training (7 studies), and programs delivered at 

diabetes camps (17 studies), as well as psychoeducation (2 studies) and a physical activity 

program (1 study). Results are presented first by outcome (e.g. HbA1c), then by intervention, 

and then by population subgroup (general population, children with newly diagnosed 

diabetes, or children with poor metabolic control). 

Results 

Included Studies 

As a result of the search, 12,756 citations were identified. One hundred articles were 

included in the review, representing 80 unique primary studies.5-84 The number of enrolled 

participants in the studies ranged from 11 to 332 (median = 50 [IQR = 30 to 89]). The mean 

age of study participants ranged from 2.7 to 16 years. 

Outcomes 

 HbA1c. 52 studies assessed the effectiveness of diabetes education programs in 

controlling HbA1c levels (Table 1). Overall, the methodological quality of studies was low, 

with three RCTs assessed as high quality and nine studies assessed as moderate quality. 

Thirty-one studies assessed the general population of children with diabetes. Nine studies 

reported that HbA1c levels decreased significantly following the interventions. The 

successful interventions fell into the categories of family therapy (n = 3), cognitive 

behavioral therapy (n = 4), general diabetes education (n = 1), and skills training (n = 1). The 

one moderate quality RCT examined the addition of a coping skills intervention to intensive 

diabetes management. Six studies found that HbA1c levels improved significantly for both 

the intervention and control groups; however, differences between groups were not 

statistically significant. The remaining 16 studies reported that diabetes education had no 

significant effect on improving HbA1c levels, thus in the majority of the studies there was no 

evidence for increase in effectiveness of the educational interventions over the education 

provided in standard care. 
4

Eight studies assessed diabetes education delivered to children with newly diagnosed 

diabetes and their families (Table 1). Three studies assessed general diabetes education or 

family therapy programs that were delivered in an ambulatory setting vs. education delivered 

during hospitalization. One study reported that the decrease in HbA1c levels was 

significantly greater for the home-based group vs. the inpatient group, whereas the other two 

found no significant differences in HbA1c levels between groups. The results of the 

remaining studies were inconsistent. Three studies reported that cognitive behavioral therapy 

and skills training interventions resulted in lower HbA1c levels in the intervention group, one 

study reported that both groups improved, and one study found no difference between the 

two groups. 

Thirteen studies examined HbA1 in children with poorly controlled diabetes (Table 1). 

Two large, high quality RCTs examining general diabetes education and family therapy 

reported that the intervention had no significant impact on HbA1c levels. The results of the 

remaining studies were inconsistent. Four studies reported that HbA1c levels improved 

following the intervention. Two studies reported an improvement in HbA1c in both 

intervention and control groups, but there was no significant difference between groups. The 

remaining five studies reported that diabetes education had no significant effect on HbA1c 

levels. Due to the heterogeneity across studies and the general low methodological quality, it 

is difficult to conclude which interventions may have an effect over and above standard care. 

 Health service utilization. Eleven studies assessed impact of diabetes education on 

health service utilization (Table 1). Measures of health service utilization included length of 

stay and hospital or ED admissions for diabetes- and non-diabetes-related complications. 

Overall, the methodological quality was moderate with one RCT assessed as high quality, six 

rated as moderate, and four rated as low quality. 

The four studies assessing this outcome in the general patient population provide some 

evidence that diabetes education has an impact on utilization (Table 1). However, there is 

considerable heterogeneity across studies making it difficult to generalize the results. 

Three of the four studies that examined children with newly diagnosed diabetes reported 

some reduction in health services utilization following the intervention. The results of the 

three studies that targeted children with poor metabolic control were inconsistent. The high 

quality RCT reported increased hospital admission rates for both intervention and control 

groups (i.e., no improvement), while the two low quality trials reported significantly fewer 

hospital admissions in the intervention group compared to the control group. 

 Complications. Fifteen studies examined the effect of diabetes education in controlling 

complications (Table 1). Most studies reported on the incidence of severe hypoglycemia; six 

reported on the incidence of DKA. Six of the studies were of moderate quality and the other 

nine were assessed as low quality. 

Of the 10 studies that examined the general population of children with diabetes, six 

found that the intervention had a significant effect. The effective interventions included 

general diabetes education (n = 2), cognitive behavioral therapy (n = 2), and skills training (n 

= 2).The remaining studies either showed that there was no improvement or that there was no 

significant difference between groups for this outcome. 

Of three studies assessing this outcome in children with newly diagnosed diabetes, two 

reported a significant improvement in the intervention group. The third study comparing 

inpatient vs. outpatient delivery of education found no difference between groups. 
5

The remaining 2 studies assessed children with poor metabolic control and the results 

both favored the interventions (general diabetes education and diabetes camp). 

 Knowledge. Thirty studies assessed the effectiveness of diabetes education in improving 

knowledge. Most studies (n = 20) were assessed as low quality, however, 10 were evaluated 

as moderate and one RCT as high quality (Table 1). Twenty-four studies examined the 

general population of children with diabetes. Interventions included general diabetes 

education (n = 8), cognitive behavioral therapy (n = 6), diabetes camps (n = 7) and skills 

training (n = 2). Two before-after studies of moderate quality studies reported gains in 

knowledge after a cognitive behavioral therapy and general diabetes education intervention; 

however, three other moderate quality before-after studies did not find a significant change 

following the intervention. The results of the remaining studies were also inconsistent: five 

reported statistically significant increases in knowledge; two reported found the interventions 

to be effective in subgroups of the study population; six reported knowledge gains that were 

not statistically significant or were not retained over the long-term. 

Three moderate quality studies compared inpatient vs. ambulatory education in children 

with newly diagnosed diabetes. All three studies reported increases in knowledge levels for 

both groups, but differences between groups were not statistically significant. It should be 

noted that the interventions and outcome measures among studies were different from one 

another, so results may not be generalizable. 

Three studies assessed knowledge among children with poor metabolic control. One high 

quality RCT did not find a significant change in knowledge for either group. One before-after 

study reported significant increases in knowledge following a diabetes camp, and one CCT 

reported significantly higher knowledge levels over the short-term but these gains were not 

sustained over the long-term. 

 Skills. Nine studies assessed the effect of diabetes education on the development of 

diabetes management skills, including self-monitoring of blood glucose (SMBG), nutrition 

and diet-related skills, and urine testing (Table 1). In the general population of children with 

diabetes, four studies (2 cognitive behavioral therapy48 and 2 camp interventions) found 

gains in these skills, while four reported no significant change in skills following the 

intervention. 

In the population of children with poor metabolic control, one RCT conducted at diabetes 

camp found no significant difference between intervention and control groups in SMBG.

 Self-management/adherence. Twenty-one studies assessed self management and 

regimen adherence (Table 1). Of these, fourteen focused on the general population of 

children with diabetes. One moderate quality and seven low quality studies reported a 

significant improvement in self-management in the intervention group. Successful 

interventions included general diabetes education (n = 2), cognitive behavioral therapy (n = 

3) and family therapy (n = 2). The remaining studies did not show a significant change. 

One study assessed this outcome among children who were newly diagnosed with 

diabetes and found no significant change. Five studies focused on children with poor 

metabolic control. One RCT found a significant effect on self-management in blood testing 

and adherence; the remaining studies found no significant change. 

 Psychosocial outcomes. Thirty-nine studies examined one or more psychosocial 

outcomes, including family or social relationships, family or social support, social skills, 

coping, self-perception, self-efficacy, stress, depression and anxiety (Table 1). Diabetes 

education was effective in improving several psychosocial outcomes; however, the 
6

methodological quality of the studies was generally low and there was considerable 

heterogeneity across interventions, time points, and measures used.

 Quality of life. Two studies found that cognitive behavioral therapy and general diabetes 

training intervention improved quality of life in the intervention group (Table 1). The 

remaining two studies that examined this outcome reported that the education interventions 

had no significant effect. 

 School performance. There was limited evidence relating to this outcome (Table 1). In 

the two studies assessing this outcome, diabetes education programs did not have a 

significant effect on school absence or sick days. 
7

Table 1. Summary table for diabetes education for children with type 1 diabetes 

Intervention Quantity 

of 

evidence 

Quality of 

evidence 

Results Summary of findings 

IG 

improved 

vs. CG; 

significant 

IG or both 

IG & CG 

changed; 

NS 

No change 

General population of children with diabetes 

HbA1c 

4 RCT Low 1 3 2 B-A Moderate 1 1 1 B-A Low 1 

General diabetes 

education 

1 Cohort Low 1 

In general, interventions were not effe

heterogeneity across interventions precluded direct comparisons; somassessed content while others lookmode of delivery (e.g., video gamevs. individual training) 

1 RCT Moderate 1 8 RCT Low 2 3 3 1 CCT Low 1 

Cognitive behavioral 

therapy 

1 Cohort Low 1 

Individual studies demonstrated that s

cognitive behavioral therapy intervemay be effective (e.g., coping skills heterogeneity across interventions precluded direct comparisons 

1 RCT Low 1 2 CCT Low 2 

Diabetes camp 

1 B-A Low 1 

No effect 

Family therapy 3 RCT Low 3 Interventions that focus on family team

support may be effective 

Physical training 1 RCT Low 1 Insufficient evidence Skills training 1 B-A Low 1 

1 Cohort Low 1 

Mixed effects 

Psychoeducation 1 RCT Moderate 1 Insufficient evidence Health services utilization

1 RCT Moderate 1 1 RCT Low 1 

General diabetes 

education 

1 B-A Moderate 1 

Individual studies demonstrated that s

interventions may be effective; heterogeneity across interventions precluded direct comparisons 

Diabetes camp 1 B-A Moderate 1 Insufficient evidence *Comparing inpatient vs. ambulatory delivery of education intervention; B-A = uncontrolled before-and-after; CCT = controlled clinical tria= intervention group; NS = non significant; RCT = randomized controlled trial
8

Table 1. Summary table for diabetes education for children with type 1 diabetes (continued) 

Intervention 

Quantity 

of 

evidence 

Quality of 

evidence Results Summary of findings 

IG 

improved 

vs. CG; 

significant 

IG or both 

IG & CG 

changed; 

NS 

No change 

General population of children with diabetes (continued) 

Short-term complications 

1 RCT Moderate 1 2 B-A Moderate 1 1 1 B-A Low 1 

General diabetes 

education

1 Cohort Low 1 

Individual studies demonstrated that s

interventions may be effective; heterogeneity across interventions precluded direct comparisons 

Cognitive behavioral 2 RCT Moderate 1 1 

therapy 1 Cohort Low 1 

Mixed effects; 1 RCT reported compli

rates decreased; however, rates weunacceptably high 

Physical training 1 RCT Low 1 Insufficient evidence Skills training 1 RCT Low 1 

1 Cohort Low 1 

Skills training interventions may be ef

Knowledge 

3 RCT Low 1 1 1 1 CCT Low 1 2 B-A Moderate 2 

General diabetes 

education 

2 B-A Low 1 1 

Specific interventions may be effectiv

heterogeneity across interventions outcome measures precluded direccomparisons 

1 RCT Moderate 1 2 RCT Low 1 1 3 CCT Low 1 2 

Cognitive behavioral 

therapy 

1 B-A Moderate 1 

Specific interventions may be effectiv

heterogeneity across interventions precluded direct comparisons 

1 RCT Moderate 1 2 RCT Low 1 1 1 CCT Low 1 

Diabetes camp 

3 B-A Low 2 1 

Mixed effects; content of specific inte

varied across studies 

Skills training 1 B-A Moderate 1 

1 B-A Low 1 

May be effective; knowledge increase

changes were NS 

Skills

1 RCT Low 1 1 CCT Low 1 

Cognitive behavioral 

therapy 

1 B-A Low 1 

Specific interventions may be effectiv

heterogeneity across interventions precluded direct comparisons 
9

Table 1. Summary table for diabetes education for children with type 1 diabetes (continued) 

Intervention 

Quantity 

of 

evidence 

Quality of 

evidence Results Summary of findings 

IG 

improved 

vs. CG; 

significant 

IG or both 

IG & CG 

changed; 

NS 

No change 

General population of children with diabetes (continued) 

Skills (continued)

3 RCT Low 3 1 B-A Moderate 1 

Diabetes camp 

2 B-A Low 2 

Mixed effects; content of specific inte

varied across studies 

Self-management or regimen adherence 

3 RCT Low 2 1 1 CCT Low 1 

General diabetes 

education 

1 B-A Moderate 1 

Specific interventions may be effectiv

heterogeneity across interventions precluded direct comparisons 

Cognitive behavioral 1 RCT Moderate 1 

therapy 4 RCT Low 2 2 

Specific interventions may be effectiv

heterogeneity across interventions precluded direct comparisons 

Family therapy 2 RCT Low 2 Specific interventions may be effectivDiabetes camp 2 CCT Low 2 No effect Psychosocial outcomes General diabetes 1 RCT Low 1 

education 1 B-A Low 1 

Specific interventions may be effectiv

improving family support and copin

3 RCT Moderate 2 1 2 RCT Low 2 3 CCT Low 2 1 1 Cohort Low 1 

Cognitive behavioral 

therapy

1 B-A Moderate 1 

Specific interventions may be effectiv

improving family relationships, famsupport, efficacy, self-perception 

Family therapy 3 RCT Low 1 2 No effect 

2 CCT Low 2 1 B-A Moderate 1 

Diabetes camp

3 B-A Low 1 2 

Mixed effects; content of specific inte

varied across studies 

Skills training 1 B-A Low 1 Insufficient evidence Quality of life General diabetes 

education 

1 B-A Moderate 1 Insufficient evidence 

Cognitive behavioral 

therapy 

1 RCT Moderate 1 Insufficient evidence 
10

Table 1. Summary table for diabetes education for children with type 1 diabetes (continued) 

Intervention 

Quantity 

of 

evidence 

Quality of 

evidence Results Summary of findings 

IG 

improved 

vs. CG; 

significant 

IG or both 

IG & CG 

changed; 

NS 

No change 

General population of children with diabetes (continued) 

Quality of life (continued)Family therapy 1 RCT Low 1 Insufficient evidence Skills training 1 B-A Low 1 Insufficient evidence School performance Diabetes camp 1 RCT Moderate 1 Insufficient evidence 

Children with newly diagnosed diabetes 

HbA1c General diabetes 1 RCT Moderate 1* education 1 Cohort Moderate 1* 

Compared inpatient vs. ambulatory d

education; mixed effects; interventidissimilar 

Cognitive behavioral 1 RCT Moderate 1 

therapy 1 CCT Low 1 

Specific interventions may be effectiv

family-based skills training); the comgroup for one study was ‘no educat

Family therapy 2 RCT Low 1* 1 Insufficient evidence; 1 study found n

difference between inpatient vs. amdelivery of education 

Skills training 1 RCT Low 1 

1 Cohort Moderate 1 

Mixed effects 

Health service utilization General diabetes 

education

2 Cohort Moderate 1 1* Insufficient evidence; 1 study compar

inpatient vs. ambulatory setting; 1 askill level of educator 

Cognitive behavioral 

therapy

1 CCT Low 1 Insufficient evidence 

Skills training 1 Cohort Moderate 1 Insufficient evidence Short-term complications General diabetes 

education

1 RCT Moderate 1* Insufficient evidence 

Cognitive behavioral 

therapy

1 CCT Low 1 Insufficient evidence 

Skills training 1 Cohort Moderate 1 Insufficient evidence 
11

Table 1. Summary table for diabetes education for children with type 1 diabetes (continued) 

Intervention 

Quantity 

of 

evidence 

Quality of 

evidence Results Summary of findings 

IG 

improved 

vs. CG; 

significant 

IG or both 

IG & CG 

changed; 

NS 

No change 

Children with newly diagnosed diabetes (continued) 

Knowledge General diabetes 1 RCT Moderate 1* 

education 2 Cohort Moderate 2* 

Compared inpatient vs. ambulatory d

education; knowledge increased in groups; interventions were dissimila

Self-management and regimen adherence General diabetes 1 RCT Moderate 1* 

education 1 Cohort Moderate 1* 

Compared inpatient vs. ambulatory d

education; mixed effects 

Psychosocial outcomes 

1 RCT High 1 1 RCT Low 1 

General diabetes 

education 

2 Cohort Moderate 2 

No effect 

Cognitive behavioral 

therapy 

1 RCT Low 1 Insufficient evidence 

Family therapy 3 RCT Low 3 No effect Skills training 1 RCT Low 1 Insufficient evidence School performance General diabetes 

education 

1 RCT Moderate 1 Insufficient evidence 

Children with poor metabolic control 

HbA1c General diabetes 1 RCT High 1 

education 1 RCT Low 1 

No effect 

Cognitive behavioral 4 RCT Low 1 3 

therapy 2 CCT Low 2 

In general, interventions were not effe

heterogeneity across interventions precluded direct comparisons 

Diabetes camp 1 B-A Low 1 Insufficient evidence Family therapy 1 RCT High 1 

1 B-A Low 1 

No effect 

Skills training 1 RCT High 1  1 RCT Low 1 

No effect 

Psychoeducation 1 CCT Low 1 Insufficient evidence 
12

Table 1. Summary table for diabetes education for children with type 1 diabetes (continued) 

Intervention 

Quantity 

of 

evidence 

Quality of 

evidence Results Summary of findings 

IG 

improved 

vs. CG; 

significant 

IG or both 

IG & CG 

changed; 

NS 

No change 

Children with poor metabolic control (continued) 

Health service utilization General diabetes 

education 

1 RCT High 1 Insufficient evidence 

Skills training 1 RCT Low 1 Insufficient evidence Psychoeducation 1 CCT Low 1 Insufficient evidence Short-term complications Diabetes camp 1 B-A Low 1 Insufficient evidence Knowledge General diabetes 

education 

1 RCT High 1 Insufficient evidence 

Cognitive behavioral 

therapy

1 CCT Low 1 Insufficient evidence 

Diabetes camp 1 B-A Low 1 Insufficient evidence Self-management and regimen adherence General diabetes 

education 

1 RCT Low 1 Insufficient evidence 

Cognitive behavioral 

therapy

2 RCT Low 1 1 No effect 

Family therapy 1 RCT High 1 

1 B-A Low 1 

No effect 

Skills Diabetes camp 1 RCT Low 1 Insufficient evidence Psychosocial outcomes General diabetes 1 RCT High 1 

education 1 RCT Low 1 

No effect 

Cognitive behavioral 4 RCT Low 4 

therapy 1 CCT Low 1 

No effect 

Family therapy 1 RCT High 1 

1 B-A Low 1 

Mixed effects 
13

Discussion 

 Key Question 1. The results of this review do not indicate that any specific educational 

intervention improves day-to-day management of metabolic control as determined by 

HbA1c. More intensive interventions such as cognitive behavioral therapy and family 

therapy appear to have a small benefit. Studies set in diabetes camps do not show any clear 

improvement in diabetes control. Diabetes education appears to be effective in decreasing 

health care utilization, and this effect appears to be associated with education that is intense, 

provided by specialists, and multidisciplinary teams, and involves some form of 

psychotherapy or psychosocial focus. 

Results were unclear in the area of diabetes-related short-term complications. Most 

studies did not have high enough rates of DKA to show significant differences. Studies 

reporting on hypoglycemia covered the spectrum of possible outcomes. A possible 

explanation for this may be that hypoglycemia has so many potential causes. For example, an 

intervention may target nocturnal hypoglycemia, but not physical activity-related 

hypoglycemia. It is also possible that both standard care and standard diabetes education 

effectively reduce the incidence of hypoglycemia, making it difficult to demonstrate 

differences among types of educational interventions. 

It has been hypothesized that changes in HbA1c may be mediated by changes in 

knowledge, skills, attitudes and/or behavior. In the 16 studies that examined the association 

between knowledge and short-term metabolic control the results were inconsistent. It appears 

that an increase in knowledge is not sufficient to bring about behavior change that improves 

metabolic control. Likewise, in the 24 studies that measured both psychosocial outcomes and 

HbA1c, the four studies that measured quality of life and HbA1c, the two studies that 

measured skills and HbA1c, and the 18 studies that measured adherence and HbA1c, there 

was little coherence across these outcomes. 

 Key Question 2. There is no clear evidence on whether medical nutrition therapy 

education does or does not improve diabetes control. We identified only one uncontrolled 

before-and-after study that specifically assessed medical nutrition therapy education as the 

intervention for children attending a diabetes camp. There were several studies that described 

a nutritional component or module as part of their intervention and reported improved 

nutritional knowledge or behavior after the intervention; however, this did not correlate with 

a lowering of HbA1c. Several other studies showed no significant changes in HbA1c or 

regimen adherence. Further research is needed to answer this question. 

 Key Question 3. There were no data to answer the question about what, if any, 

educational interventions improve long-term control and reduce long-term diabetes-related 

complications. Long-term followup in diabetes is considered 5 to 10 years. Only three studies 

followed participants for more than 2 years. 

 Key Question 4. A small number of studies reported that cognitive behavioral therapy or 

general diabetes education had an effect on knowledge scores in favor of the intervention. 

However, in the majority of studies that assessed this outcome, there was no difference in 

knowledge scores between those who received the intervention vs. those who received 

education that was part of their standard diabetes care. Therefore, no clear recommendation 

can be made on types of education, beyond standard care, that may improve knowledge. 

There was also no particular intervention that showed a consistent positive effect of diabetes 
14

education on psychosocial outcomes, including quality of life and school performance. We 

were unable to assess whether improved knowledge had an effect on long- term metabolic 

control because none of the included studies followed participants beyond 2 years. 

 Key Question 5. Three studies contributed information to the key question on training in 

intensive diabetes management in the practitioner setting. All three studies reported improved 

metabolic control after initiation of the intensive treatment which persisted up to 1 year later. 

The results of the two studies that examined refinements to the education provided suggest 

that educational interventions may support the effects of intensive diabetes management in 

reducing HbA1c levels. In terms of short-term acute complications, the studies showed 

mixed results with one group reporting an unacceptably high level of severe hypoglycemia 

suggesting that further educational interventions may need to be explored. 

Future Research Opportunities 

Recommendations for further research include: 

• Appropriately powered RCTs are needed to assess cognitive behavioral therapy, 

family therapy, motivational interviewing and frequency of contact with health care 

professionals on HbA1c and short-term complications, especially in the population of 

children with poorly controlled diabetes 

• RCTs should specify the components of education that is part of standard care and 

followup. A survey of standard diabetes education programs so that researchers are 

aware of the diversity of standard care would be a useful addition to the literature. 

• Additional research is needed in the area of medical nutrition therapy education. 

• Future studies assessing the effect of educational strategies on quality of life should 

use a standard, validated outcome measure. 

• Five- to ten-year followup will help to assess the effect of education on long-term 

complications of diabetes. 

• RCTs and CCTs should blind outcome assessors to the intervention and should report 

allocation concealment. 

• Additional research is needed to examine the aspects of education that improve 

outcomes associated with intensive diabetes management. 

Conclusions 

Due to the heterogeneity of reported diabetes education interventions that are delivered to 

children with type 1 diabetes and their families, outcome measures, and duration of followup, 

there is insufficient evidence to recommend a particular education intervention to improve 

metabolic control, reduce short-term acute complications, or improve quality of life. 
Evidence Report 
16

Chapter 1. Introduction 

Type 1 diabetes is the third most common chronic condition in children and 

adolescents in the United States.4

 This condition affects 1 in every 400 to 600 children, 

and more than 13,000 children are newly diagnosed each year.1,2 In 1995, more than 

140,000 children and adolescents were affected by this disorder,85 while in 2001, the 

prevalence was estimated to be 1.54 cases per 1000 youth in 2001.86 In 2002, the total 

estimated direct and indirect costs related to diabetes (type 1 and type 2) were $132 

billion in the United States.2

Type 1 Diabetes Mellitus 

Diabetes mellitus is the general name for a group of chronic metabolic diseases 

characterized by high blood glucose levels that result from defects in insulin secretion 

and/or action. The two main forms of diabetes are insulin-dependent diabetes mellitus 

(IDDM) or type 1 diabetes and noninsulin-dependent or type 2 diabetes. Type 2 diabetes 

is more commonly diagnosed in adulthood and is characterized by the body’s inability to 

use insulin properly. Although type 1 diabetes can be diagnosed in adulthood, it usually 

develops and is diagnosed in childhood and adolescence. 

Type 1 diabetes occurs when the beta cells of the pancreatic islets of Langerhans, 

which are responsible for insulin production, are progressively destroyed by the immune 

system. The body’s ability to produce insulin becomes progressively impaired until 

eventually no insulin is produced. The insulin deficiency results in decreased insulin 

utilization and increased hepatic glucose production leading to hyperglycemia. In 

addition, there is an increased breakdown of adipose tissue leading to ketonemia and 

eventual diabetic ketoacidosis (DKA) that, if left untreated, is potentially fatal.87

Acute Complications of Type 1 Diabetes 

Type 1 diabetes and its treatment has two major acute complications: DKA and 

hypoglycemia. DKA is a metabolic state resulting from acute hyperglycemia. DKA has a 

mortality rate of 0.5 percent, mostly due to cerebral edema, the most frequent diabetesrelated cause of death. DKA is most common at presentation, occurring in an average of 

40 percent (15 to 83 percent in population studies) of children presenting with diabetes. 

In established diabetes, the rate is 1 to 8 percent per year. Risk factors include infection, 

insulin omission, and equipment malfunction. DKA is treated with immediate 

hospitalization, insulin replacement, and rehydration. 

Hypoglycemia is a complication of insulin treatment. Symptoms caused by a fall in 

blood glucose include shakiness and emotional instability. In severe cases, there may be 

seizures or unconsciousness. There has been concern about possible brain dysfunction 

due to prolonged or repeated hypoglycemic episodes; however, there is limited evidence 

of permanent cognitive sequelae and they are considered minor.88,89 The prevalence rates 

for this complication vary due to potential under-reporting of minor episodes. Studies 

looking at the prevalence of severe hypoglycemia in children and adolescents report a 

range of 4 to 86 episodes per 100 patient years.3,90 Hypoglycemia is most frequent at 
17

night, is most serious in younger children due to their relatively higher rate of glucose 

utilization, and is a possible cause of death. It can be avoided with education about 

symptoms, careful meal planning, and nighttime glucose monitoring. 

Chronic Complications 

Chronic complications associated with type 1 diabetes include microvascular 

complications such as retinopathy, nephropathy, and neuropathy, and macrovascular 

complications. Macrovascular complications include circulatory and cardiovascular 

events such as stroke and myocardial infarction, which are rare in children and 

adolescents; however, risk factors such as hypertension, smoking and dislipidemia should 

be managed. Chronic complications have been linked to poor glycemic control and the 

duration of the disease.91 Many chronic complications are rare in childhood, but 

management of diabetes in childhood has implications for later development of 

complications. Donaghue et al.92 found that although the survival-free period of 

retinopathy and microalbinuria was significantly longer for those diagnosed before 5 

years of age compared with those diagnosed later, the risk of clinical retinopathy 

increased by 28 percent for every prepubertal year of duration and by 36 percent for 

every post-pubertal year of duration. However, there has been a declining incidence of 

some of the longterm complications over recent decades,93,94 likely due to improvements 

in diabetes management. 

Diabetes Management and Education 

Type 1 diabetes is managed by a combination of insulin replacement and balancing of 

diet and exercise in order to maintain glycemic control and prevent the occurrence of 

complications. Glycemic control, which is directly linked to complication rates,91 is 

monitored by the measurement of glycosylated hemoglobin (HbA1c), which reflects the 

mean blood glucose level over the previous 2 to 3 months. Lowering HbA1c has been 

associated with a reduction of microvascular and neuropathic complications of diabetes.3

It is generally accepted that in order to effectively manage diabetes, education about 

components of management such as blood glucose monitoring, insulin replacement, diet, 

exercise, and problem solving strategies must be delivered to the patient and family. 

Education seems necessary both at diagnosis, where there is usually no knowledge base 

and patient and family are given the basic skills for controlling the disease,4

 and 

throughout the patient’s lifetime, with ongoing attention to self-management skills, 

screening and prevention of complications, and new developments in these areas. Since 

management of diabetes requires lifestyle changes, most clinicians feel it is important for 

education to be delivered to the whole family. The following report attempts to determine 

whether there is evidence to support the general belief that diabetes education is 

necessary and/or beneficial. 
18

Current Standards 

The American Diabetes Association (ADA) has published standards regarding 

diabetes management in children95 and self-management education.96 Key points are that 

management should involve a physician-coordinated team of professionals and should 

recognize the interaction between parent and family, physician, and other members of the 

health care team. Individual factors (age, schedule, culture, family dynamics, 

developmental stage, and physiologic differences related to maturity) should be 

considered when developing a treatment plan. The goal for glycemic control is to selfmonitor and to achieve an HbA1c measure as close to normal as possible in the absence 

of hypoglycemia. Severe or frequent hypoglycemia indicates the need to modify 

treatment regimens, including setting higher glycemic goals. Since hypoglycemia is more 

of a concern in children, the optimum glycemic goals for children are set according to age 

and are higher in younger children. 

Medical nutrition therapy, the nutrition education and counseling that is intended to 

help people with diabetes achieve optimal blood glucose control, should be 

individualized. Education can help people to balance and adjust their food choices 

according to their activity and insulin levels, avoid and treat hyperglycemia and 

hypoglycemia, and adjust meal patterns when feeling ill.97 The amounts and types of 

carbohydrates in food affect blood glucose level and need monitoring; however, a lowcarbohydrate diet is not recommended. The recommended diet for diabetics is now closer 

to the recommended guidelines for all Americans, thereby eliminating the need to use 

special diabetic foods.97 In children, medical nutrition therapy should be provided at 

diagnosis and reviewed annually to ensure normal growth. 

Diabetes self-management education (DSME) is considered an integral component of 

care and is recommended at diagnosis and thereafter. DSME helps people with diabetes 

initiate effective self-care when first diagnosed and also helps people maintain effective 

self-management as diabetes presents new challenges and as treatment advances become 

available. In children, education must take into account that younger children will require 

adult supervision. As children mature, it is expected that they take on more responsibility 

for their own monitoring and care. An issue in this transition is adherence to insulin and 

diet regimens. 

DSME helps patients optimize metabolic control, prevent and/or manage 

complications, and maximize their quality of life in a cost effective manner. It is 

reimbursed as part of the Medicare program.96

Intensive Diabetes Management and DCCT 

The Diabetes Control and Complications Trial (DCCT) demonstrated that intensive 

therapy was highly beneficial in decreasing the incidence of complications in type 1 

diabetes.98 Intensive therapy included the administration of insulin by injection or pump 3 

or more times daily. The dosage was adjusted in accordance with the results of selfmonitoring of blood glucose at least 4 times per day, dietary intake, and anticipated 

exercise. Specific blood glucose concentration goals were set and patients visited the 
19

study center each month and were in telephone contact to review and adjust regimens. 

This was in contrast to conventional treatment, which had one or two daily injections of 

insulin, daily self-monitoring of urine or blood glucose, education about diet and 

exercise, and did not usually include daily adjustments in insulin dosage. Goals included 

absence of symptoms and maintenance of normal growth and development, but not 

specific blood glucose targets. 

Followup demonstrated that the benefit of intensive therapy in decreasing 

complications was maintained. This trial established a new philosophy of treatment in 

using a multidisciplinary team approach and using adjustments based on data monitored 

by the patient. It is of interest to know if families can be educated to use this intensive 

style of management outside the trial setting. 

Educational Interventions 

Educational interventions can take many forms. Didactic education, computer games, 

board games, cognitive behavioral therapy, and telephone calls are some of the possible 

methods of delivery. The education may be directed at the patient alone, parent alone, the 

whole family, and even peers. Education delivered at diagnosis is different than the 

education on self-management that occurs throughout the patient’s lifetime. At diagnosis, 

the skills needed to manage the disease are first introduced. Later, education may be 

needed to adjust to the ongoing challenges of developmental changes with a chronic 

disease, and to keep apprised of new treatments. The aim of the educational interventions 

may be, among other things, to improve metabolic control, reduce complications, gain 

skills in self-management, or improve quality of life. 

Reviews of educational and psychosocial interventions for adults with diabetes have 

been conducted and have shown beneficial effects.4

 Those reviews that have examined 

programs targeted to meet the particular needs of children have primarily focused on the 

adolescent population.4,99 The systematic review by Grey et al. (2000)21 appears to be the 

only one that has assessed diabetes education for both children and adolescents.21 The 

review by Gage et al. (2004)4

 found that most interventions could be categorized into 

programs focusing on knowledge/skills, psychosocial issues, and behavior/selfmanagement. They found that there were modest improvements across outcomes such as 

behavior and metabolic control but that there was little evidence regarding their longterm effectiveness. They also reported that hospital inpatient education at diagnosis was 

not significantly more effective than home based education and suggested that education 

may be most beneficial in patients whose metabolic control is poor. The review on 

psychological interventions by Winkley et al. (2006)100 found that psychological 

treatments such as supportive or counseling therapy, cognitive behavior therapy, 

psychoanalytically informed therapies, and family systems therapy improved glycemic 

control in children and adolescents with diabetes but had no effect in adults. The review 

by Grey et al.,21 which examined education in children specifically, concluded that 

educational interventions were useful in improving diabetes knowledge, but they were 

not consistently useful in improving metabolic control. They also reported that 

psychosocial interventions such as coping skills training helped adolescents to improve 
20

adjustment and metabolic control, and that family interventions may be helpful in 

reducing parent-child conflict about diabetes management. 

Objective of this Evidence Report 

The objective of this review is to synthesize the evidence examining the effectiveness 

of diabetes education on day-to-day management of diabetes as it relates to metabolic 

control, health care utilization, complications, knowledge about management, and its 

effect on psychosocial issues and metabolic control, and intensive diabetes management. 

The Key Questions 

The key questions for this Task Order are: 

1. What is the evidence that diabetes education on day-to-day management of diabetes 

improves metabolic control (as determined by glycosylated hemoglobin76 [HbA1c] 

values, numbers of diabetes-related hospitalizations, frequency of diabetic 

ketoacidosis [DKA] and numbers of episodes of hypoglycemia)? 

2. What is the evidence that medical nutrition therapy education in day-to-day 

management of diabetes improves HbA1c values and results in less variability in 

blood glucose levels? 

3. What is the evidence that diabetes education results in improved long-term 

management of diabetes, including better adherence to recommendations made in 

clinic and decreased hospitalizations and emergency room visits for diabetes-related 

complications? 

4. What is the evidence that diabetes education programs improve knowledge about 

diabetes management? 

a. What is the evidence that this knowledge increases the child’s self-confidence in 

his or her ability to handle the disease and has a positive impact on the child’s 

quality of life (QOL) and other psychosocial issues (e.g., school absences, school 

performance, adherence to a medical regimen)? 

b. What is the evidence that this knowledge improves long-term metabolic control 

(i.e., decreases or prevents diabetes-related complications), as shown in the 

Diabetes Control and Complications Trial (DCCT) (as measured by retinal, renal, 

cardiovascular and neurological evaluations), in children of families who receive 

these diabetes education or medical nutrition therapy program services compared 

to children of families who do not receive these services? 

5. What is the evidence that training in intensive diabetes management (consistent with 

DCCT, including blood glucose monitoring at least 4 times a day, 3 or more daily 

insulin injections or use of an insulin pump and education on when and how to adjust 

insulin doses) conducted in the practitioner setting yields: 

a. Improved metabolic control, (as determined by HbA1c values, numbers of 

diabetes-related hospitalizations, frequency of DKA and numbers of episodes of 

hypoglycemia)? 
21

b. A decrease in or prevention of diabetes-related complications (as measured by 

retinal, renal, cardiovascular and neurological evaluations), as demonstrated by 

DCCT? 
23

Chapter 2. Methods 

In this chapter, we document a prospectively designed protocol that the University of 

Alberta/Capital Health Evidence-based Practice Center (UA/CH EPC) used to develop this 

evidence report. To accomplish the tasks as directed, a core research team at the UA/CH EPC 

was assembled. In consultation with the Agency for Healthcare Research and Quality 

(AHRQ) Task Order Officer (TOO) and the American Academy of Pediatrics (AAP) 

representatives, a Technical Expert Panel (TEP) was invited to provide high-level content 

and methodological expertise in the development of the report (Appendix A).∗ 

In developing a framework for the report, the five key questions were considered parts of 

a larger question about the effectiveness of diabetes education for children and their families 

for various short- and long-term physical (metabolic) and psychosocial outcomes (Figure 1). 

Figure 1. Analytical framework for evidence report on the effectiveness of diabetes education 

 

∗

Appendixes and evidence tables cited in this report are provided electronically at http://www.ahrq.gov/clinic/tp/diabetp.htm 
24

Literature Search and Retrieval 

We systematically searched the following electronic resources: MEDLINE® Ovid, Ovid 

MEDLINE® In-Process & Other Non-Indexed Citations, Cochrane Central Register of 

Controlled Trials (contains the Cochrane Metabolic and Endocrine Disorders Group, which 

hand searches journals pertinent to its content area and adds relevant trials to the registry), 

Cochrane Database of Systematic Reviews (CDSR), Database of Abstracts of Reviews of 

Effects (DARE), HealthSTAR, EMBASE, CINAHL®, ERIC, PsycINFO®, CINAHL Plus 

with Full Text (EBSCO), Science Citation Index Expanded® and Social Sciences Citation 

Index® (both via ISI Web of KnowledgeSM), PubMed®, LILACS (Latin American and 

Caribbean Health Science Literature), Proquest® Dissertations & Theses, CRISP (Computer 

Retrieval of Information on Scientific Projects), National Library of Medicine (NLM) 

Gateway, OCLC ProceedingsFirst and PapersFirst, and trial registries such as The National 

Research Register, ClinicalTrials.gov, and Current Controlled Trials. We also searched the 

websites of relevant professional associations and research groups including the National 

Institute of Diabetes and Digestive and Kidney Diseases (NIDDK), American Association of 

Diabetes Educators, European Association for the Study of Diabetes (EASD), and TRIP 

Database (Turning Research Into Practice) for additional unpublished controlled trials and 

reports. The reference lists of relevant reviews and included studies were reviewed, and 

authors of included studies were contacted as required (e.g., to clarify the source of 

population in cases of multiple publications or to seek additional data). This search was 

limited to English language studies published after 1982. The search was not limited by study 

design or publication status. It is considered current up to March 2, 2007. 

For the search strategies, a combination of subject headings and keywords were 

developed for each electronic resource using the following terms: diabetes mellitus, type 1, 

IDDM, diabetes mellitus, DM, insulin dependent diabetes mellitus, early diabetes mellitus, 

juvenile diabetes mellitus, labile diabetes mellitus, autoimmune diabetes mellitus, sudden 

onset diabetes mellitus, diabetic ketoacidosis, DKA, ketoacidosis, patient education, health 

education, patient care management, self-care, self-regulation, self-monitoring, selfmanagement, home care services, school health services, diabetic diet, diet therapy, nutrition 

therapy, nutrition education, diabetes education, health behavior, attitude to health, 

counseling, adolescent psychology, child psychology, behavior therapy, cognitive therapy, 

family therapy, outcome assessment (health care), attitude to health, program, intervention, 

inform, teach, train, learn, educate, effect, impact, knowledge, skill, cope, video, game, 

telephone, self-help groups, treatment program, hypoglycemia, blood glucose, selfmonitoring, self-monitoring blood glucose, glycosylated hemoglobin A, hemoglobin A, 

HbA1c, metabolic control, glycemic control, self-efficacy, program evaluation, treatment 

outcome, health behavior, problem solving, compliance, improve, quality of life, 

hospitalization, admission, and service utilization. Appendix B∗

 documents the exact search 

strategy for each database. 

 

∗

Appendixes and evidence tables cited in this report are provided electronically at http://www.ahrq.gov/clinic/tp/diabetp.htm
25

Study Selection 

Our inclusion and exclusion criteria were developed in consultation with the TEP and are 

documented in Table 2. In consultation with the TEP, we made a post hoc decision to 

exclude studies that had 10 or fewer study participants. 

Table 2. Inclusion and exclusion criteria for studies assessing the effectiveness of diabetes education 

for children and their families 

Study design Include: Any study design 

Exclude: Studies with ≤10 participants 

Participants Children aged 0 to 18 years with type 1 diabetes mellitus or families of children with 

type 1 diabetes mellitus 

Interventions Diabetes education programs that incorporate at least one of the following content 

areas: (1) diabetes disease process and treatment options; (2) nutritional 

management; (3) physical activity; (4) monitoring blood glucose, urine ketones 

(when appropriate), and using the results to improve control; (5) utilizing 

medications; (6) preventing, detecting, and treating acute complications; (7) 

preventing (through risk reduction behavior), detecting, and treating chronic 

complications; (8) goal setting to promote health and problem solving for daily 

living; (9) psychosocial adjustment 

Outcomes Include: Metabolic control (HbA1c), hospitalization, ED utilization, short-term 

complications (e.g., diabetic ketoacidosis, episodes of hypoglycemia), long-term 

complications (retinal, renal, cardiovascular, neurological), quality of life, school 

attendance and performance, self-confidence in ability to cope with disease, 

psychosocial outcomes 

Exclude: lifestyle outcomes (e.g., smoking, use of recreational drugs, participation in 

extracurricular activities) 

ED = emergency department

We used a two-step process for article screening. First, two reviewers independently 

screened the titles and abstracts (when available) to determine if an article met the general 

inclusion criteria. Each article was rated as “include,” “exclude,” or “unclear.” The full text 

of all articles classified as “include” or “unclear” was retrieved for formal review. Next, two 

reviewers independently assessed each study using a standard inclusion/exclusion form 

(Appendix C).∗

 Disagreements were resolved by consensus or third party adjudication. 

Assessment of Methodological Quality 

The methodological quality of randomized controlled trials (RCTs) and controlled 

clinical trials (CCTs) was assessed independently by two reviewers using two quality 

assessment instruments. They were not blinded to authors, setting, or results. First, a fivepoint scoring system validated by Jadad101 (Appendix C)*

 was used to assess randomization, 

double blinding, and reporting of withdrawals and dropouts. These components are 

associated with a risk of bias. Second, allocation concealment, failure of which has been 

associated with an increase in the potential for selection bias, was assessed as adequate, 

inadequate, or unclear.102,103 Decision rules regarding the application of the tools were 

developed a priori and discrepancies were resolved through discussion between the two 

reviewers. In addition, the funding source was recorded.104

 

∗

Appendixes and evidence tables cited in this report are provided electronically at http://www.ahrq.gov/clinic/tp/diabetp.htm
26

A post hoc assessment of blinding of outcome assessors was carried out for all RCTs and 

CCTs. Studies were given credit for this component if they described procedures for blinding 

outcome assessors to treatment allocation of study participants. Disagreements were resolved 

through discussion between reviewers. 

The methodological quality of all other study designs was assessed independently by two 

reviewers using the Thomas Quality Assessment Tool for Quantitative Studies105-107

(Appendix C).∗ The tool aims to provide assessment criteria applicable to any study design 

and includes 21 items separated into 8 categories: selection bias, study design, confounders, 

blinding, data collection methods, withdrawals and dropouts, intervention integrity, and 

analysis. Following completion of the tool, reviewers provide an overall rating of the study 

(strong/moderate/weak) for each of the first 6 components. Decision rules for the application 

of the tool were developed a priori through discussions with the lead investigators. 

Discrepancies were resolved through discussion between the two reviewers. 

Grading the Body of Evidence 

To assess the strength of evidence for the key outcomes (HbA1c, short-term 

complications, knowledge of diabetes, self-management skills, coping with diabetes and 

quality of life), we used the approach developed by the Grading of Recommendation 

Assessment, Development, and Evaluation (GRADE) working group.108-110 This approach 

assesses the evidence based on five key elements: the strength of the study designs providing 

the evidence, the quality of the studies, the consistency of the estimates of effect across 

studies, the precision or degree of certainty surrounding an effect estimate, and the directness 

of the link between the intervention and outcome measures. We classified the strength of 

evidence as high, moderate, low, or very low. Decision rules for the application of the 

GRADE approach were developed a priori, and two reviewers scored each element 

independently. Differences in assessment were resolved by consensus. 

Data Extraction 

Data were extracted using standardized forms and entered into a Microsoft Access 

database (Microsoft Corp., Redmond, WA) (Appendix C).*

 Data were extracted by one 

reviewer (AM, CS, ES, or KO) and checked for accuracy and completeness by a second 

(AM, CS, ES, KO or YL). Extracted data included study characteristics, inclusion/exclusion 

criteria, and the characteristics of participants, interventions, and outcomes described in 

Table 2. Reviewers resolved discrepancies in data extraction by consensus or in consultation 

with a third party. 

The following broad categories were used to group studies by outcome: HbA1c, 

knowledge of diabetes, skills and self-management behaviors, psychosocial outcomes (e.g., 

coping skills, self-esteem, quality of life), complications (short- and long-term), and health 

service utilization (e.g., hospitalizations). After reviewing the included studies, we grouped 

interventions into the following broad categories: general diabetes education (which included 

education given to both inpatients and outpatients on topics addressing etiology, clinical 

course, and general management of the disease), skills training (including training in skills 

 

∗

Appendixes and evidence tables cited in this report are provided electronically at http://www.ahrq.gov/clinic/tp/diabetp.htm
27

related to self management, insulin injections, adherence, and nutrition), cognitive behavioral 

therapy (including techniques such as problem solving, goal setting, behavior modification, 

stress management, and coping skills), family systems therapy (including techniques that 

focus on family communication skills and the role of family interaction in adherence to 

health regimens), medical nutrition therapy, psychoeducation, physical activity, and diabetes 

camps. Within the parameters of each outcome and intervention, we also extracted and 

presented the results by population type: the general population of children with diabetes, 

children that were newly diagnosed with diabetes, and children who have poor metabolic 

control. For the purposes of this report, we considered an absolute change in HbA1c of 0.5 

percent (e.g. from 9.0 percent to 8.5 percent) to be a clinically important difference. 

Data Analysis 

The following data assumptions were made and imputations performed to transform 

reported data into the form required for analysis for this review. Graph extraction was 

performed using CorelDRAW®9.0 (Corel Corp., Ottawa, Canada). If necessary, means were 

approximated by medians, and 95 percent empirical confidence intervals were used to 

calculate approximate standard deviations (SD). Change from baseline data at various time 

points were used whenever possible for continuous data; however, since correlations between 

baseline data and endpoint data were never reported, a correlation of 0.5 was assumed111 to 

calculate the appropriate SD for the change from baseline data. Change from baseline and 

endpoint data were combined in the same meta-analysis; both figures estimate the difference 

between treatment groups.112 For multiarm studies, data from similar treatment groups were 

combined if appropriate. 

 Quantitative results were meta-analyzed in Review Manager version 4.2.5 (The 

Cochrane Collaboration, Copenhagen, Denmark). Dichotomous results (e.g., 

hospitalizations), are reported as relative risks (RR) for individual studies and a pooled result 

was calculated for those studies that could be combined. For continuous variables measured 

on the same scale (e.g., HbA1c), mean differences were calculated for individual studies, and 

the weighted mean difference (WMD) was calculated for the pooled estimate. For continuous 

variables measured on different scales (e.g., knowledge of diabetes), mean differences were 

calculated for separate studies and the standardized mean difference (SMD) was calculated 

for the pooled estimate. All results are reported with 95 percent confidence intervals (95% 

CI), when possible. 

Due to expected differences among studies, we decided a priori to combine results using 

random effects models.113 Statistical heterogeneity was quantified using the I-squared (I2

) 

statistic.114 A value greater than 50 percent was considered to be substantial heterogeneity, 

and grounds for not presenting the combined results.114

For our primary outcome, HbA1c, we tested visually for publication bias using the funnel 

plot and quantitatively using the rank correlation test,115 the graphical test,116 and the trim 

and fill method.117 Publication bias calculations were performed using STATA 7.0 

(STATACorp., College Station, TX). 
28

Peer Review 

Eight experts in pediatric endocrinology, diabetes education, or medical nutrition 

education agreed to act as peer reviewers (Appendix A)∗

 and were sent a copy of the draft 

report. Reviewers had one month in which to provide critical feedback. All comments and 

authors’ replies were submitted to the AHRQ for assessment and approval. The draft report 

was amended based on reviewers’ comments. 

 

∗

Appendixes and evidence tables cited in this report are provided electronically at http://www.ahrq.gov/clinic/tp/diabetp.htm 
29

Chapter 3. Results 

Literature Search 

The combined search strategies identified 12,740 citations from electronic databases 

and 17 references identified by gray literature and hand searching. Through screening 

titles and abstracts, 473 references were identified for further examination. The 

manuscripts of 46 articles could not be retrieved (Appendix D).∗

 The majority of these 

studies were abstracts from conference proceedings and dissertations. They were 

requested through the university interlibrary loan service, but did not arrive within the 7-

month cutoff that we established for article retrieval. Therefore, the full text of 427 

potentially relevant articles was retrieved and evaluated for inclusion in the review. The 

application of the selection criteria to the 427 articles resulted in 100 articles being 

included and 327 excluded. Figure 2 outlines study retrieval and selection for the review. 

From 100 included articles, 145,6,9,21,24,28,30,38,52,66,70,79,82,83 were associated with 

multiple publications that either expanded on the main results of the primary study or 

reported secondary outcomes not included in the main report. The secondary publications 

were not considered as unique studies and any information they provided was included 

with the data reported in the primary study. In most instances, the report that provided 

data for the longest followup period was regarded as the primary study; otherwise, the 

study that was published first was considered the main one. Appendix E* identifies the 

associated secondary publications for each primary study. In total, 80 primary studies 

were included in this report.5-84

The four main reasons for excluding studies from this review were (1) the population 

did not include children (≤ 18 years) with type 1 diabetes or their families (n = 108), (2) 

the study was not primary research on diabetes education (e.g., systematic reviews, 

descriptive studies) (n = 93), (3) the study did not address diabetes education (n = 50), 

and (4) the study did not include a description of the intervention in sufficient detail to 

replicate it or report measurable data for outcomes relevant to the review (n = 37). Thirtyeight studies were excluded for other reasons including small sample size (n = 9). The list 

of excluded studies and reasons for exclusion are identified in Appendix D.*

 

∗

Appendixes and evidence tables cited in this report are provided electronically at http://www.ahrq.gov/clinic/tp/diabedtp.htm 
30

Figure 2. Flow-diagram for study retrieval and selection 

Description of Included Studies 

Eighty primary studies provided evidence regarding the effectiveness of diabetes 

education for children with type 1 diabetes and their families. Tables F1 and F2 

(Appendix F)∗

 summarize the key characteristics of studies included in the review. 

Studies were published between 1983 and 2007 (median = 1996 [IQR, 1990 to 2001]). 

Most of the studies (88 percent) were published as peer reviewed publications; the 

remainder were theses or dissertations. Studies were conducted in the United States (64 

percent), Europe (21 percent), Canada (9 percent), and other regions (6 percent). 

Of the 80 included studies, 42 (53 percent) were RCTs. All were parallel trials. Eight 

of the trials had three arms5,13,17,32,52,63,82,83 and one had four arms.24 Eleven (14 percent) 

 

∗

Appendixes and evidence tables cited in this report are provided electronically at http://www.ahrq.gov/clinic/tp/diabedtp.htm
31

of the included studies were CCTs,7,14,19,42,45,48,51,62,74,76,84 and 20 (25.0 percent) were 

uncontrolled before-after studies.11,12,20,27,28,34,35,37,44,50,53,61,64,65,67,68,73,75,77,78 There were 

seven (9 percent) cohort studies: three prospective cohorts with concurrent controls,29,66,69

two prospective cohorts with historical controls,40,54 and two retrospective cohorts.39,41 

The number of enrolled participants in the studies ranged from 11 to 332 (median = 

50 [IQR, 30 to 89]). The mean age of study participants ranged from 2.7 to 16 years. For 

28 studies (35 percent), the mean age of participants was less than 12 years.11,17-

19,22,24,26,30,32,35,36,38,40-44,47,49,50,55,66,70,71,77,78,80,84 Ten17-19,26,30,40,49,66,69,70 studies (13 percent) 

examined education interventions delivered to children and their families at the time of 

diagnosis with type 1 diabetes. Fourteen studies8,13-16,25,28,34,43,51,55,57,76,83(18 percent) 

examined interventions targeted at children who demonstrated poor metabolic control, 

which was defined as children with HbA1c above a certain level, as well as, in some 

studies, problems with adherence control. Although the populations of several other 

studies had mean HbA1c levels equivalent to or higher than those exhibited by children 

in studies targeted for poor metabolic control (i.e., greater than 9.0 percent),5,7,10-

12,21,24,25,31-33,36,39,46,47,56,63,72,79,80,82,84 the samples in these studies were not specifically 

selected on this basis and, therefore, were not included in this grouping. 

The interventions examined were diverse. We grouped the interventions into nine 

broad categories. General diabetes education was assessed in 21 studies (26 

percent).9,15,18,24,30,32,39,41,42,44,50,55,61,65,66,69,71,73,75,77,79 Cognitive behavioral therapy and its 

variants was evaluated in 24 studies (30 percent).6-8,13,14,16,17,19-23 25,31,33,45,47,48,54,72,74,76,80

Family therapy interventions were considered in nine studies (11 

percent).5,26,28,36,38,63,70,82,83 Skills training programs were the focus of seven studies (8.8 

percent).11,40,43,49,52,53,57 Programs that were delivered as part of a diabetes camp were 

assessed in 17 studies (21 percent).12,29,60,67,78 27,34,35,37,46,58,59,62,64,68,81,84 The remaining 

interventions included psychotherapy51,56 and a physical activity program (3 percent).10 

 Only 20 of the included studies (25 percent) explicitly described the theoretical 

framework upon which they were based (e.g., anchored instruction, social cognitive 

theory).9,17,22,26,28-30,33,46,51,58-60,62,64,70,77,80,83,84 

More than half of the interventions (n = 43; 54 percent) were targeted at both children 

and parents or the family. Thirty-two education programs were delivered directly to the 

child.7-10,12-14,21,23,25,27,31,33-35,37,42,45,46,50,57-60,62,64,66-68,81,84 Parents were the target audience 

in four studies (5 percent).19,30,36,44 In one study,20 the intervention focused on the child 

and a close friend; in another, the intervention was aimed at the child, family, and school 

staff.54

The education interventions were delivered in a variety of settings. Most took place in 

a health care setting, such as a diabetes center (n = 12, 15 percent), outpatient clinic (n = 

9, 11 percent), hospital (n = 10, 13 percent) or a combination of health care setting and 

other location (n = 15, 19 percent). A diabetes camp was the setting for 17 studies (21 

percent). The education program was delivered at home in six studies (8 percent) and at 

summer school in one study. In 11 studies (14 percent), the setting in which the 

intervention took place was either not reported or unclear. 

The duration of the education intervention ranged from 1 day to 2 years. For 28 

studies (35 percent), the interventions were delivered for less than 1 month. For 10 

studies (13 percent) the education program took place over 1 year or 
32

longer.5,6,11,17,18,21,38,54,71,79 The duration of the intervention was not reported in six studies 

(8 percent). 

Followup assessments were defined as those taken at time points after the immediate 

post-intervention assessment. In 21 studies (26 percent),6,9-

12,20,21,24,27,31,32,38,41,50,57,60,64,73,79,81,118 there were no outcome measurements taken after the 

post-intervention assessment, including studies in which outcomes were measured 

throughout the delivery of the education program. In 55 studies that identified specific 

followup periods, the periods ranged from 2 days to more than 4 years (median = 6 

months [IQR, 3 to 12 months]). In two19,42 studies (3 percent), the followup periods were 

not consistent among participants and were reported in ranges (i.e., 4 to 22 weeks and 6 

to 24 months). In one54 study, the followup was reported as 248 patient-years with 122 

participants completing the study. The followup period was not reported in two45,68

studies (3 percent). The followup period was less than 3 months in five23,25,26,58 studies (6 

percent). Followup assessments took place between 3 and 5 months in 18 studies (23 

percent)7,8,13,15,16,29,33,36,37,44,46,47,62,67,72,78,80,84 and between 6 and 11 months in 10 studies 

(13 percent).22,28,30,56,59,61,63,65,77,83 For the remaining 21 studies (26 percent), the followup 

assessments were measured at 12 months or more. 

Methodological Quality of Included Studies 

Randomized Controlled Trials 

 Overall, the methodological quality of the 42 RCTs was low (median Jadad101 score = 

2/5; IQR, 1 to 2). The Jadad score was 3 for 4 trials,30,55,57,83, 2 for 31 trials5,6,10,16-18,21,24-

26,31-33,36,38,43,46,47,56,60,72,82 13,15,22,23,58,59,70,71,81 and 1 for 7 trials8,9,49,52,63,79,80 (Table 3). All 

were described as randomized; however, the descriptions of randomization varied. Five 

were adequately randomized;30,32,55-57,83 the rest were unclear. Two trials reported clear 

concealment of allocation30,83 and the remaining trials were unclear. No trials were 

described as double-blind (patient and outcome assessor blinded). Withdrawals and 

dropouts were clearly described in 33 trials; in 9 studies, withdrawals and dropouts were 

not described.8,9,32,49,52,56,63,79,80 The post hoc assessment of blinding revealed that 11 

RCTs had included an attempt to blind outcome assessors.17,18,21,23,26,52,56,56,59,71,72,80

The most common source of funding was government (n = 24, 57 percent of RCTs). 

Three trials (7 percent) received funding from industry.9,25,43 Other sources of funding 

included foundations (n = 10, 24 percent), internal (n = 7, 17 percent), and private (n = 4, 

10 percent). For nine trials (21 percent), the funding is not known.13,15,26,32,36,49,79-81

Several trials received funding from multiple sources (Table 3).5,9,16,17,21,33,38,52,71

Controlled Clinical Trials 

 The methodological quality of the 11 CCTs was low (median modified Jadad101 score 

= 1/3; IQR, 0 to 1) (Table 4). Seven CCTs (64 percent) obtained only 1 point for the 

individual components of the Jadad scale, all for the description of withdrawals and 

dropouts. The remaining four trials did not score any points.42,45,51,84 

The CCTs received funding from government sources (n = 2), foundations (n = 2), 

internal (n = 2), and private sources (n = 2) (Table 4). One trial received funding from 
33

multiple sources.51 For six studies (55 percent), the funding source is not 

known.7,42,45,48,62,84

Before and After Studies

 The quality of reporting of the 20 before-and-after studies was evaluated using 

individual components of the Thomas tool.105 Overall, the methodological quality of the 

before-and-after studies was weak (Table 5 and Table F3, Appendix F).∗ For 10 (50 

percent) studies participants were unlikely to be representative of the target population 

and were rated as weak on the selection bias component. The remaining studies were 

rated as moderate. Control of potential confounders (age, sex, duration of diabetes, 

socioeconomic status) was rated as weak for 13 (65 percent) studies. None of the studies 

reported the blinding of outcome assessors to the intervention. Data collection methods 

were rated as strong for 12 (60 percent) studies. For the remaining eight, the reliability 

and validity of the data collection tools was not reported. The risk of attrition bias was 

moderate with 14 (70 percent) studies rated as strong or moderate on this component. 

Data analysis was appropriate in most studies. None of the studies provided a sample size 

calculation. Nine studies reported a statistically significant difference between groups for 

the primary outcome, five studies found no significant differences, and six studies did not 

report whether group differences were statistically significant. Overall, the intervention 

integrity was moderate. For 19 (95 percent) studies, over 80 percent of participants 

received the allocated intervention. Methods to assess the consistency of the intervention 

were included in eight (40 percent) studies; for the remainder they were not reported. For 

most studies (n = 14, 70 percent), it was unlikely that contamination occurred or that 

there was a cointervention. For the remaining six, there was insufficient information to 

answer this question. Finally, funding source was disclosed in 70 percent (n = 14) of the 

before-and-after studies (Table 5). 

Cohort Studies 

 The quality of reporting of the seven cohort studies was evaluated with individual 

components of the Thomas tool.105 (Table 5 and Table F3, Appendix F).*

 Overall, the 

methodological quality was moderate. Most studies did a reasonable job of protecting 

against selection bias with five of seven (71 percent) choosing study groups that were at 

least somewhat representative of the target population. The risk of attrition bias was low; 

all but one study included a description of the number of withdrawals and the followup 

rates were unlikely to introduce differences between the comparison groups. Data 

collection methods were assessed as valid and reliable for six studies (86 percent). 

Control of potential confounders (age, sex, duration of diabetes, socioeconomic status) 

either in the design or analysis was rated as weak for six (86 percent) studies and as 

moderate in one study (14 percent). No studies reported that the ascertainment of 

outcome exposure was blinded. For all studies data analysis was considered appropriate. 

None of the studies provided a sample size calculation; however, four studies (57 

 

∗

 Appendixes and evidence tables cited in this report are provided electronically at http://www.ahrq.gov/clinic/tp/diabedtp.htm 
34

percent) reported a statistically significant difference between groups for the primary 

outcome. Intervention integrity was good. In six studies (86 percent), over 80 percent of 

participants received the allocated intervention and the risk of contamination or 

cointervention was low. Finally, three of the cohort studies (43 percent) reported the 

source of funding (Table 5). 
35

Table 3. Methodological quality and source of funding of randomized controlled trials assessing the effectiveness of diabetes 

children with type 1 diabetes and their families 

Author Year Randomization Double Blinding 

Stated Method 

Described 

Stated Method 

Described 

Description 

of 

Withdrawals/ 

Dropouts 

Jadad 

Score 

(out of 5) 

Allocation 

Concealment 

Anderson6 1989 Yes No No No Yes 2 Unclear Anderson5 1999 Yes No No No Yes 2 Unclear Boardway8 1993 Yes No No No No 1 Unclear Brown9 1997 Yes No No No No 1 Unclear Campaigne10 1985 Yes No No No Yes 2 Unclear Cigrang13 1992 Yes No No No Yes 2 Unclear Coupland15 1992 Yes No No No Yes 2 Unclear Delamater17 1990 Yes No No No Yes 2 Unclear Delamater16 1991 Yes No No No Yes 2 Unclear Dougherty18 1999 Yes No No No Yes 2 Unclear Grey21 2000 Yes No No No Yes 2 Unclear Gross23 1983 Yes No No No Yes 2 Unclear Gross22 1985 Yes No No No Yes 2 Unclear Hackett24 1989 Yes No No No Yes 2 Unclear Hains25 2000 Yes No No No Yes 2 Unclear Hakimi26 1998 Yes No No No Yes 2 Unclear Hoff30 2005 Yes Yes No No Yes 3 Adequate Horan31 1990 Yes No No No Yes 2 Unclear Howe32 2005 Yes Yes No No No 2 Unclear Kaplan33 1985 Yes No No No Yes 2 Unclear Kennedy-Iwai36

1991 

Yes No No No Yes 2 Unclear 

NR = not reported
36

Table 3. Methodological quality and source of funding of randomized controlled trials assessing the effectiveness of diabetes 

children with type 1 diabetes and their families (continued) 

Author Year Randomization Double Blinding 

Stated Method 

Described 

Stated Method 

Described 

Description 

of 

Withdrawals/ 

Dropouts 

Jadad 

Score 

(out of 5) 

Allocation 

Concealment 

Laffel38 2003 Yes No No No Yes 2 Unclear Mann43 1984 Yes No No No Yes 2 Unclear Massouh46 1989 Yes No No No Yes 2 Unclear McNabb47 1994 Yes No No No Yes 2 Unclear Mitchell49 1996 Yes No No No No 1 Unclear Nordfeldt52 2005 Yes No No No No 1 Unclear Nunn55 2006 Yes Yes No No Yes 3 Unclear Olmsted56 2002 Yes Yes No No No 2 Unclear Panagiotopoulos57

2003 

Yes Yes No No Yes 3 Unclear 

Pichert60 1993 Yes No No No Yes 2 Unclear Pichert58 1994a Yes No No No Yes 2 Unclear Pichert59 1994b Yes No No No Yes 2 Unclear Satin63 1989 Yes No No No No 1 Unclear Sundelin70 1996 Yes No No No Yes 2 Unclear Svoren71 2003 Yes No No No Yes 2 Unclear Szumowski72 1990 Yes No No No Yes 2 Unclear Wadham79 2005 Yes No No No No 1 Unclear Webb80 1999 Yes No No No No 1 Unclear Wolanski81 1996 Yes No No No Yes 2 Unclear Wysocki83 2000 Yes Yes No No Yes 3 Adequate Wysocki82 2007 Yes No No No Yes 2 Unclear 
37

Table 4. Methodological quality and source of funding for controlled clinical trials assessing the effectiveness of diabetes eduwith type 1 diabetes and their families 

Author Year Randomization Double Blinding 

Stated Method 

Described 

Stated Method 

Described 

Description 

of 

Withdrawals/ 

Dropouts 

Jadad 

Score 

(out of 3) 

Allocation 

Concealment 

Barglow7 1983 NA NA No No Yes 1 NA Couper14 1999 NA NA No No Yes 1 NA Golden19 1985 NA NA No No Yes 1 NA Lucey42 1985 NA NA No No No 0 NA Mason45 1985 NA NA No No No 0 NA Mendez48 1997 NA NA No No Yes 1 NA Moran51 1991 NA NA No No No 0 NA Remley62 1999 NA NA No No Yes 1 NA ThomasDobersen74 1993 NA NA No No Yes 1 NA Viner76 2003 NA NA No No Yes 1 NA Zorumski84 1997 NA NA No No No 0 NA NA = not applicable; NR = not reported 
38

Table 5. Methodological quality of before-and-after studies and cohort studies 

Author Year Selection 

Bias 

Study 

Design 

Confounders Blinding Data 

Collection 

Methods 

Withdrawals/ 

Dropouts 

F

Uncontrolled before-and-after studies Caravalho11 2000 Weak Weak Moderate Weak Strong Moderate NR Christensen12 2000 Weak Weak Weak Weak Weak Strong GovernmGreco20 2001 Moderate Weak Moderate Weak Strong Strong FoundatHarkavy27 1983 Moderate Weak Moderate Weak Weak Strong GovernmHarris28 2005 Weak Weak Weak Weak Strong Strong Internal Karaguzel34 2005 Weak Weak Weak Weak Weak Strong Internal Kemp35 1986 Weak Weak Weak Weak Strong Weak Industry Koontz37 2002 Moderate Weak Strong Weak Strong Weak NR Marteau44 1987 Weak Weak Weak Weak Weak Strong NR Monaco50 1996 Moderate Weak Weak Weak Strong Strong NR Povlsen61 2005 Weak Weak Weak Weak Weak Moderate GovernmSchlundt64 1996 Weak Weak Weak Weak Strong Weak GovernmShobhana65 1997 Moderate Weak Weak Weak Weak Weak Industry Smith68 1991 Moderate Weak Weak Weak Weak Strong NR Smith67 1993 Moderate Weak Moderate Weak Strong Weak NR Templeton73 1988 Weak Weak Weak Weak Weak Strong GovernmVerrotti75 1993 Weak Weak Moderate Weak Strong Strong NR von Sengbusch77 2006 Moderate Weak Moderate Weak Strong Strong Other Vyas78 1988 Moderate Weak Weak Weak Strong Moderate NR Cohort studies Hill29 2006 Weak Weak Weak Weak Strong Weak ProfessioLawson39 2000 Weak Weak Weak Weak Strong Strong FoundatLikitmaskul40 2002 Moderate Weak Weak Weak Strong Strong Private Lipman41 1988 Moderate Weak Weak Weak Strong Strong NR Nordfeldt541999 Strong Weak Weak Weak Weak Strong FoundatNordfeldt53 2002 Moderate Weak Weak Weak Strong Weak FoundatSiminerio66 1999 Moderate Weak Moderate Weak Strong Strong Internal Srinivasan69 2004 Moderate Weak Weak Weak Strong Strong NR 

NR = not reported 
39

Results of Included Studies 

This section is organized by major outcome categories: HbA1c, health service 

utilization, complications, knowledge, skills, behavior, psychosocial outcomes, quality of 

life, and school performance. For each outcome category, we provide a brief overview of 

the studies that contributed data to the outcome and a qualitative summary of the results. 

Due to considerable heterogeneity across the studies in terms of specific outcome 

measures, intervention, study population, and study design, we were unable to pool the 

results of any of the studies. 

HbA1c 

Overall, there were 52 studies that assessed the effectiveness of diabetes education in 

improving metabolic control as measured by HbA1c. Of these, 30 studies assessed the 

general population of children with type 1 diabetes, 8 studies focused on children with 

newly diagnosed diabetes, and 14 studied children with poorly controlled diabetes. 

General Diabetes Education—HbA1c 

 Description of studies. We identified 12 studies (7 RCTs,9,15,18,24,32,55,79 2 cohorts,39,69

3 uncontrolled before-and-after61,75,77) that assessed the effectiveness of general diabetes 

education on HbA1c. Studies were conducted in the United States,9,32 Europe,24,61,75,77,79

Canada,15,18,39 and Australia.55,69 The median year of publication was 2003 (IQR, 1995 to 

2005). 

The number of participants enrolled in the studies ranged from 28 to 146 (median = 

65 [IQR 35 to 109]). The mean age of participants ranged from 10 to 15.8 years (n = 9 

studies). For 3 studies, the mean age was less than 12 years.18,55,77 Two studies examined 

education interventions delivered to children and their families at the time of 

diagnosis.18,69 Two studies focused on children who demonstrated poor metabolic 

control.15,55

Most interventions were targeted to children and their parents or to the entire 

family;9,15,18,32,39,55,61,69,75,77,79 one was delivered to the child.24 The settings for the 

interventions were described as a hospital inpatient unit,61,77 outpatient clinic,24,79 or 

home.9

 For 5 studies, the setting was mixed (e.g., diabetes center and home).18,32,39,55,69

The setting was not clearly described in 2 studies.15,75 

Five studies did not measure HbA1c beyond the completion of the education 

program.9,24,32,55,79 In the 7 studies that reported post-intervention 

assessments,15,18,39,61,69,75,77 the median followup period was 12 months and ranged from 

3.5 to 36 months. 

Results 

 General population of children with diabetes. Howe et al.32 randomly assigned 75 

patients to one of three treatment groups: standard care (routine quarterly clinic visits), 

standard care plus one education session on basic diabetes management skills, and 

standard care plus the education session plus weekly telephone calls to review 
40

management techniques. At 6 months, mean HbA1c levels dropped slightly from baseline 

(0.3 percent, 0.4 percent, and 0.5 percent, respectively). The differences were not 

statistically significant; however, they do represent a clinical improvement for the 

education plus telephone call group. The trial was ended early due to lack of enrolment. 

The methodological quality of this study was rated as low (2/5 on the Jadad score; 

unclear allocation concealment). 

The retrospective cohort study (n = 28) by Lawson et al.39 compared intensive, 

individualized education to group education delivered to patients. The content for both 

interventions was the same. Both groups showed a statistically significant decrease in 

mean HbA1c at 3 months; however, over the next 12 months the HbA1c levels increased 

for both groups. For the individualized education cohort, the mean HbA1c remained 

significantly lower than at initiation of the program (9.5±0.3 vs. 8.2±0.4 percent, p = 

0.001); for the group education cohort, the mean HbA1c was not significantly different 

than baseline (8.2±0.4 vs. 8.1±0.3 percent). However, the baseline levels for the group 

education cohort were significantly lower than for the individual education group (p = 

0.02). The methodological quality of this study was rated as weak using the Thomas 

instrument. 

Povlsen et al.61 assessed the effect of an intervention targeted at 37 families from 

ethnic minority groups in Denmark. The intervention included adapted educational 

material and guidelines and re-education that focused on increasing knowledge and selfcare. The authors reported a significant difference in mean HbA1c levels immediately 

after the 12-month intervention (9.2±1.4 vs. 8.6±1.0 percent, p = 0.01); however, this 

improvement disappeared at the 6-month followup. The methodological quality of this 

study was rated as weak using the Thomas instrument. 

In an uncontrolled before-and-after study, von Sengbusch et al.77 assessed the impact 

of a mobile diabetes education service in a group of 107 children. Overall HbA1c levels 

for the whole cohort did not change significantly. The researchers conducted a post hoc 

subgroup analysis and found that among children with poor metabolic control (defined as 

HbA1c >8.0 percent), there was improved metabolic control from baseline to 6-month 

followup (9.4±0.9 vs. 8.6±1.5 percent, p<0.01). The methodological quality of this study 

was rated as moderate using the Thomas instrument. 

Brown et al.9

 randomly assigned 59 children and adolescents to a group that played a 

video game featuring characters with diabetes who manage their diabetes by monitoring 

blood glucose, taking insulin injections, and choosing foods, or a group that played a 

pinball video game with no information on diabetes. At the end of the 6-month study 

period, both groups exhibited higher levels of HbA1c (i.e., poorer metabolic control). 

There was no statistically significant difference between groups. The methodological 

quality of this study was rated as low (1/5 on the Jadad score; unclear allocation 

concealment). 

In the RCT by Hackett et al.,24 three cohorts of families received educational 

packages that were delivered over 8 months. The content was the same for all groups and 

included a nutrition therapy education component; one group (cohort 1) received a 

second reinforcement package for an additional 8 months. The comparison group did not 

receive the education package. Overall, the education program did not have an impact on 

HbA1c levels. The methodological quality of this study was rated as low (2/5 on the 

Jadad score; unclear allocation concealment). 
41

Wadham et al.79 conducted an RCT (n = 67) to evaluate a 4-session family centered, 

structured education program for adolescents and parents. The program focused on skillbased sessions and teamwork and communication between parents and adolescents. The 

control group received routine clinical care. Preliminary results at 6 months did not show 

any significant change in HbA1c levels for either group. The methodological quality of 

this study was rated as low (1/5 on the Jadad score; unclear allocation concealment). 

In an uncontrolled before-and-after study Verrotti et al.75 studied 30 adolescents who 

attended nine education sessions on general diabetes management. At the 12-month 

followup, mean baseline levels of HbA1c had decreased significantly (11.8±2.8 vs. 

10.0±2.7 percent, p = 0.019). The methodological quality of this study was rated as 

moderate using the Thomas instrument. 

 Children with newly diagnosed diabetes. Dougherty et al.18 randomly assigned 63 

newly diagnosed patients to a 24-month home-based diabetes education program or to 

traditional hospitalization and outpatient followup. Treatment differences between the 

groups consisted of duration of initial hospital stay, timing of initial teaching, and the 

nature and extent of subsequent nursing followup. Both groups exhibited significantly 

lower mean HbA1c values at the 3-month followup. These differences were still present 

at 36 months, 1 year after the intervention ended (10.5±1.3 vs. 6.4±1.4 percent for the 

home-based group and 10.0±1.3 vs. 7.1±1.3 percent for the hospital-based group). The 

difference between the two groups at 36 months was statistically significant. The 

methodological quality of this study was rated as moderate (2/5 on the Jadad score; 

unclear allocation concealment; blinding of outcome assessors). 

In the prospective cohort study by Srivivasan et al.69 a group of 61 newly diagnosed 

patients attended a diabetes day care program (DDCP) at which they received “survival 

skills” diabetes education. The pre-DDCP cohort comprised 49 patients who were 

admitted to hospital for 4 to 7 days for a detailed education program. Neither group 

demonstrated improvement in HbA1c levels at 3, 6 or 12-month followup. The 

methodological quality of this study was rated as moderate using the Thomas instrument. 

Children with poorly controlled diabetes. Nunn et al.55 randomly assigned 123 

patients to receive scheduled telephone calls from a pediatric diabetes educator or 

standard care (i.e., routine clinic visits but no telephone calls). Over the course of the 8-

month study HbA1c levels increased in both groups (i.e., poorer metabolic control). 

There was no statistically significant difference between groups. The methodological 

quality of this study was rated as high (3/5 on the Jadad score; unclear allocation 

concealment). 

In the RCT by Coupland15 adolescents and their families participated in a familybased intervention to improve adherence (n = 15); the comparison group (n = 14) 

comprised adolescents who were taught stress management techniques. At 6-month 

followup, both the intervention and comparison groups demonstrated significant 

improvements in mean HbA1c (11.6±1.41 vs. 9.8±2.23 percent and 11.3±1.22 to 

10.5±1.57 percent, respectively). There was no statistically significant difference between 

groups. The methodological quality of this study was rated as low (2/5 on the Jadad 

score; unclear allocation concealment). 
42

Cognitive Behavioral Therapy—HbA1c 

 Description of studies. Nineteen studies (14 RCTs,5,6,8,13,16,17,21,22,25,31,33,47,72,80 4 

CCTs,7,14,19,76 1 cohort54) examined various interventions that used cognitive behavioral 

therapy techniques. All but three studies were conducted in the United States; two were 

conducted in Europe,54,76 and one was conducted in Australia.14 The median year of 

publication was 1992 (IQR, 1989 to 1999) and ranged from 1983 to 2003. 

The number of participants enrolled in the studies ranged from 13 to 139 (median = 

31 [IQR 20 to 69]). The mean age of participants ranged from 2.7 to 15.4 years (14 

studies). For five studies, the mean age was less than 12 years.17,19,22,47,72 Two studies 

examined education interventions delivered to children and their families at the time of 

diagnosis.17,19 Six studies focused on children who demonstrated poor metabolic 

control.8,13,14,16,25,76

In seven studies the interventions were delivered to children;7,8,13,14,21,25,31 in two 

studies they were delivered to parents.19,33 In the remaining studies parents and children 

or the entire family were targeted.5,6,16,17,22,47,54,72,76,80 The settings for the interventions 

were described as a diabetes center,5,7,47 hospital inpatient unit,6,13,25 outpatient 

clinic,8,16,72,80 home,31 or summer school.33 In four studies, the setting was mixed (e.g., 

diabetes center and home).14,17,21,54 Two studies did not report the setting of the 

intervention.22,76 All but three studies6,19,31 conducted post-intervention assessments for 

HbA1c. The median followup period was 4 months and ranged from 1 month to 14 

months. 

Results 

 General population of children with diabetes. Anderson et al.6 randomized 70 

adolescents and parents to a group that received standard care (routine clinic visits) or a 

group that received standard care plus a problem solving intervention that focused on 

self-monitoring of blood glucose (SMBG) around meal planning. At completion of the 

18-month program, the intervention group exhibited a mean decrease of 0.37 percent in 

HbA1c levels compared with a mean increase of 0.62 percent in the standard care group. 

This difference was statistically significant (p = 0.04). The methodological quality of this 

study was rated as low (2/5 on the Jadad score; unclear allocation concealment). 

In a subsequent study, Anderson et al.5

 assessed the effectiveness of an intervention 

for families that focused on teamwork and shared parent-teen responsibility for diabetes 

tasks. Eighty-nine families were randomly assigned to the intervention group or to one of 

two comparison groups: standard care (routine clinical care from the diabetes team) or 

standard care plus didactic diabetes education. At the end of the 12-month program, there 

was no significant difference in mean HbA1c among the three groups. While the 

intervention group demonstrated improvement in HbA1c levels at the 12-month 

followup, there was no significant difference in change scores between the groups (-

0.20±1.1 percent for the teamwork group vs. 0.11±1.1 percent for the combined 

comparison groups). The methodological quality of this study was rated as low (2/5 on 

the Jadad score; unclear allocation concealment). 

Grey et al.21 randomly assigned 77 adolescents to receive intensive diabetes 

management (IDM) as described in the DCCT or IDM plus a behavioral program of 
43

coping skills training intervention. At the 12-month followup, both groups reported 

significant decreases in HbA1c levels. The change from baseline measures of HbA1c for 

the intervention group was greater than the control group and the difference was 

statistically significant (9.1±1.5 vs. 7.5±1.1 percent and 9.2±1.4 vs. 8.5±1.4 percent, 

respectively; p<0.001). The methodological quality of this study was rated as moderate 

(2/5 on the Jadad score; unclear allocation concealment; blinding of outcome assessors). 

In the study by Kaplan et al.,33 21 patients were randomly assigned to a group that 

received social skills training or a group that received lectures on diabetes. At the 4-

month followup, the social skills group reported improved HbA1c levels compared with 

the comparison group (12.6±2.4 vs. 11.72 percent [SD not reported] and 13.5±1.6 vs. 

14.42 percent [SD not reported]; p<0.05). The methodological quality of this study was 

rated as low (2/5 on the Jadad score; unclear allocation concealment). 

In a prospective study with historical controls, Nordfeldt and Ludvigsson54 examined 

the effect of multiple dose insulin therapy combined with problem-based training and 

psychosocial support. The prospective cohort comprised 248 children admitted to 

hospital in 1994 and 1995. The comparison group (156 patients admitted in 1980-81) 

received standard clinical care. The researchers reported that the annual mean levels of 

HbA1c were significantly lower in the cohorts that received intensive diabetes training 

compared with the historical cohort that did not receive the same level of education and 

support (6.9±1.3 percent [1994], 7.1±1.1 percent [1995] and 7.4±1.2 [1980-81]; p = 

0.004). The methodological quality of this study was rated as weak using the Thomas 

instrument. 

In the study by McNabb et al.47 24 children were randomly assigned to either a 6-

week self-management education program or to receive standard care (routine clinic 

visits). At the 6-week followup, HbA1c levels had decreased from baseline in both 

groups; however, the difference was not statistically significant (10.5±2.9 vs. 9.6±1.8 

percent and 12.9±3.8 vs. 12.5±3.4 percent, respectively). The methodological quality of 

this study was rated as low (2/5 on the Jadad score; unclear allocation concealment). 

Barglow et al.7 conducted a CCT (n = 42) to assess the effectiveness of a 4-month 

intensive multicomponent treatment and education program. The comparison group 

received standard care (routine clinic visits). At the 4-month followup both groups 

reported lower levels of HbA1c (change from baseline = -2.45±2.3 percent and -0.85±3.5 

percent, respectively); however, the difference was not statistically significant. The 

methodological quality of this study was rated as low (1/3 on the modified Jadad score). 

In the RCT by Gross et al.22 14 children and parents were randomly assigned to either 

behavior modification training or to a group that included discussion and role-playing. 

Both the intervention and comparison groups exhibited improvement in metabolic control 

at the 6-month followup (13.0 vs. 12.5 percent and 13.4 vs. 11.0 percent, respectively). 

There was no statistically significant difference between the groups at followup. The 

methodological quality of this study was rated as low (2/5 on the Jadad score; unclear 

allocation concealment). 

Szumowski72 randomly assigned 27 young children to an 8-week behavioral 

intervention that included information on diabetes management plus instruction and 

practice in the application of behavioral principles and goal setting to reinforce children’s 

regimen adherence, or to the comparison group that received information on diabetes 

management but no additional instruction. At the 3-month followup there were no 
44

statistically significant changes from baseline HbA1c levels for either group. The 

methodological quality of this study was rated as moderate (2/5 on the Jadad score; 

unclear allocation concealment; blinding of outcome assessors). 

Horan et al.31 conducted an RCT (n = 20) that compared goal setting and problem 

solving using dynamic computer-assisted teaching modules vs. conventional education 

using an education booklet. At the end of the 15-week program, there were no significant 

changes in HbA1c levels in either group. The methodological quality of this study was 

rated as low (2/5 on the Jadad score; unclear allocation concealment). 

In the RCT by Webb,80 45 families were assigned to a group that received intensive 

collaborative goal setting training or a group that used a goal setting worksheet with 

guidance from a therapist. At the 3-month followup neither group showed a significant 

change from baseline HbAc1 levels. The methodological quality of this study was rated 

as low (1/5 on the Jadad score; unclear allocation concealment; blinding of outcome 

assessors). 

 Children with newly diagnosed diabetes. In the CCT by Golden et al.19 11 families 

received an integrated diabetes education and psychosocial support program that was 

delivered in a motel-like setting. The comparison group (n = 8) received the same 

training 15 months after diagnosis. Overall, the children whose families received 

immediate education achieved lower levels of HbA1c at all time points during the study 

up to 24 months after diagnosis (p<0.05). Baseline levels of HbA1c were not reported; 

therefore, we could not assess whether there was a significant change from baseline for 

either group. The methodological quality of this study was rated as low (1/3 on the 

modified Jadad score). 

Delamater et al.17 conducted an RCT (n = 36) that assessed the impact of a familybased self-management training (SMT) program conducted over the 6 months following 

diagnosis of diabetes. The description of the intervention included a medical nutrition 

therapy education component. One comparison group received standard care (regular 

outpatient contact with the health care team); a second comparison group received 

standard care plus supportive counseling. HbA1c measures taken at 12 and 24 months 

after diagnosis showed that all three groups improved their metabolic control. The SMT 

group had significantly lower HbA1c levels than the standard care patients at both 1 and 

2 years after diagnosis (10.4±3.1 vs. 8.2±1.5 percent and 12.3±2.5 vs. 9.8±2.4 percent, 

respectively at 2 years). The SMT group also had lower levels than the supportive care 

group, but this difference was not statistically significant (10.4±3.1 vs. 8.2±1.5 percent 

and 11.1±2.4 vs. 9.1±1.7 percent, respectively at 2 years). The methodological quality of 

this study was rated as moderate (2/5 on the Jadad score; unclear allocation concealment; 

blinding of outcome assessors). 

 Children with poorly controlled diabetes. In a CCT by Viner et al.,76 a 6-week 

motivational and solution-focused therapy group program was delivered to 21 

adolescents and their parents. The control group comprised 20 adolescents who did not 

receive any intervention. At the 12-month followup, the intervention group demonstrated 

statistically significant decreases in HbA1c levels compared with the control group 

(10.2±1.37 vs. 8.9±1.37 percent and 10.0±1.34 vs. 9.9±2.24 percent, respectively). The 

methodological quality of this study was rated as low (1/3 on the modified Jadad score). 

In a three-arm RCT (n = 37), Cigrang13 investigated the effects of a coping skills 

program delivered to adolescents with a history of poor metabolic control. There were 
45

two comparison groups: conventional diabetes education and standard care (routine clinic 

visits). At the 3-month followup, HbA1c levels decreased for all three groups. The 

change from baseline for each group was clinically significant (1.06±1.31 percent, 

0.94±2.25 percent, 0.92±1.74 percent, respectively); however, there were no statistically 

significant differences among the three groups. It is likely that the study did not have 

sufficient power to detect a difference among the groups. The methodological quality of 

this study was rated as low (2/5 on the Jadad score; unclear allocation concealment). 

Couper et al.14 evaluated the effects of monthly home visits by a nurse educator plus 

weekly telephone calls that focused on goal-setting. Thirty-seven adolescents received 

routine care plus the intervention; 32 received routine clinical care only. At the 6-month 

followup, the intervention group reported statistically significant lower mean levels of 

HbA1c compared with the comparison group (11.1±1.3 vs. 9.7±1.6 percent and 10.5±1.6 

vs. 10.3±2.2 percent, respectively [p = 0.0001]). The difference between HbA1c levels at 

baseline and the 18-month assessment in the intervention group were clinically, but not 

statistically, significant (11.1±1.3 vs. 10.0±1.5 percent [0.06]1190.06). The methodological 

quality of this study was rated as low (1/3 on the modified Jadad score; unclear allocation 

concealment). 

Delamater et al16 randomized 13 adolescents to receive a 2-month family-based 

behavior therapy program or to standard outpatient care. The description of this 

intervention included details of a medical nutrition therapy component. There were no 

significant changes in HbA1c levels in either group at the 4-month followup (11.5±2.1 

vs. 11.0±2.4 percent and 10.4±0.8 vs. 10.3±1.5 percent, respectively). The 

methodological quality of this study was rated as low (2/5 on the Jadad score; unclear 

allocation concealment). 

In the RCT (n = 19) by Boardway et al.8

 a 3-month stress management training 

program for adolescents was compared to standard outpatient care. The intervention was 

not effective in reducing HbA1c levels. For the intervention group HbA1c increased (i.e., 

poorer metabolic control) at the 6-month followup; there was no change in HbA1c levels 

for the control group (13.98±2.41 vs. 16.4±2.41 percent and 15.75±3.52 vs. 15.69±2.76 

percent, respectively). The methodological quality of this study was rated as low (1/5 on 

the Jadad score; unclear allocation concealment). 

Hains et al.25 randomly assigned 15 adolescents to a cognitive behavioral stress 

training program or to a control group that did not receive any intervention. At 1-month 

followup there were no significant changes in HbA1c levels for either group. The 

methodological quality of this study was rated as low (2/5 on the Jadad score; unclear 

allocation concealment). 

Family Therapy—HbA1c 

 Description of studies. Seven studies (6 RCTs,36,38,63,70,82,83 1 uncontrolled beforeand-after28) assessed interventions that focused on family dynamics. Six studies were 

conducted in the United States; one took place in Europe.70 The median year of 

publication was 2000 and ranged from 1996 to 2007. 

The number of participants enrolled in the studies ranged from 18 to 119 (median = 

38 [IQR 19 to 105]). The mean age of participants ranged from 6.0 to 14.6 years. In three 

studies, the mean age was less than 12 years.28,36,70 Two studies examined education 
46

interventions delivered to children and their families at the time of diagnosis.36,70 Two 

studies focused on children who demonstrated poor metabolic control.28,83

The interventions were targeted at the entire family in six studies; in one study the 

intervention was delivered to the parents only.36 The settings for the interventions were 

described as a diabetes center,82 hospital inpatient unit,63 the doctor’s office,83 or 

home.28,36 For two studies, the setting was mixed (e.g., diabetes center and home).38,70

Two studies reported HbA1c levels immediately following the intervention.38,83 Four 

studies conducted post-intervention assessments for HbA1c.28,63,70,82 The median 

followup period was 6 months and ranged from 3 to 24 months. 

Results 

 General population of children with diabetes. Wysocki et al.82 randomized 104 

families to one of three groups: standard care plus behavioral family systems therapy 

(BFST), standard care plus family education and support, or standard care (physician 

directed clinical care). At the completion of the 6-month intervention, all groups showed 

improvement in mean HbA1c levels. However, only the BFST group maintained their 

improved HbA1c levels at 12-month followup, while both comparison groups reverted 

toward their baseline levels (BFST group: 9.6±1.6 percent at baseline vs. 8.8±1.5 percent 

at 12 months). The methodological quality of this study was rated as low (2/5 on the 

Jadad score; unclear allocation concealment). 

Satin et al.63 randomly assigned 32 adolescents and their parents to one of three 

groups. One group received multifamily training on family teamwork (MF). For the 

second group, families received the same content as group 1 plus simulation activities for 

parents (MF+S). The control group received no education intervention. At the 6-month 

followup, the MF+S group demonstrated a statistically significant improvement in 

HbA1c levels compared to the control group (WMD -1.09 percent; 95% CI, -2.11, -0.07). 

Similarly the MF group also showed improvement in HbA1c levels; however, the results 

were not statistically significant (WMD -0.31 percent; 95% CI, -1.40, 0.78). The 

methodological quality of this study was rated as low (1/5 on the Jadad score; unclear 

allocation concealment). 

Laffel et al.38 randomly assigned 105 families to a family-focused teamwork 

intervention (TW) or to standard care (i.e., routine multidisciplinary clinical care). At the 

end of the 12-month program, the TW group showed improved HbA1c levels (8.4±1.3 

percent at baseline vs. 8.2±1.1 percent) compared to the control group (8.3±1.0 percent at 

baseline vs. 8.7±1.5 percent). In a multivariable regression analysis that controlled for 

age, duration of diabetes, and diabetes management, the change in HbA1c level after 1 

year was 0.5 percent better in the TW group than in the control group (R2

 = 0.17, p = 

0.04). The methodological quality of this study was rated as low (2/5 on the Jadad score; 

unclear allocation concealment). 

 Children with newly diagnosed diabetes. The RCT by Sundelin et al.70 compared 

conventional inpatient education (n = 19 families) to a multidisciplinary program for 

family-oriented crisis intervention delivered in an outpatient setting (n = 19 families). 

There were no statistically significant differences in HbA1c levels between the two 

groups up to 5 years following diagnosis; both groups demonstrated improved levels in 

HbA1c levels compared to baseline measures. The mean baseline measure for the 
47

intervention group was 9.6±0.14 percent and at 5 years, it was 7.6±15 percent; for the 

control group, baseline HbA1c level was 9.8±0.74 percent and at 5 years it was 7.2±1.5 

percent. The methodological quality of this study was rated as low (2/5 on the Jadad 

score; unclear allocation concealment). 

Kennedy-Iwai36 randomly assigned 19 families to receive standard care (standard 

clinical treatment and diabetes education) or standard care plus a couple communication 

program delivered to parents. There was no improvement in HbA1c levels at the posttreatment assessment for children in either group. The methodological quality of this 

study was rated as low (2/5 on the Jadad score; unclear allocation concealment). 

 Children with poorly controlled diabetes. Wysocki et al.83 randomly assigned 119 

children to 3 groups: standard care (physician directed clinical therapy), education and 

support (standard care plus 10 sessions of a diabetes support group), and BFST (standard 

care plus family problem-solving and communication training and individualized 

treatment plan). At the end of the 3-month intervention none of the groups demonstrated 

any significant change from their baseline HbA1c levels. The methodological quality of 

this study was rated as high (3/5 on the Jadad score; adequate allocation concealment). 

In an uncontrolled before-and-after study, Harris et al.28 reported 6-month followup 

data for 18 adolescents and their families who enrolled in a BFST program. HbA1c levels 

were unchanged from baseline levels. The methodological quality of this study was rated 

as weak using the Thomas instrument. 

Skills Training—HbA1c 

 Description of studies. Six studies (3 RCTs,43,49,57 2 cohorts,40,53 1 uncontrolled 

before-and-after11) examined various interventions that focused on skills training. Studies 

were conducted in the United States,11 Canada,49,57 Europe,43,53 and Thailand.40 The 

median year of publication was 2001 and ranged from 1983 to 2003. 

The number of participants enrolled in the studies ranged from 32 to 130 (median = 

51 [IQR 39 to 56]). The mean age of participants ranged from 7.1 to 14.4 years. For three 

studies, the mean age was less than 12 years.11,40,49 Two studies examined education 

interventions delivered to children and their families at the time of diagnosis.40,49 Two 

studies focused on children who demonstrated poor metabolic control.43,57

Most interventions were targeted at children and their parents or the entire family; in 

one study the intervention was delivered to the child.57 The settings for the interventions 

were described as a diabetes center,49 hospital inpatient unit,40 or home.53 For three 

studies, the setting was mixed (e.g., diabetes center and home).11,43,57 All studies 

conducted post-intervention assessments for HbA1c. The median followup period for the 

studies was 18 months and ranged from 6 to 43.5 months. 

Results 

 General population of children with diabetes. Nordfeldt and Ludvigsson53

evaluated the effect of self-study material on diabetes education aimed at selfmanagement skills and the prevention of hypoglycemia. Over a 3-year period (1997 to 

1999) brochures and videos were distributed to approximately 130 patients and families 
48

each year. HbA1c levels were compared to the mean levels for 1996 (prior to the 

distribution of the brochures). Mean HbA1c levels in 1997 were statistically significantly 

lower than those reported in 1996 (6.5±1.1 vs. 6.8±1.2 percent, respectively); similar 

results were reported comparing 1998 and 1996 (6.4±1.1 vs. 6.8±1.2 percent, 

respectively). The methodological quality of this study was rated as weak using the 

Thomas instrument. 

In an uncontrolled before-and-after study by Caravalho and Saylor,11 56 children and 

their parents were taught insulin adjustment procedures and received group support and 

education to improve self-management. Among the 38 patients who were assessed at 6 

months, there was no significant improvement in HbA1c levels from baseline to postintervention (9.15±2.32 vs. 8.99±1.79 percent). The methodological quality of this study 

was rated as weak using the Thomas instrument. 

 Children with newly diagnosed diabetes. Likitmaskul et al.40 conducted a 

nonconcurrent cohort study to compare the effect of a multidisciplinary team approach to 

diabetes education to conventional education that focused on insulin injection and how to 

control diet. The 28 children who received conventional education were diagnosed with 

diabetes prior to 1996 and served as a historical comparison group to the 24 children who 

were diagnosed after 1996. The children who received the multidisciplinary education 

program demonstrated significantly lower levels of HbA1c up to 3 years after diagnosis 

(12.4±2.7 vs. 13.6±5.4 percent, respectively [p = 0.03]). The methodological quality of 

this study was rated as moderate using the Thomas instrument. 

In the study by Mitchell,49 32 children were randomly assigned to either the 

intervention or the control group. The intervention group received standard 

multidisciplinary education and support plus a booklet targeted at improving compliance 

with treatment. The control group received standard education and support. The 

intervention group showed a general trend to lower HbA1c values over the 24-month 

followup; however, the differences were not statistically significant except at 10 to 13 

months post-diagnosis. The methodological quality of this study was rated as low (1/5 on 

the Jadad score; unclear allocation concealment). Both the intervention and control 

groups had substantial dropouts over the study period (47 and 53 percent, respectively). 

 Children with poorly controlled diabetes. Children with poorly controlled diabetes 

were targeted in the RCT by Mann et al.43 Children in the intervention group (n = 19) 

received intensive diabetes education combined with regular SMBG. Children in the 

control group (n = 20) received intensive education only. At the end of the study, there 

was no significant change in HbA1c levels from baseline to 18 months in either group 

(14.1±1.3 vs. 14.3±1.9 percent for the intervention group; 12.7±2.0 vs. 12.8±2.4 percent 

for the control group). The methodological quality of this study was rated as low (2/5 on 

the Jadad score; unclear allocation concealment). 

In the RCT by Panagiotopoulos et al.57 25 children received weekly telephone calls 

and guidance with SMBG, while 25 children received standard care (i.e., routine clinical 

care). The authors reported that at 6 months, HbA1c levels decreased significantly from 

baseline in both the intervention and control groups (9.7±1.2 to 8.8±1.3 percent and 

9.6±1.3 to 9.1±1.4 percent, respectively). However, the magnitude of change between the 

two groups was not statistically significant. In a post hoc subgroup analysis of children 

with HbA1c levels greater than 9.5 percent at baseline, the authors found that HbA1c 

levels decreased significantly in the intervention group. Six months after study 
49

completion, this subset continued to have improved HbA1c levels compared to the 

control group (from 10.5±1.0 to 9.3±0.9 vs. 10.6±1.0 to 10.4±1.5, respectively). The 

methodological quality of this study was rated as high (3/5 on the Jadad score; unclear 

allocation concealment). 

Diabetes Camp—HbA1c 

 Description of studies. In five studies (1 RCT,46 2 CCTs,62,84 2 uncontrolled beforeand-after studies34,35) the education intervention was delivered as part of a diabetes camp 

program. Four studies were conducted in the United States and one took place in 

Europe.34 The median year of publication was 1997 and ranged from 1986 to 2005.

The number of participants enrolled in the studies ranged from 25 to 237 (median = 

42 [IQR 33 to 56]). The mean age of participants ranged from 10.0 to 14.5 years. In two 

studies, the mean age was less than 12 years.35,84 One study focused on children who 

demonstrated poor metabolic control.34 All interventions were delivered to the children. 

All studies conducted post-intervention assessments for HbA1c; the median followup 

period was 3.5 months and ranged from 3 to 12 months. 

Results 

 General population of children with diabetes. The specific interventions that were 

delivered during the diabetes camps were diverse. In the trial by Massouh et al.,46 34 

adolescents were randomly assigned to a group that received a daily 1-hour teaching 

session about diabetes or to a group that received the lecture plus a social learning 

intervention (relationship skills) that involved role playing. Both groups demonstrated 

increases (i.e., poorer control) in HbA1c levels at 3.5 months following the end of camp 

(1.5 percent [p = 0.008] for the intervention group; 1.2 for the comparison group [p = 

0.14]). The methodological quality of this study was rated as low (2/5 on the Jadad score; 

unclear allocation concealment). 

Remley62 conducted a CCT to compare a social cognitive theory-based program with 

a standard non-theory based camp education program. Eight 1-week camps across the 

United States were designated deliver the either the theory-based intervention or the 

standard program. At the 3-month followup, there was no significant change in HbA1c 

levels for either group. The attrition rate for both groups was high (40 percent). The 

methodological quality of this study was rated as low (1/3 on the modified Jadad score; 

unclear allocation concealment). 

 Zorumski84 investigated the effects of self-care training for 49 children. All children 

received basic self-care training from their physicians; 27 also attended a 1-week day 

camp that provided additional self-care instruction. At the 4-month followup, there was 

no significant change from baseline HbA1c levels for either group (9.93±2.9 vs. 

10.49±2.7 percent [intervention group] and 10.85±2.14 vs. 10.47±2.8 percent 

[comparison group]). The methodological quality of this study was rated as low (0/3 on 

the modified Jadad score). 

In an uncontrolled before-and-after study Kemp et al.35 assessed the effectiveness of 

diabetes education and carefully monitored blood glucose control among 42 children who 

attended a 2-week summer camp. One year later, HbA1c levels had increased (i.e., poorer 
50

control) from the baseline measure (8.1±1.9 vs. 10.1±1.9 percent). The methodological 

quality of this study was rated as weak using the Thomas instrument. 

 Children with poorly controlled diabetes. In an uncontrolled before-and-after study 

(n = 25), Karaguzel et al.34 examined the effect of a 1-week diabetes camp that 

incorporated intensive insulin treatment into a general diabetes program (n = 25). There 

was a statistically significant decrease in HbA1c levels from baseline to 12-months postintervention (9.3±2.5 vs. 8.2±1.5 percent, p<0.05). The methodological quality of this 

study was rated as weak using the Thomas instrument. 

Other Interventions—HbA1c 

 General population of children with diabetes. Campaigne et al.10 assessed the 

effects of physical training on HbA1c levels. Fourteen adolescents were randomly 

assigned to either a 12-week exercise program or to a control group that did not modify 

the usual exercise routine. At the end of the program, HbA1c levels remained unchanged 

in both groups. The methodological quality of the study was rated as low (2/5 on the 

Jadad score; unclear allocation concealment). 

The RCT by Olmsted et al.56 evaluated the effect of a 6-session intervention for 

eating disorders for young women with disturbed eating habits. Eighty-five patients were 

randomized to the psychoeducation program or to routine care at the diabetes center. At 

the 6-month followup neither group demonstrated any significant improvement in HbA1c 

levels. The methodological quality of the study was moderate (2/5 on the Jadad score; 

unclear allocation concealment; blinding of outcome assessors). 

 Children with poorly controlled diabetes. In a CCT, Moran et al.51 compared two 

equivalent groups of 11 children with a history of poor metabolic control. One group 

received an intensive inpatient psychotherapy program; the comparison group comprised 

children who were admitted to hospital for medical treatment of diabetes-related 

complications. Both groups received diabetes education while in hospital. HbA1c levels 

were significantly improved at the 12-month followup for the intervention group (14.3 vs. 

11.5 percent); there was no change in HbA1c levels for the comparison group (13.7 vs. 

13.5 percent). The methodological quality of the study was low (0/3 on the modified 

Jadad score). 

Summary of Results—HbA1c 

Overall, we identified 52 studies that assessed the effectiveness of diabetes education 

programs in controlling HbA1c levels (Table 6). Of these, 30 studies (19 RCTs, 3 CCTs, 

3 cohorts, 5 uncontrolled before-and-after) examined the general population of children 

with type 1 diabetes, 8 (5 RCTs, 1 CCT, 2 cohorts) focused on children with newly 

diagnosed diabetes, and 14 (9 RCTs, 3 CCTs, 2 uncontrolled before-and-after) considered 

children with poorly controlled diabetes. Due to substantial differences across studies in 

terms of population, interventions, comparison groups, duration of intervention, and 

followup time points, we were not able to pool the results of any of the studies. 

General population of children with diabetes. Overall, 30 studies (19 

RCTs,5,6,9,10,21,22,24,31-33,38,46,47,56,63,72,79,80,82 3 CCTs,7,62,84 3 cohorts,39,53,54 5 uncontrolled 

before-and-after11,35,61,75,77) assessed the effectiveness of diabetes education in controlling 
51

HbA1c levels in the general population of children with diabetes (Table 6). Interventions 

that were assessed included general diabetes education,9,24,32,39,61,75,77,79 cognitive 

behavioral therapy,5-7,21,22,31,33,47,54,72,80 family therapy,38,63,82 skills training,11,53 diabetes 

camp,35,46,62,84 physical training,10 and psychoeducation.56 Overall the methodological 

quality of the studies was low. Three RCTs were rated as moderate (Grey et al.,21

Olmsted et al.,56 and Szumowski72) and two uncontrolled before-and-after studies 

(Verrotti,75 von Sengbusch et al.77) were assessed as moderate. 

Results 

The results of the studies rated as moderate quality were mixed. Grey et al.21 found 

that the intervention group that received intensive diabetes management plus coping 

skills training had significantly lower HbA1c levels than the group that received intensive 

management only. Szumowski72 found no change from baseline levels of HbA1c for the 

intervention group that received goal setting training or the control group. Similarly, 

Olmsted et al.56 reported no difference in HbA1c levels among diabetic patients with 

eating disorders comparing a psychoeducation intervention with routine care. The 

uncontrolled before-and-after study by Verrotti et al.75 found decreased levels of HbA1c 

among teenagers who received general diabetes education. In contrast, the uncontrolled 

before-and-after study by von Sengbusch et al.77 assessed a mobile diabetes education 

program and found no change in HbA1c following the intervention. 

The results of the remaining studies were inconsistent. Seven studies6,33,38,53,54,63,82

reported that HbA1c levels decreased significantly following the diabetes education 

intervention. Three of these studies assessed cognitive behavioral therapy,6,33,54 three 

studies assessed family therapy programs38,63,83 and one assessed skills training.53 Six 

studies5,7,22,32,47,61 found that HbA1c levels improved significantly for both the 

intervention and control groups; however, the differences between groups were not 

statistically significant. Four of these studies assessed cognitive behavioral therapy5,7,22,47

and two assessed general diabetes education.32,61 The remaining studies9-

11,24,31,35,46,62,79,80,84 reported that diabetes education had no significant effect on improving 

HbA1c levels. 

Children With Newly Diagnosed Diabetes 

Overall, 8 studies (5 RCTs,17,18,36,49,70 1 CCT,19 2 cohorts40,69 assessed the 

effectiveness of diabetes education among children with newly diagnosed diabetes (Table 

6). Interventions that were assessed were general diabetes education,18,69 cognitive 

behavioral therapy,17,19 family therapy,36,70 skills training.40,49 In general, the 

methodological quality was low; two RCTs (Delamater et al.17 and Dougherty et al.18) 

and the two cohort studies (Likitmaskul et al.40 and Srinivasan et al.69) were assessed as 

being of moderate quality. 

Results. Three studies (Dougherty et al.,18 Sundelin et al.,70 Srinivasan et al.69

compared general diabetes education programs18,69 or family therapy programs70 that 

were delivered in an ambulatory setting vs. the same program to delivered during 

hospitalization. The findings of the studies were inconsistent (Table 6). Dougherty et al.18

reported that the decrease in HbA1c levels was significantly greater for the home-based 
52

group compared with the inpatient group. Sundelin et al.70 and Srinivasan et al.69 found 

no significant differences in HbA1c levels between groups. 

The RCT by Delamater et al.17 found that self-management training group had 

significantly lower HbA1c levels compared with the control group. Similarly, the cohort 

study by Likitmaskul et al.40) found that HbA1c levels were significantly lower in the 

cohort that received skills training. Mitchell49 assessed skills training and reported that 

HbA1c levels improved significantly for both the intervention and control groups; 

however, the difference was not statistically significant. The sample size was small and 

there may not have been sufficient statistical power to detect a difference. The remaining 

study that assessed a family therapy program delivered to parents36 reported that diabetes 

education had no significant effect on improving HbA1c levels in children with newly 

diagnosed diabetes. 

Children With Poorly Controlled Diabetes 

Overall, 14 studies (9 RCTs,8,13,15,16,25,43,55,57,83 3 CCTs,14,51,76 2 uncontrolled beforeand-after28,34) assessed the effectiveness of diabetes education among children with 

poorly controlled diabetes (Table 6). Interventions that were assessed included general 

diabetes education,15,55 cognitive behavioral therapy,8,13,14,16,76 family therapy,28,83 skills 

training,43 diabetes camp,34 and psychoeducation.51 In general, the methodological quality 

of the studies was low; three RCTs were assessed as being of high quality (Nunn et al.,55

Panagiotopoulos et al.,57Wysocki et al.83). 

Results. Two large high-quality RCTs that assessed general diabetes education (Nunn 

et al.,55) and family therapy (Wysocki et al.83) reported that diabetes education had no 

significant impact on HbA1c levels. The RCT by Panagiotopoulos et al.57 found HbA1c 

levels decreased for both groups, but the difference was not significant. 

 The results of the remaining studies were inconsistent. Four studies14,51,76 reported 

that HbA1c levels decreased significantly following the diabetes education intervention. 

Two RCTs13,15 found that HbA1c levels improved significantly for both the intervention 

and control groups; however, the differences were not statistically significant. Both 

studies had small samples (less than 40 participants each) and may not have had 

sufficient statistical power to detect a difference. The remaining studies8,16,25,28,43 reported 

that diabetes education had no significant effect on improving HbA1c levels in this 

patient population. 

 
53

Table 6. Summary of results for studies assessing the effect of diabetes education on HbA1c 

Author Year Intervention Study design 

Sample size 

Quality Conclusion 

General population of children with diabetes 

Anderson6 1989 Cognitive 

behavioral 

therapy 

RCT 

70 

Low IG had significantly lower HbA1c 

than CG at 18 mo. 

Anderson5 1999 Cognitive 

behavioral 

therapy 

RCT (3 arms) 

89 

Low IG had lower HbA1c than CG at 

24 mo.; the difference 

between groups was NS 

Barglow7 1983 Cognitive 

behavioral 

therapy 

CCT 

42 

Low HbA1c levels decreased for both 

groups at 4 mo.; difference 

between groups was NS 

Brown9 1997 General 

diabetes 

education 

RCT 

59 

Low No significant improvement for 

either group at 6 mo. 

Campaigne10 1985 Physical 

training 

RCT 

16 

Low No significant change for either 

group at 12 wk. 

Caravalho11 2000 Skills Before-after 

56 

Low No significant change in HbA1c 

at 6 mo. 

CG = control group; IG = intervention group; NS = not significant 
54

 Table 6. Summary of results for studies assessing the effect of diabetes education on HbA1c 

(continued) 

Author Year Intervention Study design 

Sample size 

Quality Conclusion 

General population of children with diabetes (continued) 

Grey21 2000 Cognitive 

behavioral 

therapy 

RCT 

77 

Moderate IG had significantly lower HbA1c 

than CG at 12 mo. 

Gross22 1985 Cognitive 

behavioral 

therapy 

RCT 

14 

Low HbA1c levels decreased for both 

groups at 6 mo.; difference 

between groups was NS 

Hackett24 1989 General 

diabetes 

education 

RCT (4 arms) 

119 

Low No significant change for any of 

the groups at 8 mo. 

Horan31 1990 Cognitive 

behavioral 

therapy 

RCT 

20 

Low No significant change in HbA1c 

for either group at 15 wk. 

Howe32 2005 General 

diabetes 

education 

RCT (3 arms) 

89 

Low HbA1c levels decreased for all 

groups at 6 mo.; differences 

between groups were NS 

Kaplan33 1985 Cognitive 

behavioral 

therapy 

RCT 

21 

Low IG had significantly lower HbA1c 

than CG at 4 mo. 

Kemp35 1986 Diabetes camp Before-after 

42 

Low No significant improvement in 

HbA1c at 12 mo. 

Laffel38 2003 Family therapy RCT 

105 

Low IG had significantly lower HbA1c 

than CG at 12 mo. 

Lawson39 2000 General 

diabetes 

education 

Cohort 

28 

Low HbA1c levels decreased in IG at 

12 mo.; no change for 

comparison group; however, 

groups had baseline 

differences 

Massouh46 1989 Diabetes camp RCT 

33 

Low No significant improvement in 

HbA1c for either group at 3.5 

mo. 

McNabb47 1994 Cognitive 

behavioral 

therapy 

RCT 

24 

Low HbA1c levels decreased for both 

groups at 6 wk.; difference 

between groups was NS 

Nordfeldt541999 Cognitive 

behavioral 

therapy 

Cohort 

139 

Low 1994-5 cohort (IG) had 

significantly lower HbA1c than 

1980-1 cohort 

Nordfeldt53 2002 Skills Cohort 

130 

Low 1997 and 1998 cohorts (IG) had 

significantly lower HbA1c than 

the1996 cohort 

Olmsted56 2002 Psychoeducati

on 

RCT 

85 

Moderate No significant change for either 

group at 6 mo. 

Povlsen61 2005 General 

diabetes 

education 

Before-after 

37 

Low Significant decrease in HbA1c 

immediately after intervention; 

no change at 3 and 6 mo. 

Remley62 1999 Diabetes camp CCT 

237 

Low No significant change in HbA1c 

for either group at 3 mo. 

Satin63 1989 Family therapy RCT (3 arms) 

32 

Low IG had significantly lower HbA1c 

than CG at 6 mo. 
55

 Table 6. Summary of results for studies assessing the effect of diabetes education on HbA1c 

(continued) 

Author Year Intervention Study design 

Sample size 

Quality Conclusion 

General population of children with diabetes (continued) 

Szumowski72 1990 Cognitive 

behavioral 

therapy 

RCT 

27 

Moderate No significant change in HbA1c 

for either group at 3 mo. 

Verrotti75 1993 General 

diabetes 

education 

Before-after 

30 

Moderate Significant decrease in HbA1c at 

12 mo. 

von Sengbusch77

2006 

General 

diabetes 

education 

Before-after 

107 

Moderate No significant change in HbA1c 

at 12 mo. 

Wadham79 2005 General 

diabetes 

education 

RCT 

67 

Low No significant change in HbA1c 

for either group at 6 mo. 

Webb80 1999 Cognitive 

behavioral 

therapy 

RCT 

66 

Low No significant change in HbA1c 

for either group at 3 mo. 

Wysocki82 2007 Family therapy RCT (3 arms) 

104 

Low IG had significantly lower HbA1c 

than either CG at 12 mo. 

Zorumski84 1997 Diabetes camp CCT 

56 

Low No significant change in HbA1c 

for either group at 4 mo. 

Children with newly diagnosed diabetes

Delamater17 1990 Cognitive 

behavioral 

therapy 

RCT (3 arms) 

36 

Moderate IG had significantly lower HbA1c 

than both CG at 24 mo. 

Dougherty18 1999 General 

diabetes 

education 

RCT 

63 

Moderate HbA1c levels decreased for both 

groups at 3 mo.; differences 

still present at 36 mo.; IG had 

significantly lower HbA1c 

compared to CG at 24–36 mo. 

Golden19 1985 Cognitive 

behavioral 

therapy 

CCT 

19 

Low HbA1c levels were significantly 

lower for IG than CG over 15 

mo.; no data provided to 

assess the change from 

baseline for HbA1c 

Kennedy-Iwai36 1991 Family therapy RCT 

19 

Low No significant change in HbA1c 

for either group at 3 mo. 

Likitmaskul40 2002 Skills Cohort 

52 

Moderate Post-1996 cohort (IG) had 

significantly lower HbA1c than 

the pre-1996 cohort over 3 yr. 

Mitchell49 1996 Skills RCT 

32 

Low HbA1c levels were lower for IG 

than CG over 24 mo.; 

difference between groups 

was NS except at 10–13 mo. 

Srinivasan69 2004 General 

diabetes 

education 

Cohort 

110 

Moderate No significant change in HbA1c 

in either cohort at 3, 6 and 12 

mo. 
56

 Table 6. Summary of results for studies assessing the effect of diabetes education on HbA1c 

(continued) 

Author Year Intervention Study design 

Sample size 

Quality Conclusion 

Children with newly diagnosed diabetes (continued) 

Sundelin70 1996 Family therapy RCT 

38 

Low HbA1c levels decreased for both 

groups up to 5 yr.; differences 

between groups were NS 

Children with poorly controlled diabetes

Boardway8 1993 Cognitive 

behavioral 

therapy 

77 

RCT 

31 

Low No significant change in HbA1c 

for either group at 6 mo. 

Cigrang13 1992 Cognitive 

behavioral 

therapy 

RCT (3 arms) 

37 

Low HbA1c levels decreased for all 

groups at 3 mo.; differences 

among groups were NS 

Couper14 1999 Cognitive 

behavioral 

therapy 

CCT 

69 

Low HbA1c levels decreased in IG at 

6 and 18 mo.; no change in 

CG 

Coupland151992 General 

diabetes 

education 

RCT 

32 

Low Significant decreases at 6 mo. in 

both groups; difference 

between groups was NS 

Delamater16 1991 Cognitive 

behavioral 

therapy 

RCT (3 arms) 

13 

Low No significant change in HbA1c 

for either group at 4 mo. 

Hains25 2000 Cognitive 

behavioral 

therapy 

RCT 

15 

Low No significant change in HbA1c 

for either group at 1 mo. 

Harris28 2005 Family therapy Before-after 

18 

Low No significant change in HbA1c 

at 6 mo. 

Karaguzel34 2005 Diabetes camp Before-after 

25 

Low Significant decrease in HbA1c at 

6 and 12 mo. 

Mann43 1984 Skills training RCT 

39 

Low No significant change in HbA1c 

for either group at 18 mo. 

Moran51 1991 Psychoeducati

on 

CCT 

22 

Low HbA1c levels decreased in IG at 

12 mo.; no change in CG 

Nunn55 2006 General 

diabetes 

education 

RCT 

123 

High No significant change at 8 mo. 

for either group 

Panagiotopoulos57

2003 

Skills RCT 

50 

High HbA1c levels decreased for both 

groups at 6 mo.; difference 

between groups was NS 

Viner76 2003 Cognitive 

behavioral 

therapy 

CCT 

21 

Low IG had significantly lower HbA1c 

than CG at 12 mo. 

Wysocki83 2000 Family therapy RCT (3 arms) 

119 

High No significant change in HbA1c 

for either group at 3 mo. 
57

Health Services Utilization 

 Overall, we identified 11 studies that assessed the impact of diabetes education on 

health service utilization. Health service utilization was measured in a variety of ways: 

length of stay, hospital or ED admissions for diabetes- and non-diabetes-related 

complications. Of the 11, 4 examined the general population of children with diabetes, 4 

focused on children with newly diagnosed diabetes and 3 targeted children with poorly 

controlled diabetes. 

General Diabetes Education—Health Services Utilization 

 Description of studies. We identified 6 studies (3 RCTs,9,55,71 2 cohorts,41,66 1 

uncontrolled before-and-after77) that assessed the effect of general diabetes education 

programs on health service utilization. Studies were conducted in the United 

States,9,41,66,71 Australia55 and Europe.77 The median year of publication was 2001 and 

ranged from 1988 to 2006. 

The number of participants in the studies ranged from 30 to 301 (median = 83 [IQR 

32 to 146]). The mean age of participants ranged from 7.4 to 11.9 years (n = 5 studies). 

Two studies focused on children with newly diagnosed diabetes.41,66 One study examined 

an education intervention delivered to children who demonstrated poor metabolic 

control.55

Five of the intervention programs targeted children and their parents or the family; 

one was delivered to children only.9 The settings for interventions were described as a 

hospital inpatient unit,41,77 diabetes center,71 home,9 or mixed (e.g., diabetes center and 

home).55,66 Three studies reported post-intervention assessments of 1 month,66 6 months77

and 24 months.71

Results 

 General population of children with diabetes. Svoren et al.71 randomly assigned 

299 patients to one of three groups: a case manager or “care ambassador” whose role was 

to monitor clinic attendance and provide telephone outreach to families (CA), a care 

ambassador plus eight psychoeducational modules on diabetes care that were delivered 

during visits to the diabetes clinic (CA+), or standard care (routine clinical care). At the 

end of the 24-month program, the CA+ group had a significantly lower rate of 

hospitalizations than the combined comparison groups (8.9 per 100 patient-years vs. 15.3 

per 100 patient-years, respectively [p = 0.04]). The rate of emergency department (ED) 

visits was also lower in the CA+ group than for the comparison groups (21.0 per 100 

patient-years vs. 34.9 per 100 patient-years, respectively [p = 0.004]). The 

methodological quality of the study was moderate (2/5 on the Jadad score; unclear 

allocation concealment; blinding of outcome assessors). 

Brown et al.9

 randomly assigned 59 children and adolescents to a group that played a 

video game featuring characters with diabetes or a group that played a pinball video game 

with no information on diabetes. At the end of the 6-month study period, the number of 
58

unscheduled urgent visits to the physician for diabetes-related problems declined in the 

intervention group (0.57 visits per child vs. 0.13 visits). For the comparison group, the 

number of visits increased (0.61 visits per child vs. 0.64). However, the difference in the 

change from baseline for the two groups was not statistically significant (p = 0.08). The 

methodological quality of the study was low (1/5 on the Jadad score; unclear allocation 

concealment). 

In an uncontrolled before-and-after study, von Sengbusch et al.77 assessed the impact 

of a mobile diabetes education service in a group of 107 children living in rural areas. At 

24 months, the number of hospitalizations decreased significantly from 17 (16.2 percent) 

at baseline to 7 (6.8 percent). The methodological quality of the study was moderate 

based on the Thomas instrument. 

 Children with newly diagnosed diabetes. In a retrospective cohort study (n = 30), 

Lipman41 compared the effect of diabetes education delivered by a clinical nurse 

specialist compared to the same program delivered by staff nurses. The authors reported 

that the length of hospitalization was significantly shorter for the intervention group than 

for the comparison group. (6.2±1.8 days vs. 8.4±1.8 days,[p<0.01], respectively). The 

methodological quality of the study was moderate based on the Thomas instrument. 

In a prospective cohort study, Siminerio et al.66 examined differences between 

outpatient and inpatient programs for newly diagnosed children (n = 32). In the month 

following diagnosis, none of the children in either group reported any diabetes-related 

hospital or ED visits. The methodological quality of the study was moderate based on the 

Thomas instrument. 

 Children with poorly controlled diabetes. Nunn et al.55 randomly assigned 123 

patients to receive telephone calls from a pediatric diabetes educator or standard care 

(i.e., routine clinic visits but no telephone calls). Over the course of the 8-month study, 

both groups showed an increase in hospitalizations of 0.02 per year; however, the 

difference in the change from baseline between the groups was not statistically significant 

(p = 0.57). The methodological quality of the study was high (3/5 on the Jadad score; 

unclear allocation concealment). 

Cognitive Behavioral Therapy—Health Services Utilization 

 Children with newly diagnosed diabetes. One CCT by Golden et al.19 examined the 

effect of an intervention that used cognitive behavioral therapy techniques. Eleven 

families received an integrated diabetes education and psychosocial support program that 

was delivered in a motel-like setting. The comparison group (n = 8) received the same 

training 15 months after diagnosis. Over 24 months following diagnosis, the intervention 

group experienced 1 hospitalization for hypoglycemia compared with 11 hospitalizations 

for the comparison group. The methodological quality of the study was low (1/3 on the 

modified Jadad score). 
59

Skills Training—Health Services Utilization 

 Children with newly diagnosed diabetes. Likitmaskul et al.40 conducted a 

nonconcurrent cohort study to compare the effect of a multidisciplinary team approach to 

diabetes education to conventional education that focused on insulin injection and how to 

control diet. The 28 children who received conventional education were diagnosed with 

diabetes prior to 1996 and served as a historical comparison group to the 24 children who 

were diagnosed after 1996. Based on a review of medical records, the hospital length of 

stay after initial diagnosis was significantly shorter for children who received the 

multidisciplinary education program than for the comparison group (17.6±9.5 days vs. 

36.0±46.5 days, respectively). The methodological quality was rated as moderate using 

the Thomas instrument. 

 Children with poorly controlled diabetes. In the RCT by Mann et al.43 children in 

the intervention group (n = 19) received intensive diabetes education combined with 

regular SMBG; children in the control group (n = 20) received intensive education only. 

Over the 18-month followup, the group that received education only had 4 diabetesrelated hospital admissions; the SMBG group reported no admissions (p< 0.04). The 

methodological quality of the study was low (2/5 on the Jadad score; unclear 

concealment of allocation). 

Diabetes Camp—Health Services Utilization 

 General population of children with diabetes. In an uncontrolled before-and-after 

study, Koontz37 examined the effect of a general diabetes education program delivered at 

a 1-week camp (n = 112). The mean age of the children was 5.0 years. At the 3-month 

followup, there were no hospitalizations reported for the 29 children who responded to 

the followup questionnaire. Three children reported physician visits for reasons other 

than their regular checkup. No baseline data were provided, therefore we do not know if 

this was different from their pre-camp experience. The methodological quality of the 

study was rated as moderate based on the Thomas instrument. 

Other Interventions—Health Services Utilization 

 Children with poorly controlled diabetes. In the CCT by Moran et al.51 a group of 

11 children received an intensive inpatient psychotherapy program; the comparison group 

comprised 11 children who were admitted to hospital for medical treatment of diabetesrelated complications. Both groups received diabetes education while in hospital. At the 

12-month followup there was no significant difference in the number of overall 

hospitalizations (1.0±1.4 admissions per child vs. 0.9±0.9 [comparison group]). When the 

number of diabetes-related hospital admissions was compared, the intervention group had 

significantly fewer admissions than the comparison group (0.3±0.5 admissions per child 

vs. 0.9±0.9 [p<0.05], respectively). The methodological quality of the study was low (0/3 

on the modified Jadad score). 
60

Summary of Results—Health Services Utilization 

We identified 11 studies that assessed the impact of diabetes education on health 

services utilization (Table 7). Of these, four studies (2 RCTs, 2 uncontrolled before-andafter) examined the general population of children with type 1 diabetes, four (1 CCT, 3 

cohort) focused on children with newly diagnosed diabetes, and three (2 RCTs, 1 CCT) 

considered children with poorly controlled diabetes. Health services utilization was 

measured in a variety of ways: length of stay, hospital or ED admissions for diabetes- and 

non-diabetes-related complications. 

General population of children with diabetes. Four studies (2 RCTs,9,71 2 

uncontrolled before-and-after37,77) assessed the effect of diabetes education on health 

services utilization in the general population of children with diabetes (Table 7). Three 

studies assessed general diabetes education programs9,71,77 and one assessed a diabetes 

camp program.37 In general, the methodological quality of the studies was moderate; only 

one RCT9

 was rated as being of low quality. 

Results. There is some evidence that diabetes education has an impact on health 

services utilization in this patient population. The RCT by Svoren et al.71 reported 

hospital and ED admissions were significantly reduced in the intervention group that 

were supported by a case manager plus psychoeducation training. The uncontrolled 

before-and-after study by von Sengbusch et al.77 reported statistically significant 

reductions in hospital admissions following the intervention. The study by Koontz37 did 

not report baseline information; however, there were no hospital or ED admissions 3 

months following the diabetes camp. The RCT by Brown et al.9 reported a nonsignificant reduction in physician visits. 

Children with newly diagnosed diabetes. Four studies (1 CCT,19 3 cohorts40,41,66) 

assessed the effect of diabetes education on health service utilization among children with 

newly diagnosed diabetes (Table 7). Overall, the methodological quality of the studies 

was moderate, with all but one19 rated as moderate quality. Two cohort studies assessed a 

skills training program (Likitmaskul et al.40) and a general diabetes education program 

(Lipman et al.41); both found that the length of stay for initial hospitalization was shorter 

for the intervention groups than the comparison groups. The cohort study by Siminerio et 

al.66 compared inpatient vs. ambulatory delivery of general diabetes education and 

reported that neither study group had any diabetes-related hospital or ED admissions. The 

RCT by Golden et al.19 reported significantly fewer hospital admissions for the 

intervention group. 

Children with poorly controlled diabetes. The large high-quality RCT by Nunn et 

al,55 reported increased rates of hospital admission for both the intervention group that 

received general diabetes education plus telephone followup and the control group (i.e., 

the intervention was not effective) (Table 7). In contrast, the two studies of low 

methodological quality43,51 reported that their intervention groups had significantly fewer 

hospital admissions than the control groups. 
61

Table 7. Summary of results for studies assessing the effect of diabetes education on health 

services utilization 

Author Year Intervention Study design 

Sample size 

Quality Conclusion 

General population of children with diabetes 

Brown9 1997 General diabetes 

education 

RCT 

59 

Low IG reported fewer physician visits 

while CG visits increased at 6 

mo.; difference was NS 

Koontz37 2002 Diabetes camp Before-after 

112 

Moderate No hospitalizations or physician 

visits reported at 3 mo.; 

however, no baseline data were 

provided 

Svoren71 2003 General diabetes 

education 

RCT (3 arms) 

299 

Moderate IG had significantly fewer hospital 

and ED admissions than either 

CG at 24 mo. 

von Sengbusch77

2006 

General diabetes 

education 

Before-after 

107 

Moderate Number of hospitalizations 

decreased significantly at 24 mo. 

Children with newly diagnosed diabetes 

Golden19 1985 Cognitive 

behavioral 

therapy 

CCT 

19 

Low IG had significantly fewer hospital 

admissions than CG at 24 mo. 

Likitmaskul40 2002 Skills training Cohort 

52 

Moderate LOS for initial hospitalization was 

significantly shorter for IG 

compared to CG 

Lipman41 1988 General diabetes 

education 

Cohort 

30 

Moderate LOS for initial hospitalization was 

significantly shorter for IG 

compared to CG 

Siminerio66 1999 General diabetes 

education 

Cohort 

32 

Moderate No reported diabetes-related 

hospital or ED admissions for 

either group at 1 mo. 

Children with poorly controlled diabetes 

Mann43 1984 Skills training RCT 

39 

Low IG had significantly fewer diabetesrelated hospital admissions than 

CG at 18 mo. 

Moran51 1991 Psychoeducation CCT 

22 

Low IG had significantly fewer diabetesrelated hospital admissions at 12 

mo. 

Nunn55 2006 General diabetes 

education 

RCT 

123 

High IG and CG reported increased 

rates of hospitalization at 8 mo.; 

difference was NS 

CG = control group; DCCT = Diabetes Control and Complications Trial; ED = emergency department; IG = 

intervention group; LOS = length of stay; NS = not significant 
62

Complications 

Overall, we identified 15 studies that assessed the effectiveness of diabetes education 

in controlling complications. While one of the objectives of this evidence report was to 

assess the effect of diabetes education on both long- and short-term complications, all of 

the complications reported in the included studies were short-term. Of the 15 identified 

studies, 11 looked at the general population of children with diabetes, 3 focused on 

children with newly diagnosed diabetes and 1 examined children with poorly controlled 

diabetes.

General Diabetes Education—Complications 

 Description of studies. We identified 6 studies (2 RCTs,18,71 1 retrospective cohort,39

3 uncontrolled before-and-after61,75,77) that assessed the effect of general diabetes 

education programs on short-term complications. Studies were conducted in the United 

States,71 Canada,18,39 and Europe.61,75,77 The median year of publication was 2001 and 

ranged from 1993 to 2006. 

The number of participants in the studies ranged from 28 to 301 (median = 50 [IQR 

30 to 107]). The mean age of participants ranged from 9.8 to 15.8 years (n = 5 studies). 

For three studies, the mean age was less than 12 years.18,71,77 One study examined 

education intervention delivered to children and their families at the time of diagnosis.18

All interventions were targeted to children and their parents or to the family. The 

settings for interventions were described as a hospital inpatient unit,61,77 diabetes center,71

or mixed (e.g., diabetes center and home).18,39 The setting was not clearly described in 

one study.75 All six studies reported post-intervention assessments; the median followup 

period was 12 months and ranged from 6 to 36 months. 

Results 

 General population of children with diabetes. Svoren et al.71 randomly assigned 

299 patients to one of three groups: a case manager or “care ambassador” whose role was 

to monitor clinic attendance and provide telephone outreach to families (CA), a care 

ambassador plus eight psychoeducational modules on diabetes care that were delivered 

during visits to the diabetes clinic (CA+), or standard care (routine clinical care). At the 

end of the 24-month program, the CA+ group had significantly reduced rates of severe 

hypoglycemic events compared with either the CA or standard care group (0.45 events 

per person-year vs. 0.56 events or 0.65 events, respectively [p = 0.02]). The 

methodological quality of the study was moderate (2/5 on the Jadad score; unclear 

allocation concealment; blinding of outcome assessors). 

The retrospective cohort study (n = 28) by Lawson et al.39 compared intensive, 

individualized education to group education delivered to patients. The content for both 

interventions was the same. After 12 months, two children (12 percent) in the 

intervention group experienced severe hypoglycemic reactions; there were no severe 

reactions in the comparison group. The difference was not statistically significant (p = 
63

0.13). There were no episodes of DKA in either group. The methodological quality of the 

study was weak based on the Thomas instrument. 

Povlsen et al.61 assessed the effect of an intervention targeted on 37 families from 

ethnic minority groups in Denmark. The intervention included adapted educational 

material and guidelines and re-education that focused on increasing knowledge and selfcare. The authors observed that the number of severe hypoglycemia episodes increased 

from 3 to 10; however, the increase was not statistically significant. There was one DKA 

event during the intervention. The methodological quality of the study was weak based 

on the Thomas instrument. 

In an uncontrolled before-and-after study Verrotti et al.75 studied 30 adolescents who 

attended nine education sessions on general diabetes management. At the 12-month 

followup, the number of severe hypoglycemia episodes decreased significantly from 

2.9±2.2 events to 1.1±1.3 events (p = 0.002). The methodological quality of the study 

was moderate based on the Thomas instrument. 

In an uncontrolled before-and-after study, von Sengbusch et al.77 assessed the impact 

of a mobile diabetes education service in a group of 107 children. At the 6-month 

followup the number of episodes of severe hypoglycemia did not change significantly 

from baseline measures (0.23 events per 100 patient-years to 0.21 events). The 

methodological quality of the study was moderate based on the Thomas instrument. 

 Children with newly diagnosed diabetes. Dougherty et al.18 randomly assigned 63 

newly diagnosed patients to a 24-month home-based diabetes education program or to 

traditional hospitalization and outpatient followup. Treatment differences between the 

groups included duration of initial hospital stay, timing of initial teaching, and the nature 

and extent of subsequent nursing followup. Over the 24-month followup period, the 

authors reported no statistically significant differences between the groups in the number 

or rate of diabetes-related adverse events (severe hypoglycemia, hyperglycemia and 

ketosis, DKA, chronic hyperglycemia). The rate in the home-based group was 0.34 

events per patient compared with 0.26 in the hospital-based group (RR = 1.45 [95% CI: 

0.59 to 3.6]). The methodological quality of the study was moderate (2/5 on the Jadad 

score; unclear allocation concealment; blinding of outcome assessors). 

Cognitive Behavioral Therapy—Complications 

 Description of studies. We identified four studies (2 RCTs,21,72 1 CCT,19 1 

prospective cohort54) that examined the effect of interventions that used cognitive 

behavioral therapy techniques. Studies were conducted in the United States19,21,72 and 

Europe.54 The median year of publication was 1995 and ranged from 1985 to 2000. 

The median number of participants in the studies was 52 and ranged from 27 to 139. 

The mean age of participants ranged from 2.7 to 14.7 years. For two studies, the mean 

age was less than 12 years.19,72 One study examined education intervention delivered to 

children and their families at the time of diagnosis.19 

Interventions were delivered to children,21 parents,19 or to both parents and children 

or the entire family.54,72 The settings for interventions were described as an outpatient 

clinic,72 or mixed (e.g., diabetes center and home).21,72 The setting was not clearly 
64

described in one study.19 All but one study19 reported post-intervention assessments; the 

followup periods were 3 months,72 12 months,21 and 248 patient years.54

Results 

 General population of children with diabetes. Grey et al.21 randomly assigned 77 

adolescents to receive intensive diabetes management (IDM) as described in the DCCT 

or IDM plus a behavioral program of coping skills training intervention (IDM+). At the 

12-month followup, the IDM+ group reported statistically lower rates for adverse events 

than the control group (severe hypoglycemia: 1.1 per patient year vs. 1.2 per patient year, 

respectively [p<0.001]; DKA: 0.02 vs. 0.06 events per patient year, respectively 

[p<0.001]). The authors observed that the incidence of hypoglycemia significantly 

decreased in females but not in males in the IDM+ group. Overall, the rate of 

complications was higher than that reported by the DCCT. The methodological quality of 

the study was moderate (2/5 on the Jadad score; unclear allocation concealment; blinding 

of outcome assessors). 

In a prospective study with historical controls, Nordfeldt and Ludvigsson54 examined 

the effect of multiple dose insulin therapy combined with problem-based training and 

psychosocial support. The prospective cohort comprised 248 children admitted to 

hospital in 1994 and 1995. The comparison group (156 patients admitted in 1980-81) 

received standard clinical care. The annual incidence of severe hypoglycemia with 

unconsciousness was 0.17 events per patient-year for the intervention group compared 

with 0.23 events per patient-year for the 1980-81 cohort (p<0.05). The incidence of DKA 

requiring hospitalization during 1994-95 was 0.015 episodes per patient-year (not 

reported for the 1980-81 cohort). The methodological quality of the study was weak 

based on the Thomas instrument. 

Szumowski72 randomly assigned 21 young children to an 8-week behavioral 

intervention that included information on diabetes management plus instruction and 

practice in the application of behavioral principles and goal setting to reinforce children’s 

regimen adherence. The comparison group received information on diabetes management 

but no additional instruction. At the 3-month followup there was no significant difference 

in the number of hypoglycemic episodes experienced by either group, nor was the change 

from baseline significantly different for either group. The methodological quality of the 

study was moderate (2/5 on the Jadad score; unclear allocation concealment; blinding of 

outcome assessors). 

 Children with newly diagnosed diabetes. In the CCT by Golden et al.19 11 families 

received an integrated diabetes education and psychosocial support program that was 

delivered in a motel-like setting. The comparison group (n = 8) received the same 

training 15 months after diagnosis. At 12-month followup, the rate of severe 

hypoglycemia episodes reported by the intervention group was significantly lower than 

the comparison group (0.25 per patient vs. 1.1 per patient, respectively [p<0.01]). The 

methodological quality of the study was low (1/3 on the modified Jadad score). 
65

Skills Training—Complications 

Three studies (1 RCT,52 2 cohorts40,53) examined the effect of skills training on shortterm complications. The studies were conducted in Europe and were published in 

200240,53 and 2005.52 

Results

 General population of children with diabetes. In the RCT by Nordfeldt et al.,52

three groups of patients (n = 332; mean age = 5.3 years) were randomized to receive 

either videotapes and a brochure with information about practical skills for self-control 

and treatment (intervention group), a videotape and brochure with general diabetes 

information, or routine clinical care. Outcomes were assessed at 12 and 24 months 

following distribution of the education materials. At 12 months there was a reduction in 

the annual incidence of severe hypoglycemia in the intervention group; there was no 

significant change for either of the controls groups. This reduction was still present at 24 

months; the incidence of severe hypoglycemia in the intervention group decreased from 

42 percent to 25 percent (p = 0.023) in the intervention group. The methodological 

quality of the study was low (1/5 on the Jadad score; unclear allocation concealment; 

blinding of outcome assessors). 

Nordfeldt and Ludvigsson53 evaluated the effect of self-study material on diabetes 

education aimed at self-management skills and the prevention of hypoglycemia. Over a 

3-year period (1997 to 1999) brochures and videos were distributed to the homes of 

approximately 130 patients and families each year. The mean age of the children was 4.6 

years. The mean incidence of severe hypoglycemia with unconsciousness was lower 

during the 1997-1999 cohort compared to 1994-1996 (pre-intervention); however, the 

difference was not statistically significant (0.14 to 0.16 events per patient-year vs. 0.17 to 

0.22 events per patient-year, respectively). The methodological quality of the study was 

weak based on the Thomas instrument. 

 Children with newly diagnosed diabetes. Likitmaskul et al.40 conducted a 

nonconcurrent cohort study to compare the effect of a multidisciplinary team approach to 

diabetes education to conventional education that focused on insulin injection and how to 

control diet. The 28 children who received conventional education were diagnosed with 

diabetes prior to 1996 and served as an historical comparison group to the 24 children 

who were diagnosed after 1996. The children who received the multidisciplinary 

education program had a 4 percent readmission rate for recurrent DKA or hyperglycemia 

during the first year following diagnosis compared with 18 percent for the comparison 

group. This difference between groups continued up to 4 years post-diagnosis. The 

methodological quality of the study was moderate based on the Thomas instrument. 
66

Diabetes Camp—Complications 

 Children with poorly controlled diabetes. In an uncontrolled before-and-after study,

Karaguzel et al.34 examined the effect of a 1-week diabetes camp that incorporated 

intensive insulin treatment into a general diabetes program (n = 25). The mean age of the 

children was 5.0 years. Over the 12-month followup, no severe hypoglycemic episodes 

were detected. As no baseline data were provided, we cannot determine if this was a 

change from pre-intervention. The methodological quality of the study was weak based 

on the Thomas instrument. 

Other Interventions—Complications 

 General population of children with diabetes. Campaigne et al.10 assessed the 

effects of physical training on short-term complications. Fourteen adolescents were 

randomly assigned to either a 12-week exercise program or to a control group that did not 

modify the usual exercise routine. At the end of the program, there was no change in the 

occurrence of hypoglycemia in either group. The methodological quality of the study was 

low (2/5 on the Jadad score; unclear allocation concealment). 

Summary of Results—Complications 

Overall, we identified 15 studies that assessed the effectiveness of diabetes education 

in controlling complications. Of these, 11 (5 RCTs, 3 cohorts, 3 uncontrolled before-andafter) examined the general population of children with type 1 diabetes, 3 studies (1 RCT, 

1 CCT, 1 cohort) focused on children with newly diagnosed diabetes, and 1 uncontrolled 

before-and-after study considered children with poorly controlled diabetes (Table 8). 

While one of the objectives of this evidence report was to assess the effect of diabetes 

education on both long- and short-term complications, all of the complications reported 

in the included studies were short-term. Most studies reported on the incidence of severe 

hypoglycemia. Six studies reported the incidence of DKA and one study measure chronic 

hyperglycemia. 

 General population of children with diabetes. Overall, 11 studies (5 

RCTs,10,21,52,71,72 3 cohorts,39,53,54 3 uncontrolled before-and-after61,75,77) assessed the 

effect of diabetes education on short-term complications among the general population of 

children with diabetes (Table 8). Three studies examined interventions based on cognitive 

behavioral therapy,21,54,72 five studied general diabetes education interventions,39,61,71,75,77

2 assessed skills training52,53 and one assessed a physical training program.10 Overall the 

methodological quality was low; only two RCTs (Grey et al.,21 Szumowski72 and two 

uncontrolled before-and-after studies (Verrotti,75 von Sengbusch et al.77) were rated as 

being of moderate quality. 
67

Results 

Grey et al.21 reported that the event rate for severe hypoglycemic events decreased 

significantly following diabetes education. Verrotti et al.75 also reported that the event 

rate for severe hypoglycemic events decreased significantly following diabetes education. 

In contrast Szumowski72 and von Sengbusch et al.77 found that diabetes education had no 

significant impact on the rate for severe hypoglycemia. 

The results of the remaining studies were inconsistent. Three studies52,54,71 reported 

that the event rate for severe hypoglycemic events decreased significantly following 

diabetes education. Nordfeldt and Ludvigsson53 found that the annual event rate for 

severe hypoglycemia decreased for both the skills training and comparison groups; 

however, the difference was not statistically significant. The remaining studies reported 

that diabetes education had no significant impact on short-term complications.10,39,61 

Children with newly diagnosed diabetes. Overall three studies (1 RCT,18 1 CCT,19

1 cohort40) assessed the effect of diabetes education on short-term complications among 

children with newly diagnosed diabetes (Table 8). One study (Likitmaskul et al.40), which 

was assessed as being of moderate quality, reported that the event rate for severe 

hypoglycemic events and the number of readmissions for DKA decreased significantly 

following a skills training intervention. Dougherty et al.18 reported that setting for 

delivery of general diabetes education (i.e., inpatient vs. ambulatory) had no significant 

impact on short-term complications. The low quality RCT by Golden et al.19 reported that 

the event rate for severe hypoglycemic events decreased significantly following a 

cognitive behavioral therapy intervention. 

Children with poorly controlled diabetes. One uncontrolled before-and-after study 

assessed the effect of a diabetes camp34 on short-term complications among children with 

poorly controlled diabetes (Table 8). No adverse events were reported by Karaguzel et 

al.34 during followup. 
68

Table 8. Summary of results of studies assessing the effect of diabetes education on short-term 

complications 

Author Year Intervention Study design 

Sample size 

Quality Conclusion 

General population of children with diabetes 

Campaigne10

1985 

Physical 

training 

RCT 

16 

Low No significant difference 

between IG and CG in event 

rate for hypoglycemia at 12 

wk. 

Grey21 2000 Cognitive 

behavioral 

therapy 

RCT 

77 

Moderate IG reported statistically lower 

event rates for severe 

hypoglycemia and DKA at 

12 mo.; rates were higher 

than those reported by the 

DCCT (i.e., poorer control) 

Lawson39 2000 General 

diabetes 

education 

Cohort 

28 

Low No significant difference 

between IG and CG in event 

rate for hypoglycemia at 12 

mo. 

Nordfeldt54 1999 Cognitive 

behavioral 

therapy 

Cohort 

139 

Low Annual event rate for severe 

hypoglycemia was 

significantly lower for IG 

Nordfeldt53 2002 Skills Cohort 

130 

Low Annual event rate for severe 

hypoglycemia lower for IG; 

difference between groups 

NS 

Nordfeldt52 2005 Skills RCT (3 arms) 

332 

Low Event rate for severe 

hypoglycemia significantly 

reduced in IG compared 

with either CG at 12 and 24 

mo. 

Povlsen61 2005 General 

diabetes 

education 

Before-after 

37 

Low Number of severe 

hypoglycemic events 

increased at 6 mo.; 

difference was NS 

Svoren71 2003 General 

diabetes 

education 

RCT (3 arms) 

299 

Low Event rate for severe 

hypoglycemia significantly 

reduced in IG compared 

with either CG at 24 mo. 

Szumowski72 1990 Cognitive 

behavioral 

therapy 

RCT 

27 

Moderate No significant change in event 

rate for severe 

hypoglycemia for either 

group at 3 mo. 

Verrotti75 1993 General 

diabetes 

education 

Before-after 

30 

Moderate Significant decrease in 

number of severe 

hypoglycemic events at 12 

mo. 

von Sengbusch77

2006 

General 

diabetes 

education 

Before-after 

107 

Moderate No significant change in event 

rate for severe 

hypoglycemia at 6 mo. 

CG = control group; DCCT = Diabetes Control and Complications Trial; IG = intervention group; NS = not 

significant 
69

 Table 8. Summary of results of studies assessing the effect of diabetes education on short-term 

complications (continued) 

Author Year Intervention Study design 

Sample size 

Quality Conclusion 

Children with newly diagnosed diabetes 

Dougherty18 1999 General 

diabetes 

education 

RCT 

63 

Moderate No significant difference 

between IG and CG in rate 

of adverse events (severe 

hypoglycemia, 

hyperglycemia and ketosis, 

DKA, chronic 

hyperglycemia) at 24 mo. 

Golden19 1985 Cognitive 

behavioral 

therapy 

CCT 

19 

Low Event rate for severe 

hypoglycemia was 

significantly lower in IG 

compared with CG at 12 

mo. 

Likitmaskul40 2002 Skills Cohort 

52 

Moderate IG had significantly fewer 

readmissions for DKA or 

hyperglycemia and severe 

hypoglycemia than CG at 12 

mo. and 4 yr. following 

diagnosis 

Children with poorly controlled diabetes 

Karaguzel34 2005 Diabetes camp Before-after 

25 

Low No severe hypoglycemic 

events were detected at 12 

mo. 

Knowledge 

Overall 30 studies assessed the effect of diabetes education on knowledge. Of these, 

24 examined the general population of children with diabetes, 3 targeted children with 

newly diagnosed diabetes and 3 considered children with poorly controlled diabetes. 

General Diabetes Education—Knowledge 

 Description of studies. We identified 13 studies (5 RCTs,9,18,24,32,55 2 cohorts,66,69 4 

uncontrolled before-and-after,61,65,75,77 2 CCTs,42,45) that assessed the effectiveness of 

general diabetes education on diabetes-related knowledge. The studies were conducted in 

the United States,9,32,45,66 Europe,24,42,61,75,77 Canada,18 India,65 and Australia.55,69 The 

median year of publication was 1999 (IQR, 1993 to 2005). 

The number of study participants ranged from 30 to 146 (median = 63 [IQR 37 to 

107]). The mean age of participants ranged from 10.1 to 15.4 (n = 8 studies). The mean 

age was less than 12 years in six studies.18,24,42,55,66,77 Three studies assessed education 

interventions delivered to children and their families at the time of diagnosis.18,66,69 One 

study examined children who demonstrated poor metabolic control.55

All of the interventions were aimed at children and their parents or to the entire 

family. The interventions were delivered in a variety of settings including hospital 

inpatient units,61,77 home,9

 and an outpatient clinic.24 In seven studies, the setting was 

mixed (e.g., hospital and home)18,32,45,55,65,66,69 and not reported in two studies.42,75 
70

There were four studies in which knowledge was not measured beyond completion of 

the education program.9,24,32,55 In the eight studies that reported post-intervention 

assessments,18,42,61,65,66,69,75,77 ranged from 1 to 36 months. 

Results 

 General population of children with diabetes. Brown et al.9

 randomly assigned 59 

children and adolescents to a group that played a video game with a focus on nutritional 

education featuring characters with diabetes or a group that played a pinball video game 

with no information on diabetes. At the end of the 6-month study period, the intervention 

group reported more gains in knowledge compared to the control group when assessed 

using the Diabetes Knowledge Test. The methodological quality of this study was low 

(1/5 on the Jadad score; unclear concealment of allocation). 

In the RCT by Hackett et al.,24 three cohorts of families received educational 

packages that were delivered over 8 months. The content was the same for all groups; one 

group (cohort 1) received a second reinforcement package for an additional 8 months. 

The comparison group did not receive the education package. The education program led 

to an increase in mean knowledge scores, as measured by a multiple choice test, across 

all cohorts. However, the knowledge was poorly retained by fathers. The methodological 

quality of this study was low (2/5 on the Jadad score; unclear concealment of allocation). 

Howe et al.32 randomly assigned 75 patients to one of three treatment groups: : 

standard care (routine quarterly clinic visits), standard care plus one education session on 

basic diabetes management skills, and standard care, the education session plus weekly 

telephone calls to review management techniques. From results of the KNOW test (46 

multiple choice questions) there were no statistically significant differences found in 

knowledge among the groups. The trial was ended early due to lack of enrolment. The 

methodological quality of this study was low (2/5 on the Jadad score; unclear 

concealment of allocation). 

In the CCT by Lucey and Wing,42 a general education intervention was delivered to 

49 families in the form of two 6-hour group sessions. In the followup period, which 

ranged from 2 to 44 weeks, the children in the intervention group performed better on a 

multiple choice questionnaire that tested knowledge than children in the comparison 

group. The methodological quality of this study was low (0/3 on the modified Jadad 

score). 

Mason45 examined a two to four player board game played by 93 groups of parents 

and children. The children would collect cards (tools) that could be used for continued 

control of diabetes. According to a questionnaire, there was no significant difference in 

knowledge between groups that played the game and those who did not play the game, 

though both groups significantly improved knowledge from baseline. The methodological 

quality of this study was low (0/3 on the modified Jadad score). 

Povlsen et al.61 assessed the effect of an intervention targeted at 37 families from 

ethnic minority groups in Denmark. The intervention included adapted educational 

material and guidelines and re-education that focused on increasing knowledge and selfcare. Using the results of a questionnaire, the authors reported a mean increase in 

knowledge from baseline; however, the differences between families were considerable 
71

at the 6-month followup. The methodological quality of this study was weak based on the 

Thomas instrument. 

In the study by Shobhana et al.65 a 1-hour didactic lecture on injection and monitoring 

skills and individualized diet counseling was delivered to 37 parent and child groups by a 

multidisciplinary team. A short questionnaire found that immediately post-intervention 

and at 3 months, there were significant increases in knowledge about diabetes, injections 

and hypoglycemia. At the 6-month followup, knowledge in all areas increased except 

with regard to self-monitoring. The methodological quality of this study was weak based 

on the Thomas instrument. 

In an uncontrolled before-and-after study Verrotti et al.75 studied 30 adolescents who 

attended nine education sessions on general diabetes management. At the 12-month 

followup, a 20-item multiple choice questionnaire showed that the participants had 

statistically higher knowledge scores compared to baseline values. The methodological 

quality of this study was moderate based on the Thomas instrument. 

In an uncontrolled before-and-after study, von Sengbusch et al.77 assessed the impact 

of a mobile diabetes education service in a group of 107 children. There was a statistical 

improvement in children’s knowledge at the 6-month followup according to the results of 

an age-adapted questionnaire. The methodological quality of this study was moderate 

based on the Thomas instrument. 

 Children with newly diagnosed diabetes. Dougherty et al.18 randomly assigned 63 

newly diagnosed patients to a 24-month home-based diabetes education program or to 

traditional hospitalization and outpatient followup. Treatment differences between the 

groups consisted of duration of initial hospital stay, timing of initial teaching, and the 

nature and extent of subsequent nursing followup. The Diabetes Knowledge Scale found 

no significant difference between the groups. The methodological quality of this study 

was moderate (2/5 on the Jadad score; unclear concealment of allocation; blinding of 

outcome assessors). 

Siminerio et al.66 conducted a prospective cohort study in which a group of 32 newly 

diagnosed children and their parents and peers received 10 to 12 hours of inpatient or 

outpatient education sessions over three days. The education addressed aspects of basic 

diabetes knowledge such as self-management skills, nutrition and exercise. The Test of 

Diabetes Knowledge found that there was no significant difference in knowledge 

between the inpatient and outpatient groups. The methodological quality of this study 

was moderate based on the Thomas instrument. 

In the prospective cohort study by Srivivasan et al.69 a group of 61 newly diagnosed 

patients attended a diabetes day care program (DDCP) at which they received “survival 

skills” diabetes education. The pre-DDCP cohort comprised 49 patients who were 

admitted to hospital for 4 to 7 days for a detailed education program. There was no 

significant difference between the groups’ results on the Test of Diabetes Knowledge. 

The methodological quality of this study was moderate based on the Thomas instrument. 

 Children with poorly controlled diabetes. Nunn et al.55 randomly assigned 123 

patients to receive scheduled telephone calls from a pediatric diabetes educator or 

standard care (i.e., routine clinic visits but no telephone calls). The intervention was 

provided for five to eight months. Immediately after the intervention, authors measured 

knowledge using a modified test of diabetes knowledge and found there to be no 
72

significant differences between groups. The methodological quality of this study was 

high (3/5 on the Jadad score; unclear concealment of allocation). 

Cognitive Behavioral Therapy—Knowledge 

 Description of studies. Seven studies (3 RCTs,22,31,72 3 CCTs,14,48,74 and 1 controlled 

before-and-after20) examined various interventions that used cognitive behavioral therapy 

techniques to increase knowledge. All but two studies were conducted in the United 

States; 1 was conducted in Europe48 and 1 was conducted in Australia.14 The median year 

of publication was 1993 (IQR, 1990 to 1998) and ranged from 1985 to 2001. 

The number of participants enrolled in the studies ranged from 14 to 69 (median = 23 

[IQR 20 to 32]). The mean age of participants ranged from 6.5 to 14.2 years (5 studies). 

For 2 studies, the mean age was less than 12 years.22,72 One study examined education 

interventions delivered to children who had poor metabolic control.14 

In three studies the interventions were delivered to children14,22,74 and to parents as 

well as children in four studies.20,31,48,72 The settings for the interventions were described 

as an outpatient clinic,20,48,72 or home.31 For one study, the setting was mixed (e.g., 

diabetes center and home).14 Two studies did not report the setting of the intervention.22,74

All but 2 studies20,31 conducted post-intervention assessments for knowledge. The median 

followup period was 12 months and ranged from 3 to 13 months. 

Results 

 General population of children with diabetes. In the RCT by Gross et al.22 14 

children and parents were randomly assigned to either behavior modification training or 

to a group that included discussion and role-playing. At 6-month follow up, the 

intervention group scored significantly higher on the Behavior Modification Test than the 

control group (p<0.01). The methodological quality of this study was low (2/5 on the 

Jadad score; unclear allocation concealment). 

Szumowski72 randomly assigned 21 young children to an 8-week behavioral 

intervention that included information on diabetes management plus instruction and 

practice in the application of behavioral principles and goal setting to reinforce children’s 

regimen adherence. The comparison group received information on diabetes management 

but no additional instruction. At the 3-month followup parents were assessed using the 

Knowledge of behavioral principles as applied to children (KBPAC) and the Test of 

Diabetes Knowledge while children’s knowledge was assessed using the Children’s 

Diabetes Quiz. The authors found that there was a significant group by time interaction 

(p<0.008) for both groups at 3 months. Both children and parents increased their 

knowledge scores from baseline to 3 months but statistical significance was not reported. 

The methodological quality of this study was moderate (2/5 on the Jadad score; unclear 

allocation concealment; blinding of outcome assessors). 

Horan et al.31 conducted an RCT (n = 20) that compared goal setting and problem 

solving using dynamic computer-assisted teaching modules vs. conventional education 

using an education booklet. At the end of the 15-week program, assessments of diabetes 

knowledge were made using multiple choice questions modified from the Test of 

Diabetes Knowledge. There was no significant difference between the groups with 
73

regards to their applied knowledge of diabetes. However more individuals in the 

intervention group showed improvement in their factual diabetes knowledge than 

individuals in the control group. The methodological quality of this study was low (2/5 

on the Jadad score; unclear allocation concealment). 

In a controlled clinical trial, Mendez and Belendez48 delivered 12 sessions to children 

(n = 37) that provided them with audiovisual and print material and also allowed them to 

practice their skills. Their parents were taught to reinforce adherence behaviors rather 

than punish non-compliance. Immediately after the sessions ended, the intervention group 

had significantly higher results on the Diabetes Information Survey for Children (DISC) 

(p < 0.001) but at 13 months, the difference between the intervention and control group 

was not significant (p = 0.087). The methodological quality of this study was low (1/3 on 

the modified Jadad score). 

Thomas-Dobersen et al.74 conducted a controlled clinical trial in which 20 adolescents 

received 14 sessions over three months addressing various areas of diabetes management 

such as diet and knowledge of hypoglycemia. Youth Evaluation Scales (YES) found that 

at 1-year followup, the intervention group showed a statistically significant increase in 

knowledge compared to the control group (p<0.01). The methodological quality of this 

study was low (1/3 on the modified Jadad score). 

Greco at al.20 conducted an uncontrolled before-and-after study that aimed to 

implement a structured intervention for integrating peers into diabetes care in a healthy 

and adaptive manner. There were 23 pairs of patients and peers who were assessed using 

the Diabetes Education and Support Assessment (DESAT) tool. After the 4-week 

intervention, the children as well as their peers experienced a significant increase in 

knowledge compared to baseline (p<0.0001). The methodological quality of this study 

was moderate based on the Thomas instrument. 

 Children with poorly controlled diabetes. Couper et al.14 evaluated the effects of 

monthly home visits by a nurse educator plus weekly telephone calls that focused on 

goal-setting. Thirty-seven adolescents received routine care plus the regular intervention; 

32 received routine clinical care only. At the 6-month followup, both parents and children 

in the intervention groups, assessed with the Diabetes Knowledge Assessment Scale, had 

significantly higher knowledge scores than those in the control group (p = 0.001). At 12 

months, only the parents maintained this difference between the groups (p = 0.005). The 

methodological quality of this study was low (1/3 on the modified Jadad score). 

Diabetes Camp—Knowledge 

 Description of studies. In eight studies (3 RCTs58-60, 1 CCT,62 and 4 uncontrolled 

before-and-after studies12,27,34,35) the education intervention was delivered as part of a 

diabetes camp program. Seven studies were conducted in the United States; one took 

place in Europe.34 The median year of publication was 1994 and ranged from 1983 to 

2005. 

The number of participants enrolled ranged from 25 to 237 (median = 76.5 [IQR 61 to 

86]). The mean age of participants ranged from 10.0 to 14.83 years. For 1 study, the 

mean age was less than 12 years.35 One study focused on children who demonstrated 

poor metabolic control.34 
74

In one study, the intervention was aimed at families35 while the rest of the 

interventions were targeted only at children. Only three studies conducted assessments 

immediately after the intervention.12,27,60 The remaining five studies conducted postintervention assessments for knowledge; the median followup period was 8 months and 

ranged from 2 days to 12 months. 

Results 

 General population of children with diabetes. In the uncontrolled before-and-after 

study by Christensen et al.12 the campers attended two sessions on carbohydrate counting 

and two sessions on food portioning. They used flash cards, practiced reading labels, 

measuring utensils, used scales with real food and played a card game. The authors used 

laboratory values to assess the correlations between HbA1c and knowledge and found 

that the correlation was not statistically significant (p = 0.09). The methodological quality 

of this study was weak based on the Thomas instrument. 

The campers in the controlled before-and-after study by Harkavy et al.27 received 

informal and formal teaching sessions which covered diabetes etiology/pathology, selfmanagement skills, effects of diabetes on stress and social issues. Immediately after the 

2-week camp was over, campers completed a multiple choice questionnaire to assess 

their knowledge of etiology, pathophysiology and diabetes in general. The authors found 

that campers 12–13 years and 14–15 years of age showed a significant improvement in 

knowledge. There was no significant difference found in the 10–11 year olds. The 

methodological quality of this study was weak based on the Thomas instrument. 

In an RCT by Pichert et al.,60 64 campers were randomly assigned to one of two 

groups: four 45-minute problem-solving sessions where they learned about metabolic 

management skills, diabetes and exercise guidelines and the social issues surrounding 

diabetes or the control group that received traditional instruction that did not emphasize 

problem solving. Immediately following the camp, the campers were asked to complete 

multiple choice and short answer tests to assess their factual knowledge of and ability to 

apply diabetes-related exercise guidelines. Repeated measures analysis of variance 

revealed that problem-solving groups gained more in factual knowledge and the ability to 

apply it to new problems than did the control group. The methodological quality of this 

study was low (2/5 on the Jadad score; unclear allocation concealment). 

In another RCT by Pichert et al.,58 69 campers were randomized either to the 

intervention group comprising three 45-minute groups sessions using a problem-solving 

format devoted to nutrition-related skills and knowledge, or to the control group that 

received conventional direct instruction. When assessments were performed 2–4 or 5–6 

days post-intervention, there was significant improvement in the knowledge in both 

groups when they were asked to complete a personal meal plan recall, but there was no 

significant difference between groups. The methodological quality of this study was low 

(2/5 on the Jadad score; unclear allocation concealment). 

In the third RCT by Pichert et al.,59 81 campers were randomized to participate in two 

45-minute sessions on sick day management that were taught via a problem-solving 

format, or to the control group that received conventional direct instruction. Knowledge 

was assessed using a Sick Day Knowledge Test and a Sick Day Problem Solving Test. At 

the 8-month followup, there was no significant difference between groups; however, the 
75

intervention group was better able to explain why the management guidelines applied to a 

hypothetical example. The methodological quality of this study was moderate (2/5 on the 

Jadad score; unclear allocation concealment; blinding of outcome assessors). 

Remley62 conducted a CCT to compare a social cognitive theory-based program with 

a standard non-theory based camp education program. Eight 1-week camps across the 

United States were designated deliver either the theory-based intervention or the standard 

program. At the 3-month followup, there was no significant change in knowledge levels 

for either group. The attrition rate for both groups was high (40 percent). The 

methodological quality of this study was low (1/3 on the modified Jadad score). 

In an uncontrolled before-and-after study, Kemp et al.35 assessed the effectiveness of 

diabetes education and carefully monitored blood glucose control among 42 children who 

attended a 2-week summer camp. One year later, there was a significant improvement in 

knowledge when comparing pre to post intervention groups (p<0.01 vs. pre-camp). The 

methodological quality of this study was weak based on the Thomas instrument. 

 Children with poorly controlled diabetes. In an uncontrolled before-and-after study 

(n = 25), Karaguzel et al.34 examined the effect of a 1-week diabetes camp that 

incorporated intensive insulin treatment into a general diabetes program which included 

dietary education. There was a statistically significant increase in knowledge about 

diabetes and diabetes nutrition at 6 and 12 month followup. The methodological quality 

of this study was weak based on the Thomas instrument. 

Skills Training—Knowledge 

Results 

 General population of children with diabetes. In the uncontrolled before-and-after 

study by Monaco et al.,50 children were divided into two groups, ages 6–8 years and 9–11 

years, to receive one session in which they were instructed in the use of injection site 

charts and injection site bears. The authors found that children in both age groups 

committed significantly fewer injection site identification errors when using the injection 

bears compared to using the chart. The methodological quality of this study was moderate 

based on the Thomas instrument. 

 In the uncontrolled before-and-after study by Templeton et al.,73 adolescents attended 

one 90-minute session in which they were taught skills that would help them monitor 

their blood glucose. Immediately after the session they were asked to complete a five 

item true/false test. While the authors provided data on the percentages of questions 

correct, they did not comment on the statistical significance of results. The 

methodological quality of this study was weak based on the Thomas instrument. 

Summary of Results—Knowledge 

Overall, we identified 30 studies that assessed the effectiveness of diabetes education 

in improving knowledge (Table 9). Of these, 24 studies (9 RCTs, 5 CCTs, 10 

uncontrolled before-and-after) examined the general population of children with type 1 

diabetes, 3 studies (1 RCT, 2 cohorts focused on children with newly diagnosed diabetes, 
76

and 3 studies (1 RCT, 1 CCT, 1 uncontrolled before-and-after) considered children with 

poorly controlled diabetes. 

General population of children with diabetes. Twenty-four studies (9 

RCTs,9,22,24,31,32,58-60,72 5 CCTs,42,45,48,62,74 10 uncontrolled before-andafter12,20,27,35,50,61,65,73,75,77) assessed the effectiveness of diabetes education in improving 

diabetes-related knowledge among the general population of children with diabetes. Eight 

studies assessed general diabetes education,9,24,32,42,45,61,65,77 six examined interventions 

that used cognitive behavioral therapy techniques,20,22,31,48,72,74 7 assessed interventions 

delivered at diabetes camps,12,27,35,58-60,62 and two assessed skills training.50,73 Overall the 

methodological quality of the studies was low; only 2 RCTs59,72 and 34 uncontrolled 

before-and-after studies20,50,75,77 were rated as being of moderate quality. 

Results. The results of the 5 moderate quality studies were inconsistent (Table 9). 

Sumowski72 reported increased knowledge levels in both the intervention and control 

groups, but the difference between groups was not statistically significant. Three 

uncontrolled before-and-after studies (Greco et al.,20 Verrotti et al.,75 and von Sengbusch 

et al.77) reported gains in knowledge following a cognitive behavior therapy and general 

diabetes intervention, respectively. Monaco et al.50 reported increases in knowledge 

levels, but the difference was not statistically significant. In the RCT by Pichert et al.59

knowledge of nutrition and meal planning improved for both intervention and control 

groups, but the difference was not statistically significant. 

The results of the remaining studies were also mixed. Two RCTs,22,60 one CCT74 and 

two uncontrolled before-and-after studies35,65 reported statistically significant increases in 

diabetes-related knowledge following the education interventions. Two studies reported 

that their interventions were effective in subgroups of the study population.24,27 Three 

trials and three uncontrolled before-and-after studies reported knowledge gains but the 

differences were not statistically significant9,42,58,61,73 or were not retained over the longer 

term.48 In the remaining studies, the education interventions did not have significant 

effect on knowledge outcomes.12,31,32,45,62 

Children with newly diagnosed diabetes. Three moderate quality studies (1 RCT by 

Dougherty et al.,18 2 cohorts by Siminerio et al.66 and Srinivasan et al.69) compared 

groups of children with newly diagnosed diabetes that received general diabetes 

education programs delivered in an ambulatory setting (e.g., home, outpatient clinic) vs. a 

hospital inpatient setting (Table 9). In all three studies, the knowledge levels increased 

for both intervention and comparisons groups; however, the differences were not 

statistically significant. The setting of the education program does not appear to have an 

effect on knowledge outcomes. 

Children with poorly controlled diabetes. The large high-quality RCT by Nunn et 

al,55 reported no significant differences in knowledge between the intervention group that 

received general diabetes education plus telephone followup and the control group that 

received diabetes education with no telephone followup (Table 9). The remaining studies 

that targeted patients with poorly controlled diabetes were of low quality. One 

uncontrolled before-and-after reported significant increases in knowledge following a 

diabetes camp;34 one CCT reported significantly higher knowledge levels over the shortterm, but these gains were not sustained over the long-term.14
77

Table 9. Summary of results of studies assessing the effect of diabetes education on knowledge 

Author Year Intervention Study design 

Sample size 

Quality Results 

General population of children with diabetes 

Brown9 1997 General 

diabetes 

education 

RCT 

59 

Low IG significantly improved 

knowledge scores 

compared to CG at 6 mo.; 

difference was NS 

Christensen12 2000 Diabetes camp Before-after 

68

Low No significant change from 

baseline levels of 

knowledge 

Greco20 2001 Cognitive 

behavioral 

therapy 

Before-after 

23 

Moderate Adolescents and their peers 

achieved significant 

increases in knowledge 

Gross22 1985 Cognitive 

behavioral 

therapy 

RCT 

14 

Low IG had significantly higher 

knowledge scores 

compared to CG at 6 mo. 

Hackett24 1989 General 

diabetes 

education 

RCT (4 arms) 

119 

Low Knowledge scores increased 

significantly for children, 

mothers and fathers in IG; 

gains not sustained by 

fathers over 8 mo. 

Harkavy27 1983 Diabetes camp Before-after 

93 

Low Significant improvement in 

knowledge for 12–13 and 

14–15-yr. olds; no 

significant difference for 10–

11-yr. olds 

CG = control group; IG = intervention group; NR = not reported; NS = not significant 
78

 Table 9. Summary of results of studies assessing the effect of diabetes education on knowledge 

(continued) 

Author Year Intervention Study design 

Sample size 

Quality Results 

General population of children with diabetes (continued) 

Horan31 1990 Cognitive 

behavioral 

therapy 

RCT 

20 

Low No significant difference 

between groups postintervention 

Howe32 2005 General 

diabetes 

education 

RCT (3 arms) 

89 

Low No significant differences 

among groups at 6 mo. 

Kemp35 1986 Diabetes camp Before-after 

42 

Low Knowledge scores improved 

significantly from baseline to 

post-intervention 

Lucey42 1985 General 

diabetes 

education 

CCT 

49 

Low IG performed better on 

general information 

questions than CG 

Mason45 1986 Cognitive 

behavioral 

therapy 

CCT 

93 

Low Both groups significantly 

improved knowledge scores; 

difference was NS 

Mendez48 1997 Cognitive 

behavioral 

therapy 

CCT 

37 

Low IG significantly higher than CG 

at post-intervention; 

difference was NS at 13 mo. 

Monaco50 1996 Skills training Before-after 

58 

Moderate Both groups significantly 

improved knowledge scores 

from baseline; difference 

was NS 

Pichert60 1993 Diabetes camp RCT 

146 

Low IG knowledge improved 

significantly more than CG 

for diabetes-related exercise 

guidelines and ability to 

apply knowledge 

Pichert58 1994a Diabetes camp RCT 

83 

Low Both groups improved 

significantly in recall of 

nutritional meal plans, 

knowledge of food groups, 

exchange equivalents, 

portions; difference was NS 

at post-camp

Pichert59 1994b Diabetes camp RCT 

84 

Moderate No significant difference 

between groups at 8 mo. 

Povlsen61 2005 General 

diabetes 

education 

Before-after 

37 

Low Knowledge increased from 

baseline; difference was NS 

Remley62 1999 Diabetes camp CCT 

237 

Low No significant increase in 

knowledge levels for either 

group 

Shobhana65 1997 General 

diabetes 

education 

Before-after 

37 

Low Significant increase in 

knowledge at 6 mo. 
79

 Table 9. Summary of results of studies assessing the effect of diabetes education on knowledge 

(continued) 

Author Year Intervention Study design 

Sample size 

Quality Results 

General population of children with diabetes (continued) 

Szumowski72 1990 Cognitive 

behavioral 

therapy 

RCT 

27 

Moderate Parents in IG increased 

knowledge of behavioral 

principles compared to CG 

at 3 mo. 

Parents in both groups 

increased knowledge of 

diabetes at 3 mo.; difference 

was NS 

Children in both groups 

increased knowledge of 

diabetes at 3 mo.; difference 

was NS 

Templeton73 1988 Skills training Before-after 

30 

Low Knowledge increased from 

baseline; statistical 

significance NR 

Thomas-Dobersen74

1993 

Cognitive 

behavioral 

therapy 

CCT 

20 

Low IG had significant increase in 

knowledge compared to CG 

at 15 mo. 

Verrotti75 1993 General 

diabetes 

education 

Before-after 

30 

Moderate Significantly higher knowledge 

scores at 12 mo. 

von Sengbusch77

2006 

General 

diabetes 

education 

Before-after 

107 

Moderate Significant improvement in 

knowledge scores 

compared to baseline 

Children with newly diagnosed diabetes

Dougherty18 1999 General 

diabetes 

education 

RCT 

63 

Moderate No significant difference 

between groups at 36 mo. 

Siminerio66 1999 General 

diabetes 

education 

Cohort 

32

Moderate No significant difference 

between groups at 1 mo. 

Srinivasan69 2004 General 

diabetes 

education 

Cohort 

110 

Moderate No significant difference 

between groups at 12 mo. 

Children with poorly controlled diabetes

Couper14 1999 Cognitive 

behavioral 

therapy 

CCT 

69 

Low IG children had significantly 

higher knowledge scores 

than CG at 6 mo.; difference 

was NS at 12 mo. 

IG parents had significantly 

higher knowledge scores 

than CG at 6 and 12 mo. 

Karaguzel34 2005 Diabetes camp Before-after 

25 

Low Significant increase in 

knowledge scores at 12 mo. 

Nunn55 2006 General 

diabetes 

education 

RCT 

146 

High No significant difference in 

knowledge scores between 

groups 
80

Skills 

 Overall, there were nine studies were assessed the effect of diabetes education on 

skills. Of these, all studies evaluated the general population of children with diabetes. 

Cognitive Behavioral Therapy—Skills 

Results 

 General population of children with diabetes. Anderson et al.6

 randomized 70 

adolescents and parents to a group that received standard care (routine clinic visits) or a 

group that received standard care plus a problem solving intervention that focused on 

self-monitoring of blood glucose (SMBG). At the 18-month followup the authors found 

no significant difference between groups in their use of SMBG to modify their diet, 

insulin or daily exercise. The methodological quality of the study was low (2/5 on the 

Jadad score; unclear allocation concealment).

In the CCT by Mendez et al.,48 37 adolescents and parents were divided into 

experimental and control groups. The intervention group underwent 12 sessions. The 

sessions delivered to the adolescents included review, new content (audiovisual and 

printed material), skill practice and homework assignment. Parents attended two sessions 

emphasizing reinforcement and adherence behaviors rather than punishing 

noncompliance. There was no description of the control group. At the 13-month followup 

the authors found that the intervention group had significantly higher posttest scores than 

the control group on blood glucose testing skills. The methodological quality of the study 

was low (1/3 on the modified Jadad score). 

Diabetes Camp—Skills 

 Description of studies. We identified seven studies (2 RCTs,58,81 1 CCT,62 4 

uncontrolled before-and-after12,27,37,78) that assessed the effects of diabetes camp on the 

development of diabetes-related skills. Studies were conducted in the United 

States,12,27,37,58,62 Canada,81 and Europe.78 The median year of publication was 1996 and 

ranged from 1983 to 2001. 

The number of participants in the studies ranged from 41 to 237 (median = 83, [IQR 

63 to 112]). The mean age of participants ranged from 8.4 years to 14.53 years (n = 3 

studies).27,62,78 For one study the mean age of participants was less than 12 years.78 One 

study focused on children who demonstrated poor metabolic control.81

Three studies reported immediate post-intervention assessment.12,27,81 The remaining 

followup times were 2 to 6 days post-intervention,58 2 months,78 and 3 months.37,62

Results 

 General population of children with diabetes. In the RCT by Pichert et al.58 83 

children were randomized into two groups, where the intervention group received three 

45-minute sessions devoted to nutrition-related skills and knowledge through the use of 
81

written material and video. The sessions were based on anchored instruction. The control 

group also received three 45-minute sessions using flash cards to learn food 

group/exchange equivalents and meal planning. On an observed test to see if campers 

could select an appropriate meal, both groups showed improvement, but there was no 

significant difference. In a challenge to choose meals for an overnight trip no significant 

difference was observed between groups, although both showed improvement. The 

methodological quality of the study was low (2/5 on the Jadad score; unclear allocation 

concealment). 

Remley62 conducted a CCT to compare a social cognitive theory-based program with 

a standard non-theory based camp education program. The curriculum included assertive 

communication training, group discussion, role-playing and nutrition education. Eight 1-

week camps across the United States delivered either the intervention or control program. 

The attrition rate, at the 3-month followup, for both groups was high (40 percent). 

Participants in the theory-based program decreased slightly in the self-management skills, 

meal planning self-efficacy, from pre- to post-camp measurements. Control group scores 

increased slightly. The methodological quality of the study was low (1/3 on the modified 

Jadad score). 

In an uncontrolled before-and-after study, Christensen et al.12 observed 68 children 

attending a 2-week camp in the United States. Children were grouped by age so that each 

class could be tailored to developmental needs. Classes used flash cards, a card game, 

practiced reading labels, and used measuring utensils and scales with real food. Topics 

included carbohydrate counting, reading labels, and portion sizes and how to adjust for 

activity level. Immediate followup demonstrated a 24 percent increase in the campers’ 

abilities to write out meal plans and a 19 percent increase in the ability to accurately 

describe a meal plan. The change in ability to select appropriate portion sizes was not 

statistically significant. There was a significant correlation with correctly measuring 

carbohydrates and participant HbA1c. The methodological quality of the study was low 

based on the Thomas instrument. 

In the uncontrolled before-and-after study by Harkavy et al.,27 93 children 

participated in a 2-week camp held in the United States. During the camp there were 

formal and information sessions, but most teaching was completed informally. Topics 

included general diabetes knowledge, daily management, diet, exercise, hypoglycemia, 

the effects of illness/stress, and teen social issues. Two skills were assessed: urine testing 

and insulin injection. At the end of camp, all campers demonstrated improved urine test 

skills, although girls performed urine tests more accurately than boys. Improvement was 

significant for 12- to 13- and 14- to 15-year-olds but not significant for 10- to 11-yearolds. In regard to insulin injection skills, girls performed more accurately than boys and 

improved their accuracy during the camp; boys demonstrated no significant change. The 

methodological quality of the study was low based on the Thomas instrument. 

Koontz37 conducted an uncontrolled before-and-after study that involved 112 children 

at a 1-week camp in the United States. Education sought to increase self-management 

skills by teaching insulin administration, relationships between diet, exercise and insulin, 

meal and snack planning, measuring food portions, and how to identify and treat insulin 

reactions. The camp also aimed to enhance emotional adjustment, improve self-esteem, 

and develop positive attitudes toward the outdoors. Followup took place 3 months postintervention. There was no significant difference in self-management scores from pre-to 
82

post-camp. The methodological quality of the study was moderate based on the Thomas 

instrument. 

One study, a RCT81 assessed the effects of a diabetes camp on the development of 

diabetes-related skills among children with poorly controlled diabetes. This study took 

place in Canada and involved 41 children. Participants were randomized to either the 

control group, or the intervention group, where campers received one to two 

individualized sessions and participated in small group discussion on self-testing. 

Children in the control group received no specialized education. Immediate followup 

revealed no significant differences between groups on absolute systematic errors in 

SMBG comparing baseline to post-intervention. The methodological quality of the study 

was low (2/5 on the Jadad score; unclear allocation concealment). 

The last uncontrolled before-and-after study was conducted in the United Kingdom 

by Vyas et al.78 and involved 63 children separated into two camps. Children 5 to 7 years 

of age attended a camp for 10 days and children 9 to 14 years of age attended a different 

camp for 14 days. Activities at each camp were similar and children learned selfmanagement and problem solving skills through daily activities. Additional opportunities 

for learning occurred through small informal discussions. Significant increases were seen 

in the ability of campers to self-test at 3 months post-holiday compared to before camp. 

The ability to independently self-inject also increased significantly at the post-holiday 

assessment. The methodological quality of the study was low based on the Thomas 

instrument. 

Summary of Results—Skills 

 General population of children with diabetes. Overall, nine studies (3 RCTs,6,58,81 2 

CCTs,48,62 4 uncontrolled before-and-after12,27,37,78) assessed the effects of diabetes 

education on the development of diabetes-related skills (Table 10). The interventions that 

were assessed were cognitive behavioral therapy6,48 and diabetes camps.12,27,37,58,62,78 In 

general, the methodological quality of the studies was low; one study was rated as 

moderate quality (Koontz37). 

 Results. The uncontrolled before-and-after study by Koontz37 examined a range of 

self-management skills aimed at improving glycemic control. There were no significant 

differences in self-management scores at the 3-month followup.The results of the 

remaining low quality studies were inconsistent. The outcomes of three studies were 

associated with monitoring blood glucose. One study6

 found no significant difference 

between intervention and control groups on the use of SMBG to modify diet, insulin or 

daily exercise, whereas, the other48 found improved posttest scores on blood glucose 

testing in the intervention group compared to the control group. The third81 found no 

significant difference between intervention and control groups in regard to performing 

SMBG (Table 10). 

Three studies examined nutrition and diet related skills, all of which were tested in a 

diabetes camp setting. Two studies found no improvement in ability to choose meals or 

pack for an over-night trip58 or in meal-planning self-efficacy.62 Conversely, another 

study12 noted increases in the ability to write-out and describe meal plans, but no change 

in the ability to select appropriate meal sizes. 
83

Skills such as urine and blood testing and insulin injection were assessed in two 

studies in a camp setting. Both studies found improvements in these skills.27,78 

Table 10. Summary of results of studies assessing the effect of diabetes education on skills 

Author Year Intervention Study design 

Sample size 

Quality Conclusion 

General population of children with diabetes 

Anderson6 1989 Cognitive 

behavioral 

therapy 

RCT 

70 

Low No significant difference in 

self-monitoring skills 

Christensen12 2000 Diabetes camp Before-after 

68 

Low Create meal plans—24% 

increase in pre–post 

values; 

Describe meal plan—19% 

increase in pre–post 

values; 

Portion sizes—no 

significant difference; 

Carbohydrate measuring—

significant improvement 

Harkavy27 1983 Diabetes camp Before-after 

93 

Low Urine testing—both sexes 

improved significantly, but 

girls performed more 

accurately; 

Significant improvement for 

12–13 and 14–15-yr. 

olds, no significant 

difference in 10–11-yr. 

olds; 

Insulin injection—girls 

performed more 

accurately and improved 

their accuracy during 

camp

Koontz37 2001 Diabetes camp Before-after 

112 

Moderate No significant difference in 

self-management skills 

Mendez48 1997 Cognitive 

behavioral 

therapy 

CCT 

37 

Low IG had significantly 

improved selfmanagement skills than 

CG at 13 mo. 

Pichert58 1994a Diabetes camp RCT 

83 

Low Behavioral measures—no 

significant difference 

between groups 

Meal selection—no 

significant difference 

between groups 

Remley62 1999 Diabetes camp RCT 

237 

Low IG self-management skills 

decreased slightly, CG 

increased slightly; 

difference was NS 

CG = control group; IG = intervention group; NS = not significant; SMBG = self-monitoring blood glucose 
84

 Table 10. Summary of results of studies assessing the effect of diabetes education on skills 

(continued) 

Author Year Intervention Study design 

Sample size 

Quality Conclusion 

General population of children with diabetes (continued) 

Vyas78 1988 Diabetes camp Before-after 

63 

Low Self testing—significant 

increase in ability; 

Independent self-injection—

significant increase in 

ability 

Wolanski81 1996 Diabetes camp RCT 

41 

Low SMBG—no significant 

difference in absolute or 

random errors

Self-Management/Adherence 

We identified 21 studies that assessed the effect of education on self-management and 

regimen adherence. Of these, 14 studies targeted the general population of children with 

diabetes, 2 examined children with newly diagnosed diabetes, and 5 looked a children 

with poorly controlled diabetes. 

General Diabetes Education—Self-Management/Adherence 

 Description of studies. We identified seven studies (5 RCTs,9,15,18,24,32 1 cohort,66 1 

uncontrolled before-and-after20) that assessed the effect of general diabetes education 

programs on self-management and adherence outcomes. Studies were conducted in the 

United States,9,20,32 Canada,15,18 and Europe.24 The median year of publication was 1998 

and ranged from 1989 to 2005. 

The number of participants in the studies ranged from 23 to 119 (median = 48 [IQR 

32 to 76]). The mean age of participants ranged from 9.8 to 14.7 years (n = 7 studies). 

Two studies included participants where the mean age was less than 12 years.18,24 Two 

studies focused on children and their families with newly diagnosed diabetes18,66 and one 

targeted children with poor metabolic control.15

Most interventions were delivered to both children and their parents or the family; in 

one study the intervention was delivered to children only.9

 The settings for interventions 

were described as home,9

 clinic,24 or mixed (e.g., hospital and home).18,32,66 The setting 

was not clearly described in two studies.15,20 Three studies reported post-intervention 

followup assessments ranging from 1 to 36 months.15,18,66 The median follow-up period 

was 13 months. The remaining studies did not report outcomes beyond the end of the 

education program.9,24,32,83 
85

Results 

 General population of children with diabetes. Brown et al.9

 randomly assigned 59 

children and adolescents to a group that played a video game featuring characters that had 

diabetes, who manage their diabetes by monitoring blood glucose, taking insulin 

injections and choosing foods, or a group that played a pinball video game with no 

information about diabetes. Parents rated their child’s motivation to manage their 

diabetes in terms of behaviors such as testing blood sugar, taking insulin, cooperating 

with parents and doctor, and eating a good diet. At the end of the 6-month study period, 

the treatment group demonstrated significantly more gains in self-care behavior than the 

control group (change score 0.28±0.86 vs. -0.38±0.79, respectively [p = 0.003]). The 

methodological quality of this study was rated as low (1/5 on the Jadad score; unclear 

allocation concealment). 

In the RCT by Hackett et al.,24 three cohorts of families received educational 

packages delivered over 8 months that included information on diabetes, diet and 

concentration of HbA1c. The content was the same for all groups; one group (cohort 1) 

received a second reinforcement package for an additional 8 months. The comparison 

group did not receive the education package. Outcomes included self-reported (by diary) 

fat, carbohydrate, and fiber intake. Children whose families had attended all educational 

sessions reported lower fat and higher carbohydrate and fiber intake than those who did 

not attend, however, this effect was not statistically significant. The methodological 

quality of this study was rated as low (2/5 on the Jadad score; unclear allocation 

concealment). 

Howe et al.32 randomly assigned 75 patients to one of three treatment groups: : 

standard care (routine quarterly clinic visits), standard care plus one education session on 

basic diabetes management skills (SC+ED), and standard care plus the education session 

plus weekly telephone calls to review management techniques (SC+TCM). The authors 

assessed child and family behaviors related to diabetes safety and control using the 

Adherence Evaluation scale. At the 6-month followup, adherence improved significantly 

in the SC+TCM group compared to the standard care group (24 percent vs. 2 percent 

respectively [p = 0.0003]). Furthermore, children in the SC+TCM group were better able 

to assume age-appropriate behaviors related to diabetes management, and parents were 

better able to provide age-appropriate supervision. All outcomes were physician assessed 

using the TEAM checklist. TEAM scores in the education and telephone case 

management group improved by 24 percent over a 6-month period, while the standard 

care group reduced their score by 5.4 percent (p = 0.003). The methodological quality of 

this study was rated as low (2/5 on the Jadad score; unclear allocation concealment). 

The uncontrolled before-and-after study by Greco et al.20 delivered the intervention in 

2-hour sessions over 4 weeks to groups of three to six diabetes patient-peer pairs. The 

intervention consisted of homework review on etiology, physiology and treatment of 

diabetes, reflective listening skills, problem solving related to diabetes, stress 

management, games or exercises to practice concepts and homework assignments. 

Regimen adherence was measured using the Self-Care Inventory. There was no 

significant change in adherence scores between baseline and post-intervention. The 

methodological quality of this study was rated as moderate using the Thomas instrument.
86

 Children with newly diagnosed diabetes. Dougherty et al.18 randomly assigned 63 

newly diagnosed patients to a 24-month home-based diabetes education program or to 

traditional hospitalization and outpatient followup. Treatment differences between the 

groups consisted of duration of initial hospital stay, timing of initial teaching, and the 

nature and extent of subsequent nursing followup. The authors assessed adherence using 

the Diabetes Regimen Adherence Questionnaire There were no significant differences in 

adherence scores between the groups at any time during the 2-year followup. Adherence 

was high in both the hospital- and home-based groups: 85.5 percent vs. 82.5 percent, 

respectively at 1-month and declining slightly to 74.1 percent vs. 73.9 percent at 24-

months post-intervention. The methodological quality of this study was rated as moderate 

(2/5 on the Jadad score; unclear allocation concealment; blinding of outcome assessors). 

Siminerio66 compared a 3 to 5 day education program delivered on an inpatient vs. 

outpatient basis. Patients were divided into two cohorts of 16 patients each. The 

education program included basic education on diabetes, complications, self-management 

skills, and nutrition and exercise. The authors assessed food regulation, exercise, blood 

glucose regulation and emergency precautions. At 1-month followup, both groups had a 

high level of adherence for food regulation and exercise; there were no statistically 

significant differences between the groups. However, the inpatient group scored 

significantly higher in blood glucose monitoring than the outpatient group (4.93 vs. 4.47, 

respectively [p < 0.01]). The outpatient group scored higher in adhering to emergency 

precautions (4.71 vs. 4.44, respectively [p < 0.001]). The methodological quality of this 

study was rated as moderate using the Thomas instrument. 

 Children with poorly controlled diabetes. In the RCT by Coupland15 adolescents 

and their families participated in a family-based intervention to improve adherence (n = 

15); the comparison group (n = 14) comprised adolescents who were taught stress 

management techniques. Adherence behaviors consisted of self-reported regularity of 

insulin injections, blood glucose testing timeliness and frequency, and diet and exercise 

levels. At the 3- and 6-month followup, adolescents in the intervention group had a 

significant increase in mean frequency of daily blood glucose testing compared to the 

control group; they also had significantly greater adherence for timing of blood glucose 

testing. Adolescents in the control group showed decreased adherence to correct timing 

of insulin injections. There was no significant difference between groups in adherence to 

diet or daily exercise levels. The methodological quality of this study was rated as low 

(2/5 on the Jadad score; unclear allocation concealment).

Cognitive Behavioral Therapy—Self-Management/Adherence 

 Description of studies. We identified eight studies (7 RCTs,8,16,31,47,72,80 1 CCT48) that 

assessed the effect of interventions using cognitive behavioral therapy techniques on selfmanagement and adherence outcomes. One study was conducted in Europe;48 the 

remaining studies were conducted in the United States. The median year of publication 

was 1991 and ranged from 1985 to 1999. 

The number of participants in the studies ranged from 13 to 66 (median = 24 [IQR 17 

to 29]). The mean age of participants ranged from 6.4 to 15.4 years (n = 6 studies). Four 
87

studies included participants whose mean age was less than 12 years.22,47,72,80 Two studies 

examined interventions delivered to children with poor metabolic control.8,16

Interventions were delivered to children8,31 or to parents and children or the entire 

family.16,22,47,72,80 The settings for interventions were described as an outpatient 

clinic,8,16,72,80 home,31 diabetes center,47 or mixed.48 The setting was not clearly described 

in one study.22 All but one study31 reported post-intervention followup assessments 

ranging from 6 weeks to 6 months (median = 3 months). 

Results 

 General population of children with diabetes. In the RCT by Gross et al.22 14 

children and parents were randomly assigned to either behavior modification training or 

to a group that included discussion and role-playing. The authors assessed adherence 

using a subjective rating scale in which parent rated child behavior on a 4-point scale. At 

6 months parents from the intervention group rated children as improved on all measures 

while control group parents gave decreased ratings. The methodological quality of this 

study was rated as low (2/5 on the Jadad score; unclear allocation concealment). 

Horan et al.31 conducted an RCT (n = 20) that compared goal setting and problem 

solving using dynamic computer-assisted teaching modules that focused on selfmanagement training versus conventional education using an education booklet. At the 

end of the 15-week study, participants were asked if they, rather than parents or doctor, 

were more active in controlling their diabetes. Sixty percent of intervention group vs. 20 

percent of the control group reported they were more active at the end of the study. The 

methodological quality of this study was rated as low (2/5 on the Jadad score; unclear 

allocation concealment). 

In the study by McNabb et al.47 24 children were randomly assigned to either a 6-

week self-management education program or to receive standard care (routine clinic 

visits). Parents were surveyed using the Children’s Diabetes Inventory to report the 

frequency with which self-care behaviors were practiced in the home and the degree of 

responsibility assumed by the child. At the end of the program, children in the 

intervention group were assuming significantly more responsibility for self-care than 

children in the control group (2.9±0.4 vs. 2.3± 0.6, respectively [p < 0.01]). There was no 

difference between the groups in frequency of self-care behaviors (4.5±0.4 vs. 4.2±0.6 

for the control group). This supported the hypothesis that children would become more 

responsible for self-care while continuing to maintain self-care frequency. The 

methodological quality of this study was rated as low (2/5 on the Jadad score; unclear 

allocation concealment). 

The CCT by Mendez and Belendez48 used an intervention comprising 12 sessions of 

content delivery, skill practice and homework assignment, and involved parents for two 

of the sessions. The emphasis was on reinforcement of adherence behaviors rather than 

punishing noncompliance. The intervention delivered to the control group care was not 

described. The authors reported that frequency of self-monitoring of blood glucose 

improved in the intervention group immediately following the intervention (18.42±10.92 

vs. 21.28±9.78 compared to 18.57±11.78 vs. 18.69±11.67 for the control group, p = 

0.016). However, at 13 months post-intervention, the frequency dropped to baseline 

levels. The authors also assessed self-reported physical activity and nutritional 
88

management; they found that the program did not have any effect on dietary or exercise 

adherence. The methodological quality of this study was rated as low (1/3 on the 

modified Jadad score). 

Szumowski72 randomly assigned 21 young children to an 8-week behavioral 

intervention that included information on diabetes management plus instruction and 

practice in the application of behavioral principles and goal setting to reinforce children’s 

regimen adherence. The comparison group received information on diabetes management 

but no additional instruction. At the 3-month followup, the intervention group reported 

increased cooperation with diabetes tasks compared to the control group; however, the 

change from baseline was not statistically significant (2.4±0.8 vs. 2.1±1.0 and 2.4±1.4 vs. 

2.9±0.8, respectively [p = 0.09]). There was no significant change for either group in 

daily average exercise and diet exchange errors (daily average proportion of total 

recommended exchanges which were added or deleted). There was no significant change 

in the percent carbohydrate and fat consumed by either group; however, there was a 

significant decrease in consumption of concentrated sweets in the intervention group vs. 

no change for the control group. The methodological quality of this study was rated as 

moderate (2/5 on the Jadad score; unclear allocation concealment; blinding of outcome 

assessors). 

In the RCT by Webb,80 45 families were assigned to a group that received intensive 

collaborative goal setting training or a group that used a goal setting worksheet with 

guidance from a therapist. The author used the Goal Attainment Scaling to measure goal 

attainment in self-care behavior areas such as insulin administration, SMBG, food intake 

and physical activity. At the 3-month followup, both groups reported significant gains in 

goal attainment for all four areas. The gains reported by the intervention group were 

significantly greater than those of the control group. The methodological quality of this 

study was rated as low (1/5 on the Jadad score; unclear allocation concealment; blinding 

of outcome assessors).

 Children with poorly controlled diabetes. In the RCT (n = 19) by Boardway et al.,8

a 3-month stress management training program for adolescents was compared to standard 

outpatient care. The authors used a 24-hour recall interview to assess regimen adherence. 

At the end of the intervention, there were no significant changes in regimen adherence for 

either group. The methodological quality of this study was rated as low (1/5 on the Jadad 

score; unclear allocation concealment).

Delamater et al.16 randomized 13 adolescents to receive a 2-month family-based 

behavior therapy program with training in parent-teen communication, problem solving 

and goal setting, with focus on adjusting meals and insulin in response to self-monitoring 

of blood glucose- or to standard outpatient care. Regimen adherence was measured 

through using the Diabetes Management Questionnaire. At the 4-month followup, 

patients in both groups improved their adherence ratings; however, there was no 

significant difference between the groups. Parent ratings of adherence did not show any 

significant effects for either group. The methodological quality of this study was rated as 

low (2/5 on the Jadad score; unclear allocation concealment).
89

Family Therapy—Self-Management/Adherence 

 General population of children with diabetes. Laffel et al.38 randomly assigned 105 

families to a family-focused teamwork intervention (TW) or to standard care (i.e., routine 

multidisciplinary clinical care). Measures of parental involvement in management tasks 

were reported by both parents and children. At the end of the 12-month intervention the 

TW families maintained or increased family involvement significantly more than families 

in the control group (30 percent vs. 14 percent, respectively [p = 0.05]). The 

methodological quality of this study was low (2/5 on the Jadad score; unclear 

concealment of allocation). 

Wysocki et al.82 randomized 104 families to one of three groups: standard care plus 

behavioral family systems therapy (BFST), standard care plus family education and 

support (ES), and standard care (physician directed clinical care). Treatment adherence 

was assessed using the Diabetes Self-Management Profile (DSMP). At all followup 

periods up to 12-months post-intervention, the BFST group had significantly better 

DSMP scores than the standard care group. There were no significant differences 

between the BFST and the ES groups or between the ES and standard care groups at any 

followup point. A significantly higher percentage of BFST group members attained 

moderate or greater improvement (i.e., an increase in score of ≥5 points on the DSMP) in 

treatment adherence compared with either of the comparison groups. Changes in 

treatment adherence correlated significantly with change in HbA1c at each time point. 

The methodological quality of this study was low (2/5 on the Jadad score; unclear 

concealment of allocation).

 Children with poorly controlled diabetes. Wysocki et al.83 randomly assigned 119 

children to 1 of 3 groups: standard care (physician directed clinical therapy), education 

and support (standard care plus 10 sessions of a diabetes support group), and BFST 

(standard care plus family problem-solving and communication training and 

individualized treatment plan). The authors measured adherence with the Self-Care 

Inventory (SCI). At the end of the 3-month intervention, there were no significant 

differences in regimen adherence among the three groups. The methodological quality of 

this study was high (3/5 on the Jadad score; adequate concealment of allocation). 

In an uncontrolled before-and-after study, Harris et al.28 reported 6-month followup 

data for 18 adolescents and their families who enrolled in a BFST program. The authors 

used two self-report measures to assess adherence: the SCI (measuring treatment 

adherence over 2 weeks) and the Diabetes Mismanagement Questionnaire. There was a 

small improvement in reports from fathers on the SCI at immediate post-intervention. 

However, there were no significant differences in adherence reports from adolescent, 

mother or father at the 6-month followup. The methodological quality of this study was 

low based on the Thomas instrument. 

Diabetes Camp—Self-Management/Adherence 

 General population of children with diabetes. Remley62 conducted a CCT to 

compare a social cognitive theory-based program that focused on assertive 
90

communication and nutrition education with a standard non-theory based camp education 

program. Eight 1-week camps across the United States were designated to deliver either 

the theory-based intervention or the standard program. At the 3-month followup there 

were no significant differences in self-reported self-management skills between the 

groups. The methodological quality of this study was low (1/3 on the modified Jadad 

score). 

Zorumski84 investigated the effects of self-care training for 49 children. All children 

received basic self-care training from their physicians; 27 also attended a 1-week day 

camp that provided additional self-care instruction. At the 4-month followup both groups 

reported an increase in the number of self-care behaviors that they practiced; however, 

there was no statistically significant difference between groups. The methodological 

quality of this study was low (0/3 on the modified Jadad score). 

Summary of Results—Self-management/Adherence 

Overall, we identify 21 studies that assessed self-management or regimen adherence. 

Of these, 15 studies examined the general population of children with type 1 diabetes, 

five examined children with poorly controlled diabetes, and one focused on children with 

newly diagnosed diabetes(Table 11). We were unable to pool the results of any of the 

studies due to differences across studies in terms of population, interventions, comparison 

groups, duration of intervention and followup timepoints. 

General population of children with diabetes—self-management and regimen 

adherence. Fourteen studies (10 RCTs,9,22,24,31,32,38,47,72,80,82 3 CCTs,48,62,84 1 uncontrolled 

before-and-after20) assessed self-management or regimen adherence in the general 

population of children with type 1 diabetes. The education interventions that were 

assessed included general diabetes education,9,20,24,32,48 cognitive behavioral 

therapy,22,31,47,72,80 family therapy,38,82 and diabetes camp.62,84 In general, the 

methodological quality of the studies was low, with only one RCT (Szumowski72) and 

one uncontrolled before-after (Greco et al.20) rated as being of moderate quality. 

Results. The RCT by Szumowski72 found that children in the group that received a 

behavioral intervention were more compliant in performing diabetes tasks and decreased 

their intake of sweets compared to the control group. Other measures of self-management 

were unchanged in either group following the intervention. The uncontrolled before-andafter study by Greco et al.20 assessed an intervention aimed at integrating teenage peers 

into the diabetes care of a friend with diabetes. There was not significant change in 

adherence scores following the intervention. 

The results of the remaining studies were mixed. Two RCTs reported that groups 

receiving family therapy interventions38,82 demonstrated increased levels of selfmanagement or regimen adherence compared to the control group. Studies assessing 

interventions based cognitive behavioral therapy were inconsistent with two studies22,31

reporting gains in self-management for the intervention group compared to control group 

and two studies47,80 reporting no change following the intervention. Similarly, some 

studies examining general diabetes education programs reported that self-management 

skills improved,9,32 while others found no change following the intervention.24,48 The two 
91

studies that took place at diabetes camps62,84 found that self-management/adherence were 

unchanged following camp. 

Children with Newly Diagnosed Diabetes 

 One RCT (Dougherty et al.18) and one cohort study (Siminerio66) assessed selfmanagement or regimen adherence in the children with newly diagnosed diabetes (Table 

11). The methodological quality of both studies was moderate. Both compared general 

diabetes education programs that were delivered in inpatient vs. ambulatory settings. 

Dougherty et al. found that there was no significant difference in adherence between the 

intervention and control groups. Siminerio reported that the inpatient group scored higher 

on some elements of adherence (e.g., blood glucose monitoring) but lower on others (e.g., 

adherence to emergency precautions). For others, there were no significant differences 

(e.g., adherence to food regulation and exercise). 

Children with Poorly Controlled Diabetes 

The large high-quality RCT by Wysocki et al.83 that assessed family therapy reported 

improved levels of adherence at 3 months post-intervention; the improvements 

disappeared by 6 months (Table 11). The results of the remaining studies were mixed. 

One RCT reported improved self-management/adherence compared to the control 

group;15 one RCT found improved levels of adherence, but the difference between groups 

was not significant.16 Two studies found that adherence was unchanged following the 

intervention.9,28
92

 Table 11. Summary of results of studies assessing the effect of diabetes education on self 

management/regimen adherence 

Author Year Intervention Study design 

Sample size 

Quality Conclusion 

General population of children with diabetes 

Brown9 1997 General diabetes 

education 

RCT 

59 

Low Self-Management—IG had 

significant gains in self-care 

compared to CG at 6 mo. 

Greco20 2001 General diabetes 

education 

Before-after 

23 

Moderate Adherence—No significant 

change for either group at 4 

wk. 

Gross22 1985 Cognitive 

behavioral 

therapy 

RCT 

14 

Low Adherence—IG showed an 

increase in compliance 

compared to CG at 6 mo. 

Hackett24 1989 General diabetes 

education 

RCT (4 arms) 

119 

Low Self-Management—No 

significant difference for either 

group in nutritional 

management 

Horan31 1990 Cognitive 

behavioral 

therapy 

RCT 

20 

Low Self-Management—IG showed 

greater behavioral change 

compared to CG at 15 wk. 

Howe32 2005 General diabetes 

education 

RCT (3 arms) 

89 

Low Self-Management—Significant 

group x time interaction; 

significant increase in ED+ 

group compared to CG for 

roles/responsibilities 

Laffel38 2003 Family therapy RCT 

105 

Low Self-Management—IG had 

significantly more involvement 

in roles/responsibilities than 

CG at 12 mo. 

McNabb47 1994 Cognitive 

behavioral 

therapy 

RCT 

24 

Low Self-Management—No 

significant difference between 

groups after 12 wk. 

Mendez48 1997 General diabetes 

education 

CCT 

37 

Low Self-Management—IG 

significantly higher skills than 

CG at posttest; IG significantly 

higher at nutritional 

management and physical 

activity than CG at posttest 

(loses significance at 13 mo.) 

Remley62 1999 Diabetes camp CCT 

237 

Low Self-Management—No 

significant difference between 

groups at 3 mo. 

Szumowski72 1990 Cognitive 

behavioral 

therapy 

RCT 

27 

Low Self-Management—Significant 

interaction comparing baseline 

to 3 mo.; 

Roles/responsibilities—No 

significant change in either 

group at 3 mo.; 

Physical activity or nutritional 

management— No significant 

change in either group at 3 

mo. 

BG = blood gas; CG = control group; IG = intervention group; NS = not significant 
93

 Table 11. Summary of results of studies assessing the effect of diabetes education on selfmanagement/regimen adherence (continued) 

Author Year Intervention Study design 

Sample size 

Quality Conclusion 

General population of children with diabetes (continued) 

Webb80 1999 Cognitive 

behavioral 

therapy 

RCT 

66 

Low Self-Management—No 

significant differences between 

groups at 3 mo. 

Wysocki82 2007 Family therapy RCT (3 arms) 

104 

Low Adherence—Significantly higher 

scores for BFST-D compared 

to SC at each followup (up to 

18 mo.); All other group 

differences NS; Significant 

main effects for groups 

Zorumski84 1997 Diabetes camp CCT 

56 

Low Self-Management—No 

significant difference between 

groups at 4 mo. 

Children with newly diagnosed diabetes

Dougherty18 1999 General diabetes 

education 

RCT 

63 

Moderate Adherence—No significant 

change for either group at 36 

mo. 

Siminerio66 1999 General diabetes 

education 

Cohort 

32 

Moderate Self-Management—Inpatient 

group significantly higher than 

outpatient group at 1 mo. For 

BG regulation; Outpatient 

group significantly higher than 

inpatient group at 1 mo. For 

emergency precautions 

Children with poorly controlled diabetes

Boardway8 1993 Cognitive 

behavioral 

therapy 

RCT 

31 

Low Adherence—No significant 

change for either group at 6 

mo. 

Coupland15 1992 General diabetes 

education 

RCT 

32 

Low Self-management—IG 

significantly higher compared 

to CG at 6 mo. (also at 3 mo. 

For mean % BG testing); 

Adherence—IG significantly 

different than CG at 6 mo. 

Delamater16 1991 Cognitive 

behavioral 

therapy 

RCT (3 arms) 

13 

Low Adherence—IG higher when 

compared to CG at 4 mo.; 

difference between groups 

was NS 

Harris28 2005 Family therapy Before-after 

18 

Low Self-Management—No 

significant change at 6 mo.; 

Adherence—No significant 

change at 6 mo. 

Wysocki83 2000 Family therapy RCT (3 arms) 

119 

High Adherence—Improvement in 

younger children at 3 mo. NS, 

effect dissipated by 6 mo. 
94

Psychosocial Outcomes

 We identified 40 studies that assessed the effect of education on psychosocial 

outcomes. Of these studies, 22 examined the general population of children with diabetes, 

9 focused on children with newly diagnosed diabetes and 9 considered children with 

poorly controlled diabetes. The psychosocial outcomes reported on were grouped into the 

following categories: family or social relationships (16 studies), family or social support 

(9 studies), social skills (3 studies), coping (14 studies), self-perception (8 studies), selfefficacy (9 studies), stress (2 studies), and anxiety and depression (6 studies). 

Family or Social Relationships 

General Diabetes Education—Family or Social Relationships 

 Children with newly diagnosed diabetes. In the prospective cohort study by 

Srinivasan et al,69 a 4- to 16-week outpatient day care program was compared with a 4- to 

7-day inpatient program for delivering general diabetes education to 110 newly 

diagnosed patients and their families. Using the Diabetes Responsibility and Conflict 

Scale, there were no significant differences between the cohorts in the area of diabetes 

responsibility and conflict or parent-child conflict at the 12-month followup. The 

methodological quality of the study was moderate based on the Thomas instrument. 

Cognitive Behavioral Therapy—Family or Social Relationships 

 General population of children with diabetes. Anderson et al.5 assessed the 

effectiveness of an intervention for families that focused on teamwork and shared parentteen responsibility for diabetes tasks. It was delivered in the form of 20- to 30-minute 

sessions every 3 to 4 months for 12 months. Eighty-nine families were randomly assigned 

to the intervention group or to one of two comparison groups: standard care (routine 

clinical care from the diabetes team) or standard care plus didactic diabetes education. 

The two comparison groups were combined to increase the power of the study. Using the 

Diabetes Family Conflict Scale, at the 12-month followup, the mean level of diabetesrelated family conflict in the intervention group decreased significantly compared to the 

control group (4.8±3.09 vs. 3.8± 2.75 and 3.6± 2.6 to 3.9±2.6, respectively [p<0.02]). 

The methodological quality of this study was rated as low (2/5 on the Jadad score; 

unclear allocation concealment). 

Gross et al.22 randomly assigned 14 children and parents to either an intervention or 

control group. The intervention comprised eight weekly 90-minute sessions on selfmanagement training for both parents and children. The control group attended eight 

weekly 90-minute sessions of open ended discussion for both parents and children. In 

both groups there were separate sessions for parents and children. The number of familychild conflicts was recorded on worksheets by parents. At 6 months post-intervention, the 

intervention group reported fewer conflicts than control group (1.6 conflicts vs. 0.1 

conflicts per week; the control group remained at 1.1 conflicts per week). The 
95

methodological quality of this study was rated as low (2/5 on the Jadad score; unclear 

allocation concealment). 

Szumowski72 randomized 27 children and parents to either an intervention or control 

group. Parents and children in the control group met for six group sessions over 2 months 

and were given information on glucose testing, insulin injection and adjustment, diet and 

exercise. The intervention group received the same intervention as the control group plus 

they received additional instruction and practice in diabetes behavioral education and 

goal setting. At each assessment point, parents monitored the occurrence of diabetesrelated family conflict. At the 3-month followup there was no significant change in 

conflict scores for either group. The methodological quality of this study was rated as 

moderate (2/5 on the Jadad score; unclear allocation concealment; blinding of outcome 

assessors). 

The uncontrolled before-and-after study by Greco et al.20 examined an intervention 

targeted at integrating peers into diabetes care. It comprised four 2-hour sessions 

delivered to three to six diabetes adolescent and peer pairs. Sessions included lectures and 

games or exercises on diabetes, problem solving, and stress management. Family conflict 

was assessed using the Diabetes Responsibility and Conflict Scale; information was 

obtained separately from parents and adolescents. The Peer Interaction Record was used 

to measure the adolescents’ social interactions. Following the intervention, parents 

reported significantly less diabetes-related conflict (26.5± 8.5 vs. 23.7±6.4, p<0.05); 

however, the adolescents did not report a significant change. On the Peer Interaction 

Record, peers reported significant improvement following the intervention; however, the 

adolescents with diabetes did not report a significant change. The methodological quality 

of the study was rated as moderate based on the Thomas instrument. 

 Children with poorly controlled diabetes. Delamater et al.16 randomized 13 patients 

with poor metabolic control to receive a 2-month family-based behavior therapy program 

or to standard outpatient care. The intervention comprised six 90-minute group sessions 

that focused on self-management and psychosocial skills. There were separate parent and 

teen sessions. Global ratings of parent-teen relationships were made using a 7-point 

Likert scale. At the end of the intervention, the adolescents from the intervention group 

showed improvement in the ratings of parent-teen relationships compared to the control 

group. At the 4-month followup, there was no difference between the groups. Ratings by 

parents in either group were unchanged over time. The methodological quality of this 

study was rated as low (2/5 on the Jadad score; unclear allocation concealment). 

Family Therapy—Family or Social Relationships 

 General population of children with diabetes. Laffel et al.38 randomly assigned 105 

families to a family-focused teamwork intervention (TW) or to standard care (routine 

multidisciplinary clinical care). Diabetes-related conflict was measured with the Diabetes 

Family Conflict Scale. At the end of the 12-month program, there were no significant 

differences between groups on this measure. The methodological quality of this study 

was rated as low (2/5 on the Jadad score; unclear allocation concealment). 

Satin et al.63 randomized 32 adolescents to one of three groups. The first group 

participated in a multifamily support group where families met for six weekly sessions of 

90-minutes each to discuss diabetes management and feelings about diabetes and to 
96

receive group support. The second group received the same intervention plus parents 

participated in simulated diabetes management for one week. The third group received no 

intervention. Family relationships were assessed using the Family Environment Scale 

(FES). At the 6-month followup, there were no significant changes for any of the groups 

on the subscales of the FES. The methodological quality of this study was rated as low 

(1/5 on the Jadad score; unclear allocation concealment). 

Wysocki et al.82 randomized 104 families to one of three groups: standard care plus 

behavioral family systems therapy (BFST), standard care plus family education and 

support, and standard care (physician directed clinical care). Family conflict about 

diabetes was measured using the Diabetes Responsibility and Conflict scale. At the 12-

month followup, the BFST group demonstrated a greater reduction in family conflict 

scores; however, the difference was not statistically significant. The methodological 

quality of this study was rated as low (2/5 on the Jadad score; unclear allocation 

concealment). 

 Children with newly diagnosed diabetes. The RCT by Sundelin et al.70 compared 

conventional inpatient education (n = 19 families) to a multidisciplinary program 

delivered in an outpatient setting (n = 19). Families in the intervention group were 

encouraged to move in to a training apartment for 2 weeks to receive a family-oriented 

crisis therapy program that developed customized management strategies based on 

problems and questions formulated by the family. The control group received the 

established clinic protocol, in which the child was hospitalized with one parent, and 

families were encouraged to attend information sessions with medical staff. Family and 

social relationships were evaluated using the Family Relations Scale and the Family 

Climate test. There were no statistically significant differences between groups over the 

24-month followup period. The methodological quality of this study was rated as low 

(2/5 on the Jadad score; unclear allocation concealment). 

Kennedy-Iwai36 randomly assigned 19 families to receive standard care (standard 

clinical treatment and diabetes education) or standard care plus a couple communication 

program delivered to parents. The effects of communication training with parents of 

newly diagnosed diabetic children was examined. Family relationships were measured by 

two subscales in the Family Environment Scale: cohesion and conflict. In the conflict 

subscale, mothers from the intervention group had less family conflict than mothers from 

the control group immediately following the intervention; however, at 3 months postintervention this difference had disappeared. There were no differences for fathers at 

either time point. The methodological quality of this study was rated as low (2/5 on the 

Jadad score; unclear allocation concealment). 

 Children with poorly controlled diabetes. Wysocki et al.83 randomly assigned 119 

families of adolescents to three groups: standard care (physician directed clinical 

therapy), education and support (ES) (standard care plus 10 sessions of a diabetes support 

group), behavioral family systems therapy (BFST) (standard care plus family problem 

solving and communication training and individualized treatment plans). Family 

relationships were assessed with the Parent-Adolescent Relationship Questionnaire 

(PARQ), the Diabetes Responsibility and Conflict Scale (DRC), the Issues Checklist, and 

a telephone recall interview to collect descriptions of conflict situations from participants. 

On the PARQ, there were no significant differences between groups on the family 

structure subscale. On the overt conflict/skill deficits subscale and the extreme beliefs 
97

subscale, at 3-months post-intervention, the BFST group had significantly lower scores 

(indicating less conflict) than the standard care group, but not the ES group. On the Issues 

Checklist, at 6- and 12-month followups, negative communication for both adolescents 

and mothers significantly decreased in the BFST group compared to the other groups. As 

well, BFST families significantly improved on measures of negative reciprocity and 

problem resolution. On the DRC, the BFST group showed significantly greater 

improvement than the comparison groups at 6-month followup; however, this difference 

was not sustained at the 12-month followup. Finally, there were no significant differences 

for family conflict reported during recall interviews. The methodological quality of this 

study was rated as high (3/5 on the Jadad score; adequate allocation concealment). 

In an uncontrolled before-and-after study, Harris et al.28 evaluated 18 adolescents and 

their families who enrolled in a BFST program. Family relationships were assessed using 

the Diabetes Family Behavior Checklist. There were no statistically significant 

differences between baseline and 6-month followup measures. The methodological 

quality of this study was weak based on the Thomas instrument. 

Skills Training—Family or Social Relationships 

 Children with newly diagnosed diabetes. One RCT by Mitchell49 assessed the effect 

of a skill training intervention on family relationships among 32 newly diagnosed 

patients. The intervention group received standard multidisciplinary education and 

support plus a booklet targeted at improving compliance with treatment. The booklet 

identified problems with adherence and offered basic self-management skills. The 

standard care group received standard education and support. Social relationships were 

assessed by the externalizing behavior subscale of the Childhood Behaviour Checklist. At 

the 12-month followup, there were no significant differences between groups. The 

intervention group showed a decrease in externalizing behaviors; however, the change 

was not statistically significant. No change was observed for the control group. The 

methodological quality of the study was low (1/5 on the Jadad score; unclear 

concealment of allocation). 

Diabetes Camp—Family or Social Relationships 

 General population of children with diabetes. The uncontrolled before-and-after 

study by Smith et al.67 examined the effect of an intervention delivered to 120 

adolescents during a 5-day diabetes camp. The objective of the intervention was to 

develop assertive communication and included daily 1-hour sessions that provided 

information, facilitated sharing, and provided opportunities to practice assertive 

communication, problem solving and negotiation skills. Family relationships were 

assessed using the Parent-Adolescent Communication Scale (P-ACS), which yields a 

total score and two subscale scores that measure open communication and problems in 

communication. Overall, at the 3-month followup, there were no significant changes in 

the degree of problems in communicating. However, adolescents reported a significant 

decrease in open communication with fathers (p<0.05). The methodological quality of the 

study was weak based on the Thomas instrument. 
98

The prospective cohort study by Hill et al.29 compared two different diabetes camps: 

one camp (n = 60) offered a program based on self-determination theory and one camp (n 

= 74) offered a program that had similar types of activities but was not theory-based. 

Social relationships were assessed using the Basic Psychological Needs Scale. At the 3-

month followup, the children who attended the intervention camp reported a stronger 

sense of relatedness compared with the comparison camp (p = 0.03). The methodological 

quality of the study was weak based on the Thomas instrument. 

Summary of Results—Family or Social Relationships 

Overall, we identified 16 studies that assessed the effect of diabetes education on the 

psychosocial outcome of family and social relationships (Table 12). Of these, nine studies 

(6 RCTs, 1 cohort, 2 uncontrolled before-and-after) examined the general population of 

children with type 1 diabetes, four studies (3 RCTs, 1 cohort) focused on children with 

newly diagnosed diabetes, and three (2 RCTs, 1 uncontrolled before-and-after) examined 

children with poorly controlled diabetes. Due to substantial differences across studies in 

terms of population, intervention, comparison groups, duration of intervention and 

followup timepoints, we were unable to pool the results of any of the studies. 

General population of children with diabetes. Nine studies (6 RCTs,5,38,63,72 1 

cohort,29 2 uncontrolled before-and-after20,67) assessed the effectiveness of diabetes 

education on family and social relationships in the general population of children with 

type 1 diabetes (Table 12). Four studies assessed the effectiveness of cognitive behavioral 

therapy,5,20,22,72 three examined family system therapy interventions,38,63,82 and two 

assessed the effect of diabetes camps.29,67 In general, the methodological quality of the 

studies was low, with only one RCT72 and one before-and-after study20 rated as being of 

moderate quality. 

The results of the two moderate quality studies do not suggest that diabetes education 

has an effect on family or social relationships. The RCT by Szumowski72 compared a 

group that received a combination of cognitive behavior therapy and standard diabetes 

management training with a group that received standard diabetes management training 

only. There was no significant difference between the groups in diabetes-related conflict. 

The before-and-after study by Greco et al.20 assessed an intervention aimed at integrating 

teenage peers into the diabetes care of a friend with diabetes. Following the intervention, 

peers reported improved interaction with their friend; however, no change in peer 

interaction was reported by the adolescents with diabetes. Parents of the adolescent with 

diabetes reported less diabetes-related conflict. 

The results of the remaining studies were inconsistent. Three studies (2 RCTs,5,22 1 

cohort29) found that family or social relationships improved following diabetes education. 

In contrast, four studies (3 RCTs,38,63,82 1 uncontrolled before-and-after67) found that the 

intervention had no effect on the outcome. 

Children with newly diagnosed diabetes. Four studies (3 RCTs,36,49,70 1 cohort69) 

assessed the effectiveness of diabetes education on family or social relationships among 

children with newly diagnosed diabetes (Table 12). In general, the methodological 

quality of the studies was low, with only the cohort study by Srinivasan69 assessed as 

being of moderate quality. Three studies found that diabetes education was not effective 

in improving family or social relationships.36,49,69 One study70 compared the setting for 
99

delivery of a family-based education program (ambulatory vs. inpatient) and found no 

difference between groups on measures of family or social relationships. This was a small 

study and there may not have been sufficient statistical power to detect a difference 

between groups. 

Children with poorly controlled diabetes. Three studies (2 RCTs,16,83 1 

uncontrolled before-and-after28) assessed the effectiveness of diabetes education on 

family or social relationships among children with poorly controlled diabetes (Table 12). 

The large, high-quality RCT by Wysocki et al.83 assessed a family systems therapy 

intervention and found that the intervention group demonstrated improved levels of 

family conflict and communication on several of the measures used by the researchers. 

The remaining two studies found that the intervention had no effect on the outcome.16,28 

 Table 12. Summary of results of studies assessing the effect of diabetes education on family/social 

relationships 

Author Year Intervention Study design 

Sample size 

Quality Results 

General population of children with diabetes 

Anderson5 1999 Cognitive 

behavioral 

therapy 

RCT 

89 

Low IG reported significantly less 

conflict than CG at 12 mo. 

Greco20 2001 Cognitive 

behavioral 

therapy 

Before-after 

23 

Moderate Parents reported significantly 

less diabetes-related 

conflict following 

intervention; Adolescents 

reported no significant 

change in peer-interaction 

following intervention; 

Peers reported significant 

improvement in peerinteraction following 

intervention 

Gross22 1985 Cognitive 

behavioral 

therapy 

RCT 

14 

Low IG reported significantly less 

conflict; CG remained 

unchanged at 6 mo. 

Hill29 2006 Diabetes camp Cohort 

134 

Low IG reported significantly 

higher sense of 

relatedness than CG at 3 

mo. 

CG = control group; IG = intervention group; NS = not significant; PARQ = Parent-Adolescent Relationship 

Questionnaire
100

 Table 12. Summary of results of studies assessing the effect of diabetes education on family/social 

relationships (continued) 

Author Year Intervention Study design 

Sample size 

Quality Results 

General population of children with diabetes (continued) 

Laffel38 2003 Family therapy RCT 

105 

Low No significant difference in 

diabetes-related conflict 

between IG and CG 

(children or parents) at 12 

mo. 

Satin63 1989 Family therapy RCT 

32 

Low No significant change in 

family environment at 6 

mo. 

Smith67 1993 Diabetes camp Before-after 

120 

Low No significant change in 

degree of problems in 

communicating following 

camp; adolescents 

reported significant 

decrease in open 

communication with 

fathers following camp 

Szumowski72 1990 Cognitive 

behavioral 

therapy 

RCT 

27 

Moderate No significant difference 

between groups in 

diabetes-related conflict at 

3 mo. 

Wysocki82 2007 Family therapy RCT (3 arms) 

104 

Low IG had lower family conflict 

scores than either CG; 

difference NS at 12 mo. 

Children with newly diagnosed diabetes 

Kennedy-Iwai36 1991 Family therapy RCT 

19 

Low No difference between 

groups for family 

environment or conflict at 

3 mo. 

Mitchell49 1996 Skills training RCT 

32 

Low No significant difference 

between groups at 12 mo. 

Srinivasan69 2004 General 

diabetes 

education 

Cohort 

110 

Moderate No significant difference 

between groups for 

diabetes responsibility and 

conflict and parent-child 

conflict at 12 mo. 

Sundelin70 1996 Family therapy RCT 

38 

Low No significant difference 

between groups for parent 

perception of child 

behavioral disturbances at 

24 mo.; 

No significant difference 

between groups for family 

emotional climate at 24 

mo. 

Children with poorly controlled diabetes 

Delamater16 1991 Cognitive 

behavioral 

therapy 

RCT 

13 

Low No significant difference 

between groups for 

parent-teen relationship at 

4 mo. 

Harris28 2005 Family therapy Before-after 

18 

Moderate No significant change from 

baseline to 6 mo. 
101

 Table 12. Summary of results of studies assessing the effect of diabetes education on family/social 

relationships (continued) 

Author Year Intervention Study design 

Sample size 

Quality Results 

Children with poorly controlled diabetes (continued) 

Wysocki83 2000 Family therapy RCT (3 arms) 

119 

High PARQ overt conflict/skill 

deficits—IG had 

significantly lower scores 

compared to CG1 but not 

CG2 at 3 mo.; 

PARQ family structure—No 

significant difference 

between groups at 12 mo.; 

Parent-child division of 

diabetes responsibilities 

and family conflict—IG 

had significantly greater 

improvement than either 

CG at 6 mo.; difference 

was NS at 12 mo.; 

Adolescent negative 

communication—IG 

significantly improved 

compared to either CG at 

12 mo.; 

Mother negative 

communication—IG 

significantly improved 

compared to either CG at 

12 mo.; 

Negative reciprocity—IG 

showed significant 

improvement compared to 

either CG at 12 mo.; 

Problem resolution—IG 

showed significant 

improvement compared to 

either CG at 12 mo.; 

PARQ extreme beliefs—IG 

had significantly lower 

scores compared to either 

CG at 3 mo. 

Family or Social Support 

General Diabetes Education—Family or Social Support 

 General population of children with diabetes. Brown et al.9 randomized 59 children 

to an intervention group that viewed a diabetes-related interactive video game, or to a 

comparison group that received an entertainment video game with no diabetes-related 

content. Social support was measured by parent report of how many times in the previous 

month the child initiated discussions about diabetes care and about their feelings related 

to having diabetes. At 6-month followup, the intervention group had increased 

communication significantly compared to the control group (9.8±9.5 vs. 19.3±25.1 

instances and 18.9±25.1 vs. 15.0±20.6 instances, respectively [p = 0.025]). The 
102

methodological quality of this study was low (1/5 on the modified Jadad scale; unclear 

concealment of allocation). 

 Children with newly diagnosed diabetes. Siminerio et al.66 compared a 3- to 5-day 

education program delivered on an inpatient vs. outpatient basis. Patients were divided 

into two cohorts of 16 patients each. The education program included basic education on 

diabetes, complications, self-management skills, and nutrition and exercise. Family 

support was measured by the Coping Health Inventory for Parents, which has three 

subscales measuring maintenance of family integration, maintaining social support, and 

understanding the medical situation through consultation with medical support personnel. 

There were no significant differences between the groups at the 1-month followup. The 

methodological quality of this study was moderate using the Thomas instrument. 

 Children with poorly controlled diabetes. In the RCT by Coupland,15 adolescents 

and their families participated in a family-based intervention to improve adherence (n = 

15); the comparison group (n = 14) consisted of adolescents who were taught stress 

management techniques. Perceived diabetes-specific family support was assessed with 

the supportive items of the Diabetes Family Behaviour (DFB) checklist and general 

family support was assessed with the Family APGAR. At the 6-month followup, the 

intervention group reported improved general family support (p < 0.001). There was no 

significant difference between the two groups on the DFB checklist. The methodological 

quality of this study was low (2/5 on the modified Jadad scale; unclear concealment of 

allocation). 

Cognitive Behavioral Therapy—Family or Social Support 

 General population of children with diabetes. Anderson et al.5

 assessed the 

effectiveness of an intervention for families that focused on teamwork and shared parentteen responsibility for diabetes tasks. Eighty-nine families were randomly assigned to the 

intervention group or to one of two comparison groups—standard care (routine clinical 

care from the diabetes team) or standard care plus didactic diabetes education. Family 

support was measured with the Diabetes Family Behavior Checklist (Unsupportive 

behavior subscale). At 12-month followup, the intervention group showed a significantly 

greater decrease in unsupportive behavior compared with the comparison groups 

(p<0.02). The methodological quality of this study was low (2/5 on the Jadad score; 

unclear concealment of allocation). 

The CCT by Mendez and Belendez48 used an intervention comprising 12 sessions of 

content delivery, skill practice and homework; parents were involved for two of the 

sessions. The emphasis was on reinforcement of adherence behaviors rather than 

punishing noncompliance. The intervention delivered to the control group care was not 

described. Family support was measured using the Diabetes Family Behavior Checklist. 

There were no significant differences between intervention and control groups for 

positive or negative family support at 13-month followup. The methodological quality of 

this study was low (1/3 on the modified Jadad score). 

The uncontrolled before-and-after study by Greco et al.20 delivered the intervention in 

2-hour sessions over 4 weeks to groups of three to six diabetes patient-peer pairs. The 

intervention consisted of a review of the etiology, physiology and treatment of diabetes, 

reflective listening skills, problem solving related to diabetes, stress management, games 
103

or exercises to practice concepts and homework assignments. Family and peer support 

were measured using the Diabetes Social Support Inventory. Perceived levels of support 

did not improve significantly following the intervention. The methodological quality of 

this study was moderate based on the Thomas instrument. 

 Children with poorly controlled diabetes. Delamater et al.16 randomized 13 

adolescents to receive a 2-month behavior therapy program or to standard outpatient care. 

Patient and parent ratings of parental supportiveness and non-supportiveness were 

compared between the two groups. There were no significant differences between groups 

at 4-month followup. The methodological quality of this study was low (2/5 on the 

modified Jadad score; unclear concealment of allocation). 

Family Therapy Family or Social Support 

 Children with poorly controlled diabetes. In an uncontrolled before-and-after study, 

Harris et al.28 evaluated 18 adolescents and their families who enrolled in a behavioral 

family systems therapy (BFST) program. Family supportive and non-supportive 

behaviors were assessed using the Diabetes Family Behavior Checklist. There were no 

statistically significant differences between baseline and 6-month followup measures. 

The methodological quality of this study was weak based on the Thomas instrument. 

Diabetes Camp—Family or Social Support 

 General population of children with diabetes. Remley62 conducted a CCT (n = 237) 

to compare a social cognitive theory-based camp program with a standard non-theory 

based camp education program. Eight 1-week camps across the United States were 

designated to deliver either the theory-based intervention or the standard program. Social 

support was measured using the Diabetes Social Support index. At the 3-month followup, 

there were no significant changes in outcomes for either group. The methodological 

quality of this study was low (1/3 on the modified Jadad scale). 

Summary of Results—Family or Social Support 

Overall, we identified nine studies that assessed the effect of diabetes education on 

the psychosocial outcome of family and social support (Table 13). Of these, five studies 

(2 RCTs, 2 CCTs, 1 uncontrolled before-and-after) examined the general population of 

children with type 1 diabetes, one cohort study focused on children with newly diagnosed 

diabetes, and three (2 RCTs, 1 uncontrolled before-and-after) examined children with 

poorly controlled diabetes. 

General population of children with diabetes. Five studies (2 RCTs,5,9 2 CCTs,48,62

1 uncontrolled before-and-after20) assessed the effectiveness of diabetes education on 

family and social support in the general population of children with type 1 diabetes 

(Table 13). Three studies assessed the effectiveness of cognitive behavioral therapy,5,20,48

one examined general diabetes education,9 and one assessed the effect of diabetes 

camps.120 In general, the methodological quality of the studies was low, with only the 

before-and-after study by Greco et al.20 rated as being of moderate quality. 
104

The uncontrolled before-and-after study by Greco et al.20 assessed an intervention 

aimed at integrating teenage peers into the diabetes care of a friend with diabetes. There 

was no change in perceived levels of family support following the intervention. The 

results of the remaining studies were inconsistent. Two RCTs,5,9 found that family/social 

support improved following diabetes education. In contrast, two CCTs48,62 found that the 

intervention had no effect on the outcome. 

Children with newly diagnosed diabetes. The moderate quality cohort study by 

Siminerio et al.66 compared inpatient vs. ambulatory delivery of general diabetes 

education among children with newly diagnosed diabetes (Table 13). There were no 

significant differences between groups for the family/social support outcome. 

Children with poorly controlled diabetes. Three studies (2 RCTs,15,16 1 

uncontrolled before-and-after28) assessed the effectiveness of diabetes education on 

family/social support among children with poorly controlled diabetes (Table 13). The 

methodological quality of the studies was low. None of the studies found that the 

intervention had an effect on the outcome. 

Table 13. Summary of results of studies assessing the effect of diabetes education on family and 

social support 

Author Year Intervention Study design 

Sample size 

Quality Results 

General population of children with diabetes

Anderson5 1999 Cognitive behavioral 

therapy 

RCT 

89 

Low IG reported significant 

decreases in 

unsupportive behavior 

compared with CG at 12 

mo. 

Brown9 1997 General diabetes 

education 

RCT 

59 

Low IG significantly increased 

communication skills 

compared to CG at 6 mo. 

CG = control group; IG = intervention group
105

 Table 13. Summary of results of studies assessing the effect of diabetes education on family and 

social support (continued) 

Author Year Intervention Study design 

Sample size 

Quality Results 

General population of children with diabetes (continued)

Greco20 2001 Cognitive behavioral 

therapy 

Before-after 

23 

Moderate No significant change 

following the intervention 

Mendez48 1997 Cognitive behavioral 

therapy 

CCT 

37 

Low No significant difference 

between groups on any of 

the social support 

measures at 13 mo. 

Remley62 1999 Diabetes camp CCT 

237 

Low No significant difference 

between groups on any of 

the social support 

measures at 3 mo. 

Children with newly diagnosed diabetes 

Siminerio66 1999 General diabetes 

education 

Cohort 

32 

Moderate No significant difference 

between groups at 1 mo. 

Children with poorly controlled diabetes

Coupland15 1992 General diabetes 

education 

RCT 

32 

Low No significant difference 

between groups at 6 mo. 

Delamater16 1991 Cognitive behavioral 

therapy 

RCT 

13 

Low No significant difference 

between groups on any of 

the social support 

measures at 4 mo. 

Harris28 2005 Family therapy Before-after 

18 

Low No significant change at 6 

mo. for diabetes support; 

No significant change at 6 

mo. for diabetes nonsupport 

Social Skills 

General Diabetes Education—Social Skills 

 Children with poorly controlled diabetes. Nunn et al.55 conducted a RCT to assess 

the effect of a general diabetes education intervention on social skills. One hundred and 

twenty-three patients were randomized to either the intervention group, comprising 15- to 

30-minute telephone calls on three main topics: current insulin, carbohydrate intake and 

blood glucose values; events which may impact diabetes management; and delivery of an 

educational program, or to the standard care group (routine clinical care). Social skills 

were measured using the Strengths and Difficulties Questionnaire. At the end of the 5- to 

8-month program, there were no significant differences between groups for various social 

skills (emotional, conduct, hyperactive, peer problem, and pro-social scores). The 

methodological quality of the study was high (3/5 on the Jadad score; unclear 

concealment of allocation) 

In the CCT by Viner et al.76 a 6-week motivational and solution-focused therapy 

group program that used systematic questions, a narrative approach and cognitive 

behavioral therapy was delivered to 21 adolescents and their parents. The control group 

comprised 20 adolescents who did not receive any intervention. Social skills were 
106

assessed using the Strengths and Difficulties Questionnaire (SDQ). There were no 

significant changes in mean SDQ scores for either group. The methodological quality of 

the study was low (2/5 on the Jadad score; unclear concealment of allocation). 

Cognitive Behavioral Therapy—Social Skills 

 General population of children with diabetes. Gross et al.23 randomized six children 

to a social skills training intervention and five to a control group. The social skills 

training consisted of modeling and role-playing exercises and took place in two 45-

minute per week sessions for 5 weeks. The control group subjects did not interact with 

the experimenters except at assessment times (baseline, post training, one and six-week 

followups). At the 6-week followup, the intervention group demonstrated increased 

incidence of certain social skills, including percentage eye contact time (from 53 to 95 

percent), percentage verbalizations (from 24 to 79 percent), and speech duration (from 

1.7 to 6 seconds). There were no changes observed in these behaviors for the control 

group. The methodological quality of the study was moderate (2/5 on the Jadad score; 

unclear concealment of allocation; blinding of outcome assessors). 

Summary of Results—Social Skills 

 General population of children with diabetes. One moderate quality RCT (Gross et 

al.23) assessed the effect of cognitive behavioral therapy on social skills in the general 

population of children with type 1 diabetes (Table 14). They found that the intervention 

group significantly improved their social skills compared to the control group. 

 Children with poorly controlled diabetes. The large high quality RCT by Nunn et 

al,55 reported no significant differences in social skills between the intervention group 

that received general diabetes education plus telephone followup and the control group 

that received diabetes education with no telephone followup (Table 14). Similarly, the 

CCT that assessed this population did not find any change in social skills.76
107

Table 14. Summary of results of studies assessing the effect of diabetes education on social skills 

Author Year Intervention Study design 

Sample size 

Quality Results 

General population of children with diabetes 

Gross23 1983 Cognitive 

behavioral 

therapy 

RCT 

11 

Moderate IG improved significantly for 

increased eye contact, appropriate 

verbalization, speech duration, 

affect ratings at 6 wk.; no change 

for CG 

Children with poorly controlled diabetes

Nunn55 2006 General 

diabetes 

education 

RCT 

123 

High No significant change for either group 

at 5-8 mo. in emotional, conduct, 

hyperactive, peer problem, and 

pro-social scores 

Viner76 2003 Cognitive 

behavioral 

therapy 

CCT 

21 

Low No significant change for either group 

at 12 mo. 

CG = control group; IG = intervention group 

Coping 

General Diabetes Education—Coping 

 General population of children with diabetes. In the uncontrolled before-and-after 

study by Marteau et al.,44 a multidisciplinary team delivered a weekend program to 97 

parents. There were sessions on problem solving, forming self-help groups, and ways to 

achieve best care. Parents rated themselves as significantly more confident in looking 

after their child both immediately following the intervention and at the 3-month 

followup. However, their perception of the difficulty of looking after their child remained 

unchanged at 3-months post-intervention. The methodological quality of this study was 

rated as weak based on the Thomas instrument. 

 Children with newly diagnosed diabetes. Dougherty et al.18 delivered a general 

diabetes education intervention to 63 newly diagnosed patients. Thirty-one patients were 

randomized to receive the education as inpatients; the other 32 received their education at 

home in the form of home visits. At 24 months following diagnosis, there was no 

significant difference between groups on the Impact on Family Scale. The 

methodological quality of the study was moderate (2/5 on the Jadad score; unclear 

concealment of allocation; blinding of outcome assessors). 

Siminerio et al.66 compared a 3- to 5-day education program delivered on an inpatient 

vs. outpatient basis. Patients were divided into two cohorts of 16 patients each. The 

education program included basic education on diabetes, complications, self management 

skills, and nutrition and exercise. At 1-month post-intervention, there were no significant 

differences between the groups in coping as measured by the Coping Health Inventory 

for Parents and the Coping Health Inventory for Children questionnaires. The 

methodological quality of this study was rated as moderate based on the Thomas 

instrument. 

In a prospective cohort study by Srinivasan et al.,69 a 4- to 16-week outpatient day 

care program was compared with a 4- to 7-day inpatient program for delivering general 

diabetes education to 110 newly diagnosed patients and their families. There was no 
108

difference between groups for the outcome of coping. The methodological quality of this 

study was rated as moderate based on the Thomas instrument. 

Cognitive Behavioral Therapy—Coping 

 General population of children with diabetes. The RCT by Grey et al.21 examined a 

coping skills training intervention in a group of 77 adolescents that received intensive 

diabetes management as their standard care. Forty-one children were randomized to the 

coping skills training group and the training was delivered at 6 weekly sessions. Based on 

the Issues in Coping with IDDM scale, at 12-month followup, both groups reported 

significantly less upset about coping with diabetes and found it significantly less difficult 

to cope with their diabetes. The difference between the groups was not statistically 

significant. The methodological quality of the study was moderate (2/5 on the Jadad 

score; unclear concealment of allocation; blinding of outcome assessors). 

The CCT by Mendez and Belendez48 used an intervention comprising 12 sessions of 

content delivery, skill practice and homework assignment; parents were involved for two 

of the sessions. The emphasis was on reinforcement of adherence behaviors rather than 

punishing noncompliance. The intervention delivered to the control group care was not 

described. The questionnaires used were the Diabetic Daily Hassles Scale and the 

Diabetic Adolescents Social Skills Inventory. The authors reported that the intervention 

group had a significantly lower incidence of daily diabetes-related hassles and a lower 

degree of unease and likelihood of response in a social interaction relating to diabetes at 

post-intervention and 13-month followup. The methodological quality of the study was 

low (1/3 on the modified Jadad score). 

The uncontrolled before-and-after study by Greco et al.20 delivered the intervention in 

2-hour sessions over 4 weeks to groups of three to six diabetes patient-peer pairs. The 

intervention consisted of homework review on etiology, physiology and treatment of 

diabetes, reflective listening skills, problem solving related to diabetes, stress 

management, games or exercises to practice concepts and homework assignments. Using 

the Teen Adjustment to Diabetes Scale, the authors reported a trend toward improved 

behavioral, affective, and attitudinal adjustment to diabetes post-intervention; however, 

the change was not statistically significant. The methodological quality of this study was 

rated as moderate based on the Thomas instrument. 

 Children with poorly controlled diabetes. In a three-arm RCT (n = 37) Cigrang13

investigated the effects of a coping skills program delivered to adolescents with a history 

of poor metabolic control. There were two comparison groups: conventional diabetes 

education (8 lectures on diabetes topics including a question and answer session and time 

for skills practice) and standard care (routine clinical visits). The intervention group 

received eight sessions that focused on identifying issues that were perceived as difficult 

and stressful and developing adaptive coping strategies; the group was asked to 

implement new coping strategies in real life situations during the week. At 3-months 

followup, there were no significant differences among any of the groups for the outcome 

of coping using the Acceptance of Illness scale. The methodological quality of the study 

was low (2/5 on the Jadad score; unclear concealment of allocation). 

Boardway et al.8

 randomized 31 children to either a 3-month stress management 

program or to standard outpatient care. The intervention included group sessions in three 
109

phases of self-monitoring, stress management and regimen adherence. At the 6-month 

followup, there were no significant differences between the groups on the Ways of 

Coping questionnaire. The methodological quality of the study was low (1/5 on the Jadad 

score; unclear concealment of allocation). 

Hains et al.25 randomly assigned 15 adolescents to a 3-phase stress inoculation 

program or to a control group that received no intervention. At the 1-month followup, 

there was no difference between groups on the KIDSCOPE questionnaire. The 

methodological quality of the study was low (2/5 on the Jadad score; unclear 

concealment of allocation). 

Family Therapy—Coping 

 Children with poorly controlled diabetes. Wysocki et al.83 randomly assigned 119 

families to three groups: standard care (physician directed clinical therapy), education 

and support (standard care plus 10 sessions of a diabetes support group), and behavioral 

family systems therapy (BFST) (standard care plus family problem solving and 

communication training and individualized treatment plans). No significant difference 

was found among the groups for the outcome of coping at any time point up to 12-months 

post-intervention. The methodological quality of the study was rated as high (3/5 on the 

Jadad score; adequate allocation of concealment). 

Skills Training 

 Children with newly diagnosed diabetes. One RCT by Mitchell49 assessed the effect 

of a skills training intervention on coping abilities among 32 newly diagnosed patients 

(mean age 10.7 years). The intervention group received standard multidisciplinary 

education and support plus a booklet targeted at improving compliance with treatment. 

The booklet identified problems with adherence and offered basic self-management 

skills. The standard care group received standard education and support. Using the 

Problem Situations Questionnaire, at the 12-month followup there were no significant 

differences in coping outcomes between the groups. The methodological quality of the 

study was low (1/5 on the Jadad score; unclear concealment of allocation). 

Diabetes Camp—Coping 

 General population of children with diabetes. The uncontrolled before-and-after 

study by Koontz37 (n = 112) took place during a 1-week camp. Children were distributed 

in study groups according to age (grades 2–5, 6–8, and 9–10). The intervention included 

education on self-management skills, insulin administration, the relationship between 

diet, exercise and insulin, meal and snack planning, selecting and measuring food 

portions, SMBG, and identifying and treating insulin reactions, and was aimed to 

enhance camper’s emotional adjustment and improve self-esteem. At the 3-month 

followup, there was no effect of the intervention on coping strategies. However, the 

author noted that coping strategies differed as a function of age. The methodological 

quality of the study was moderate based on the Thomas instrument. 
110

The intervention in the uncontrolled before-and-after study by Smith68 (n = 108) 

consisted of daily 1-hour sessions on stress and diabetes in which management 

techniques were described, modeled and practiced using a variety of techniques. There 

was no significant change in coping abilities from pre- to post-camp. The methodological 

quality of the study was weak based on the Thomas instrument. 

Summary of Results—Coping 

Overall we identified 14 studies that examined the psychosocial outcome of coping 

(Table 15). Of these, six studies (1 RCT, 1 CCT, 4 uncontrolled before-and-after) 

examined the general population of children with type 1 diabetes. Four studies (2 RCTs, 

2 cohorts,) focused on children with newly diagnosed diabetes. Four RCTs targeted 

children with poorly controlled diabetes. 

General population of children with diabetes. Six studies (1 RCT,21 1 CCT,48 4 

uncontrolled before-and-after20,37,44,68) assessed the effect of diabetes education on coping 

in the general population of children with diabetes (Table 15). Three studies assessed the 

effectiveness of cognitive behavioral therapy,20,21,48 one examined general diabetes 

education,44 and two assessed the effect of diabetes camps.37,68 In general the 

methodological quality of the studies was low, with only one RCT (Grey et al.21) and two 

uncontrolled before-after studies (Greco et al.20 and Koontz37) rated as being of moderate 

quality. 

The results of the three moderate quality studies do not suggest that diabetes 

education has an effect on coping abilities. The RCT by Grey et al.21 found that both the 

intervention and control groups reported improved coping abilities; however, the 

difference between groups was not statistically significant. Similarly, the before-after 

studies Koontz37 and Greco et al.20 did not find that coping abilities were significantly 

improved following the education interventions. 

The results of the remaining studies were mixed. One uncontrolled before-and-after 

study found that parents were more confident about their ability to care for their children. 

44 One CCT that focused on improving adherence behavior and stress management had a 

significant impact on coping abilities.48 One uncontrolled before-and-after studies that 

assessed the effect of an intervention delivered at diabetes camps found no change in 

coping behaviors.68 

Children with newly diagnosed diabetes. Three moderate quality studies (1 RCT18

and 2 prospective cohort studies66,69) examined whether the setting for delivery of general 

diabetes education (i.e., delivery of education in an inpatient setting vs. an ambulatory 

setting) had an impact on coping behaviors (Table 15). None of the studies reported 

significant group differences in coping outcomes. The remaining study assessed a skills 

training intervention and found no difference between study groups.49 

Children with poorly controlled diabetes. The large high-quality RCT by Wysocki 

et al,83 reported no significant differences in coping behaviors between the intervention 

group that received behavioral family systems therapy and the control groups that 

received standard care and education support (Table 15). Similarly, the remaining low 

quality studies did not report any significant differences between intervention and control 

groups.8,13,25
111

Table 15. Summary of results of studies assessing the effect of diabetes education on coping 

Author Year Intervention Study design 

Sample size 

Quality Results 

General population of children with diabetes

Greco20 1991 Cognitive 

behavioral 

therapy 

Before-after 

23 

Moderate Trend toward improved 

behavioral, affective, and 

attitudinal adjustment; 

difference was NS 

Grey21 2000 Cognitive 

behavioral 

therapy 

RCT 

77 

Moderate Both groups reported less 

upset about coping with 

diabetes and less difficult to 

cope with diabetes at 12 

mo.; difference between 

groups was NS 

Koontz37 2002 Diabetes camp Before-after 

112 

Moderate No significant change at 3 mo. 

Marteau44 1987 General 

diabetes 

education 

Before-after 

97 

Low Parents rated themselves 

significantly more confident 

in looking after their child at 

3 mo.; 

Parents perception of difficulty 

in looking after child did not 

change at 3 mo. 

Mendez48 1997 Cognitive 

behavioral 

therapy 

CCT 

37 

Low IG reported significantly fewer 

daily diabetes-related 

hassles at 13 mo.; 

IG reported significantly lower 

degree of unease and 

likelihood of response in 

social situation relating to 

diabetes at 13 mo. 

Smith68 1991 Diabetes camp Before-after 

108 

Low No significant change from 

pre- to post-camp 

Children with newly diagnosed diabetes

Dougherty18 1999 General 

diabetes 

education 

RCT 

63 

Moderate No significant difference 

between groups on family 

impact at 24 mo. 

CCT = controlled clinical trial; IG = intervention group; NS = not significant 
112

 Table 15. Summary of results of studies assessing the effect of diabetes education on coping 

(continued) 

Author Year Intervention Study design 

Sample size 

Quality Results 

Children with newly diagnosed diabetes (continued)

Mitchell49 1996 Skills RCT 

32 

Low No significant differences 

between groups in 

perceived difficulties in 

diabetes management at 12 

mo.; 

No significant differences 

between groups in social 

function and general 

adjustment at 12 mo. 

Siminerio 66 1999 General 

diabetes 

education 

Cohort 

32 

Moderate No significant difference 

between groups at 1 mo. 

Srinivasan69 2004 General 

diabetes 

education 

Cohort 

110 

Moderate No significant difference 

between groups at 12 mo. 

Children with poorly controlled diabetes

Boardway8 1993 Cognitive 

behavioral 

therapy 

RCT 

31 

Low No significant difference 

between groups at 6 mo. 

Cigrang13 1992 Cognitive 

behavioral 

therapy 

RCT 

37 

Low No significant difference 

between groups at 3 mo. 

Hains25 2000 Cognitive 

behavioral 

therapy 

RCT 

15 

Low No difference between groups 

at 1 mo. 

Wysocki83 2000 Family therapy RCT 

119 

High No significant difference 

between groups at 12 mo. 

Self-Perception 

Cognitive Behavioral Therapy—Self-Perception 

 General population of children with diabetes. The uncontrolled before-and-after 

study by Greco et al.20 delivered the intervention in 2-hour sessions over 4 weeks to 

group of three to six diabetes patient-peer pairs. The intervention comprised information 

about diabetes, reflective listening skills, problem solving, stress management, and games 

or exercises to practice concepts. Self-perception was assessed using the global selfworth scale of the Self Perception Profile. At the end of the intervention, there was no 

significant change from baseline in self-perception among adolescents with diabetes. The 

methodological quality of this study was moderate based on the Thomas instrument. 

Thomas-Dobersen et al.74 conducted a CCT in which 11 obese adolescents 

participated in the SHAPEDOWN program which included 14 sessions over 3 months 

addressing various aspects of diabetes management such as diet and knowledge of 

hypoglycemia. The control group (n = 9) received standard diabetes treatment. Selfesteem was measured using the global self-esteem scale of the Self Perception Profile. At 

15 months, more children in the intervention group (4/11) showed clinical improvement 
113

in their self-perception compared to the control group (1/9). The methodological quality 

of this study was low (1/3 on the modified Jadad score). 

 Children with poorly controlled diabetes. In a 3-arm RCT, Cigrang13 investigated 

the effects of a coping skills program delivered to 37 adolescents with a history of poor 

metabolic control. There were two comparison groups: conventional diabetes education 

and standard care. Self-perception was assessed using the Self Perception Profile for 

Children. At 3-months post-intervention there were no significant differences among the 

three groups. The methodological quality of this study was low (2/5 on the Jadad score; 

unclear allocation concealment). 

Diabetes Camp—Self-Perception 

 General population of children with diabetes. In a CCT, Zorumski84 assigned 56 

children to attend either a 1-week camp that used active participation and educational 

presentations to teach all aspects of diabetic self-management, or to a control group that 

received standard clinical care but did not attend a camp. At the 4-month followup, the 

intervention group had a significantly lower score in self-perception (i.e., did not 

improve) compared to their baseline level (3.52±0.55 vs. 3.41±0.50), whereas the control 

group improved their score over the same time period (3.27±0.63 to 3.56±0.52). The 

methodological quality of this study was low (0/3 on the modified Jadad score). 

The uncontrolled before-and-after study by Koontz37 (n = 112) took place during a 1-

week camp. Participants were divided into 3 age groups (grades 2–5, 6–8, and 9–10). The 

intervention included education on self-management skills, insulin administration the 

relationship between diet, exercise and insulin, meal and snack planning and food 

portions, SMBG, and identifying and treating insulin reactions. Several subscales of the 

Self Perception Profile were used: social competence, physical attractiveness, athletic 

ability and global self-worth. At the 3-month followup, there were no significant 

differences in social competence and physical attractiveness within or between groups. 

Campers in the two younger age groups felt more athletically competent than those in the 

oldest group. Among the older campers, global self-worth decreased over the 3-month 

followup period; for younger campers, this attribute increased. The methodological 

quality of this study was moderate based on the Thomas instrument. 

In an uncontrolled before-and-after study, Smith et al.67 used the Adolescent Self 

Expression scale to measure changes in assertive behavior among adolescents attending a 

diabetes camp. At the 3-month followup, there was a significant increase in perception of 

assertive behavior. The methodological quality of this study was weak based on the 

Thomas instrument. 

Family Therapy—Self-Perception 

 Children with newly diagnosed diabetes. The RCT by Sundelin et al.70 compared 

conventional inpatient education (n = 19 families) to a multidisciplinary program for 

family-oriented crisis intervention delivered in an outpatient setting (n = 19 families). 

Self-esteem was measured using the “I think I am” test. At 24-month followup, there was 

no statistically significant difference between groups on this measure. The 
114

methodological quality of this study was low (2/5 on the Jadad score; unclear allocation 

concealment). 

 Children with poorly controlled diabetes. In the uncontrolled before-and-after study 

by Harris et al.28 reported 6-month followup data for 18 families who enrolled in a BFST 

program. Self-perception was measured using the Adjustment to Illness Scale which 

assesses feelings of self-acceptance and acceptance by others despite their illness. There 

were no significant differences in adjustment scores between baseline and 6-month 

followup for adolescents, mothers or fathers. The methodological quality of this study 

was weak based on the Thomas instrument. 

Summary of Results—Self-perception 

General Population of Children with Diabetes 

Five studies (2 CCTs,74,84 3 uncontrolled before-and-after20,37,67) examined the effect 

of diabetes education on self-perception in the general population of children with type 1 

diabetes (Table 16). Three studies examined interventions based on cognitive behavioral 

techniques20,67,74 and two assessed intervention delivered at a diabetes camp.37,67 Overall 

the methodological quality of the studies was low, with only two uncontrolled beforeand-after studies considered to be of moderate quality (Greco et al.20and Koontz37). 

With the exception of one uncontrolled before-and-after study,67 none of the studies 

found that diabetes education had an effect on self-perception. 

Children with newly diagnosed diabetes. One study70 compared the setting for 

delivery of a family-based education program (ambulatory vs. inpatient) and found no 

difference between groups on measures of self-perception (Table 16). This was a small 

study and there may not have been sufficient statistical power to detect a difference 

between groups. 

Children with poorly controlled diabetes. Two studies13,28 examined the effect of 

diabetes education on self-perception among children with poorly controlled diabetes. 

Neither study found that the education intervention had an effect on self-perception 

(Table 16). 
115

Table 16. Summary of results of studies assessing the effect of diabetes education on selfperception 

Author Year Intervention Study design 

Sample size 

Quality Results 

General population of children with diabetes 

Greco20 2001 Cognitive 

behavioral 

therapy 

Before-after 

23 

Moderate No significant change in social, 

academic, job, behavior, 

athletic competence 

Koontz37 2002 Diabetes camp Before-after 

112 

Moderate No significant change in social 

competence and physical 

attractiveness at 3 mo.; 

Younger campers felt more 

athletically competent than 

older campers at 3 mo. 

Smith67 1993 Cognitive 

behavioral 

therapy 

Before-after 

120 

Low Significant increase in 

assertive behavior at 3 mo. 

ThomasDobersen74 1993 

Cognitive 

behavioral 

therapy 

CCT 

20 

Low 4/11 IG subjects showed 

improvement at 15 mo. 

compared to 1/9 in CG; 

significance NR 

Zorumski84 1997 Diabetes camp CCT 

56 

Low IG had significantly lower 

score than CG at 4 mo. 

Children with newly diagnosed diabetes 

Sundelin70 1996 Family therapy RCT 

38 

Low No significant difference 

between groups at 24 mo. 

Children with poorly controlled diabetes 

Cigrang13 1992 Cognitive 

behavioral 

therapy 

RCT 

37 

Low No significant difference 

between groups at 3 mo. 

Harris28 2005 Family therapy Before-after 

18 

Moderate No significant change in self 

acceptance or acceptance 

by others at 6 mo. 

CG = control group; IG = intervention group; NR = not reported 

Self-Efficacy 

General Diabetes Education—Self-Efficacy 

 General population of children with diabetes. Brown et al.9

 randomized 59 children 

to receive either a diabetes related interactive video game (intervention group), or an 

entertainment video game with no diabetes related content (control group). Perceived 

self-efficacy was evaluated using a validated yielding a self-efficacy score from 1 to 7. 

Assessments took place at baseline, 3 and 6 months. The intervention group improved 

relative to the control group on self-efficacy ratings (0.45±0.60 vs. 0.17±0.57, 

respectively), but this change was not significant (p = 0.07). The methodological quality 

of the study was low (1/5 on the Jadad score; unclear allocation of concealment). 

 Children with newly diagnosed diabetes. In the study by Hoff et al.30 46 parents of 

children newly diagnosed with diabetes (mean age = 9.4 years) were randomly assigned 

to the intervention or control group. The intervention was delivered to parents and 
116

comprised two 2.5-hour group sessions designed to teach skills to manage uncertainty 

and to decrease parental distress and child behavioral problems. Parents assigned to the 

control group did not receive an intervention. Self-efficacy regarding dealing with the 

child’s illness was assessed using the Parent Perception of Uncertainty Scale. At the 3- 

and 6-month followup assessments, there were no significant changes for mothers and 

fathers in either group. The methodological quality of the study was high (3/5 on the 

Jadad score; adequate allocation of concealment). 

Cognitive Behavioral Therapy—Self-Efficacy 

 General population of children with diabetes. The RCT by Grey et al.21 randomized 

77 children to either a coping skills training combined with intensive diabetes 

management or to standard care (intensive management only). Self-efficacy was 

measured using the Self Efficacy for Diabetes Scale. At 12 months, adolescents in both 

groups reported significantly improved general, medical, and diabetes self-efficacy. The 

intervention group had significantly better diabetes and medical self-efficacy compared to 

the control group. The methodological quality of the study was moderate (2/5 on the 

Jadad score; unclear allocation of concealment; blinding of outcome assessors). 

 Children with newly diagnosed diabetes. Boardway et al.8

 randomized 31 children 

to either a 3-month stress management program or to standard outpatient care. The 

intervention included group sessions in three phases of self-monitoring, stress 

management and regimen adherence. Self-efficacy was measured using the Self-Efficacy 

for Diabetes Scale. At the 3-month followup, there were no significant changes in selfefficacy. The methodological quality of the study was low (1/5 on the Jadad score; 

unclear allocation of concealment). 

 Children with poorly controlled diabetes. In the CCT (n = 21), Viner et al.76 used 

motivational and solution focused therapy techniques for their intervention group 

compared to a no treatment control group. Self-efficacy was measured using the SelfEfficacy for Diabetes (SED) Scale. Mean SED scores improved significantly from 

baseline to the 6-month followup for the intervention group compared to no change in the 

control group. The methodological quality of the study was low (1/3 on the modified 

Jadad score). 

Skills Training—Self-Efficacy 

 General population of children with diabetes. In an uncontrolled before-and-after 

study by Caravalho and Saylor,11 56 children and their parents were taught insulin 

adjustment procedures and received group support and education to improve selfmanagement. Self-efficacy was assessed using the 13-item adapted Self-Efficacy for 

Diabetes Parent Questionnaire. After the 1-year intervention, self-efficacy scores had 

increased significantly from 56.2±7.7 to 59.3±6.9 (p = 0.01). The methodological quality 

of the study was weak using the Thomas instrument. 
117

Diabetes Camp—Self-Efficacy 

 

 General population of children with diabetes. Remley62 conducted a CCT (n = 237) 

to compare a social cognitive theory-based program with a standard non-theory based 

camp education program. Eight 1-week camps across the United States were designated 

to deliver either the theory-based intervention or the standard program. At the end of the 

camp and at the 3-month followup, there was no significant difference in self-efficacy for 

either group. The methodological quality of the study was low (1/3 on the modified Jadad 

score). 

In an uncontrolled before-and-after study, Schlundt et al.64 delivered an intervention 

to 86 campers. The program consisted of two sessions and used a 17-minute video on 

obstacles faced by adolescents with diabetes. Campers identified, analyzed and proposed 

solutions and then attempted to apply them to their own lives. Self-efficacy was measured 

by Self Efficacy for Diabetes (SED) Scale and the Situational Obstacles to Dietary 

Adherence (SODA) questionnaire. No change in the SED score occurred in either group 

from baseline to end of the 2-week camp. However, the SODA questionnaire indicated 

that children had significant increases in confidence to handle dietary obstacles. The 

methodological quality of the study was weak using the Thomas instrument. 

 The prospective cohort study by Hill et al.29 compared two different diabetes camps: 

one camp (n = 60) offered a program based on self-determination theory and one camp (n 

= 74) offered a program that had similar types of activities but was not theory-based. 

Self-efficacy was assessed with a Treatment Self Regulation Scale and a Perceived 

Confidence scale. At 3-month followup there were no significant differences between the 

intervention and comparison groups in perceived competence for diabetes management. 

There was a significant decrease in autonomy for diabetes management in the 

intervention group vs. and increase in autonomy for the comparison group the 

intervention group. The methodological quality of the study was weak based on the 

Thomas instrument. 

Summary of Results—Self-Efficacy 

 General population of children with diabetes. Six studies (2 RCTs,9,21 1 CCT,62 1 

cohort,29 2 uncontrolled before-and-after11,64) examined the effect of diabetes education 

on self-efficacy in the general population of children with type 1 diabetes (Table 17). 

Three studies examined interventions delivered at diabetes camp29,62,64 and 1 each studied 

general diabetes education,9 cognitive behavioral therapy,21 and skills training.11 Overall 

the methodological quality of the studies was low, with only one RCT assessed as being 

of moderate quality (Grey et al.21). 

The RCT by Grey et al.21 reported that the cognitive behavioral intervention had a 

positive effect on self-efficacy. The results of the remaining studies were mixed. Two 

studies found self-efficacy improved following the intervention.11,64 One found that both 

the intervention and control groups improved, but the difference between groups was not 
118

statistically significant.9

 The remaining studies reported no change in self-esteem 

measures following the education intervention.29,62 

 Children with newly diagnosed diabetes. The high quality RCT by Hoff et al.30

assessed an intervention delivered to parents of children with newly diagnosed diabetes to 

help them manage the uncertainty of how to care for their children (Table 17). There was 

no significant difference in parental self-efficacy between the intervention and control 

groups. The remaining study examined the effect of a stress management program on 

self-efficacy among children with newly diagnosed diabetes and found no difference 

between the intervention and control groups.8

 Children with poorly controlled diabetes. One low quality CCT76 found that an 

intervention based on cognitive behavior therapy techniques resulted in improved levels 

of self-efficacy among children with poorly controlled diabetes (Table 17). 

Table 17. Summary of results of studies assessing the effect of diabetes education on self-efficacy 

Author Year Intervention Study design 

Sample size 

Quality Results 

General population of children with diabetes

Brown9 1997 General diabetes 

education 

RCT 

59 

Low Both groups improved; 

difference was NS at 6 mo. 

Caravalho11 2000 Skills training Before-after 

56 

Low Significant improvement in 

scores at 12 mo. 

Grey21 2000 Cognitive 

behavioral 

therapy 

RCT 

77 

Moderate Both groups showed significant 

improvement in general selfefficacy at 12 mo.; 

IG did significantly better for 

diabetes and medical selfefficacy than CG at 12 mo. 

Hill29 2006 Diabetes camp Cohort 

134 

Low No significant difference 

between groups in 

competence or degree of 

autonomy at 3 mo. 

Remley62 1999 Diabetes camp CCT 

237 

Low No significant difference 

between groups at 3 mo. 

Schlundt64 1996 Diabetes camp Before-after 

86 

Low Statistically significant increase 

in confidence to overcome 

diabetes-related obstacles; 

No significant change in patient 

belief in self-care abilities 

Children with newly diagnosed diabetes 

Hoff30 2005 General diabetes 

education 

RCT 

46 

High No significant difference 

between groups at 6 mo. 

CG = control group, IG = intervention group; NS = not significant 
119

 Table 17. Summary of results of studies assessing the effect of diabetes education on self-efficacy 

(continued) 

Author Year Intervention Study design 

Sample size 

Quality Results 

Children with poorly controlled diabetes

Boardway8 1993 Cognitive 

behavioral 

therapy 

RCT 

31 

Low No significant difference 

between groups at 3 mo. 

Viner76 2003 Cognitive 

behavioral 

therapy 

CCT 

21 

Low Significant improvement for IG 

at 6 mo.; no change for CG 

intervention 

Stress 

Cognitive Behavioral Therapy—Stress 

 Children with poorly controlled diabetes. Boardway et al.8 randomized 31 

adolescents to either a 3-month stress management program or to a control group that 

received standard outpatient care. Stress was measured using the Diabetes Stress 

Questionnaire (DSQ). At the 6-month followup, the intervention group reported 

significantly improved stress levels compared to the control group (93.6±39.0 vs. 

56.1±43.7 and 88.4±33.5 vs. 83.4±31.3, respectively). The methodological quality of the 

study was low (1/5 on the Jadad score; unclear concealment of allocation). 

The RCT by Hains et al.25 randomized 15 middle school children to either a stress 

inoculation training program delivered over 6 weeks or to a waiting list control group. 

Stress was measured using the DSQ. At 1-month followup, the intervention group 

showed improvement in stress levels compared to the control group; however, the 

difference between the groups was not statistically significant. The methodological 

quality of the study was low (2/5 on the Jadad score; unclear concealment of allocation). 

Summary of Results—Stress 

Two RCTs assessed the effect of cognitive behavioral therapy interventions on stress 

among children with poorly controlled diabetes (Table 18).8,25 and found that the 

interventions groups had reduced stress levels compared to the control groups. However, 

the methodological quality for both studies was low and the results must be interpreted 

with caution. 

Table 18. Summary of results of studies assessing the effect of diabetes education on stress 

Author 

Year 

Intervention Study design 

Sample size 

Quality Results 

Children with poorly controlled diabetes 

Boardway8 1993 Cognitive 

behavioral 

therapy 

RCT 

31 

Low IG had significantly reduced 

stress levels compared to CG 

at 6 mo. 

Hains25 

2000 

Cognitive 

behavioral 

therapy 

RCT 

15 

Low IG had reduced stress levels 

compared to CG at 1 mo; 

difference was NS 

CG = control group, IG = intervention group; NS = not significant 
120

Anxiety and Depression 

General Diabetes Education—Anxiety and Depression 

 Children with newly diagnosed diabetes. In the study by Hoff et al.30 46 parents of 

children newly diagnosed with diabetes were randomly assigned to the intervention or 

control group. The intervention was delivered to parents and comprised two 2.5-hour 

group sessions designed to teach skills to manage uncertainty and to decrease parental 

distress and child behavioral problems. Parents assigned to the control group did not 

receive an intervention. Children continued to receive routine clinical care and intensive 

education. Mothers in the intervention group reported decreased child internalizing 

problems at the 1- and 6-month followup points; mothers in control group did not report 

any changes. Conversely, fathers in the intervention group did report changes in child 

internalizing problems during followup; however, fathers in the control group reported 

decreased child decreased child internalizing problems at the 1-month followup. This 

change disappeared at the 6-month followup. The methodological quality of the study 

was high (3/5 on the Jadad score; adequate concealment of allocation). 

Cognitive Behavioral Therapy—Anxiety and Depression 

 General population of children with diabetes. The RCT by Grey et al.21 examined a 

coping skills training intervention in a group of 77 adolescents who received intensive 

diabetes management as their standard care. Forty-one children were randomized to the 

coping skills training group and the training was delivered at six weekly sessions. Using 

the Children’s Depression Inventory, at the 12-month followup, both groups reported 

significantly less depression; however, the difference between the groups was not 

statistically significant. The methodological quality of the study was moderate (2/5 on the 

Jadad score; unclear concealment of allocation; blinding of outcome assessors). 

 Children with poorly controlled diabetes. In a three-arm RCT (n = 37) Cigrang13

investigated the effects of a coping skills program delivered to adolescents with a history 

of poor metabolic control. There were two comparison groups: conventional diabetes 

education (eight lectures on diabetes topics including a question and answer session and 

time for skills practice) and standard care (routine clinical visits). The intervention group 

received eight sessions that focused on identifying issues that were perceived as difficult 

and stressful and developing adaptive coping strategies; the group was asked to 

implement new coping strategies in real life situations during the week. Immediately 

following the intervention, there were no significant differences among any of the groups 

on measures of depression from the Dimensions of Depression Profile. The 

methodological quality of the study was low (2/5 on the Jadad score; unclear 

concealment of allocation). 

Hains et al.25 randomly assigned 15 adolescents to a 3-phase stress inoculation 

program delivered to patients and parents or to a control group that received no 

intervention. Anxiety was measured using the State-Trait Anxiety Inventory. At 1-month 

followup, there were no significant decreases in anxiety for either group. The 
121

methodological quality of the study was low (2/5 on the Jadad score; unclear 

concealment of allocation). 

Family Therapy—Anxiety and Depression 

 Children with newly diagnosed diabetes. Hakimi26 conducted an RCT to assess 

effectiveness of a family-based psychosocial intervention designed to ameliorate the 

negative psychological impact of diabetes. There were 35 patients with a mean age of 

11.5 years. The setting was not reported, but followup time was reported to be 6 weeks, 

and there were no significant differences in levels of depression or anxiety between 

groups. The methodological quality of the study was low (1/5 on the Jadad score; unclear 

concealment of allocation; blinding of outcome assessors). 

Skills Training—Anxiety and Depression 

 Children with newly diagnosed diabetes. One RCT by Mitchell49 assessed the effect 

of a skills training intervention on coping abilities among 32 newly diagnosed patients 

(mean age 10.7 years). The intervention group received standard multidisciplinary 

education and support plus a booklet targeted at improving compliance with treatment. 

The booklet identified problems with adherence and offered basic self-management 

skills. The standard care group received standard education and support. At the 12-month 

followup, the intervention group reported significant improvement in anxiety, depression 

and withdrawal characteristics as measured with the Child Behaviour Checklists. There 

was no change for the control group. The methodological quality of the study was low 

(1/5 on the Jadad score; unclear concealment of allocation). Both the intervention and 

control groups had substantial dropouts over the study period (47 and 53 percent, 

respectively). 

Summary of Results—Anxiety and Depression 

General population of children with diabetes. One moderate quality RCT (Grey et 

al.21) assessed the effect of a cognitive behavioral therapy intervention on depression in 

the general population of children with type 1 diabetes (Table 19). Both the intervention 

and control groups reported reduced depression; however, the difference was not 

statistically significant. 
122

 Children with newly diagnosed diabetes. One high-quality RCT (Hoff et al.30) 

reported mixed results of a general diabetes education delivered to parents of children 

with newly diagnosed diabetes (Table 19). Mothers in the intervention group reported 

that children had fewer internalizing problems compared to mothers in the control group. 

Conversely, fathers in the intervention group reported no change in children’s 

internalizing problems. The remaining two studies that focused on children with newly 

diagnosed diabetes were of low quality. One RCT reported improvement on a composite 

measure of depression, anxiety and withdrawal for the intervention group;49 the RCT 

found no difference in anxiety and depression levels between the intervention and control 

groups.26

 Children with poorly controlled diabetes. Two low-quality RCTs found no 

difference between intervention and control groups on measures of anxiety25 and 

depression13 in the population of children with poorly controlled diabetes (Table 19). 

 Table 19. Summary of results of studies assessing the effect of diabetes education on anxiety and 

depression 

Author Year Intervention Study design 

Sample size 

Quality Results 

General population of children with diabetes 

Grey21 2000 Cognitive 

behavioral 

therapy 

RCT 

77 

Moderate Depression—Both groups reported 

less depression at 12 mo.; 

difference between groups was 

NS 

Children with newly diagnosed diabetes 

Hakimi26 Family therapy RCT 

35 

Low Anxiety—No significant difference 

between groups at 6 wk. 

Depression—No significant 

difference between groups at 6 

wk. 

Hoff30 2005 General 

diabetes 

education 

RCT 

46 

High Child internalizing problems—

(maternal report) IG reported 

decreased levels at 1 and 6 mo.; 

no change for CG 

Child internalizing problems—

(paternal report) IG reported no 

change at 1 and 6 mo.; CG 

reported decreased levels at 1 

mo. but no change at 6 mo. 

Mitchell49 1996 Skills RCT 

32 

Low Depression, anxiety and 

withdrawal—IG reported 

significant improvement at 12 mo.; 

no change for CG 

Children with poorly controlled diabetes

Cigrang13 1992 Cognitive 

behavioral 

therapy 

RCT (3 arms) 

37 

Low Depression—No significant 

difference between groups at 3 

mo. 

Hains25 2000 Cognitive 

behavioral 

therapy 

RCT 

15 

Low Anxiety—No significant difference 

between groups at 1 mo. 

CG = control group; IG = intervention group; NS = not significant 
123

Quality of Life 

Overall there were four studies that assessed the effect of diabetes education on 

quality of life (QOL). All examined the general population of children with diabetes. 

General Diabetes Education—Quality of Life 

 General population of children with diabetes. In an uncontrolled before-and-after 

study, von Sengbusch et al.77 assessed the impact of a mobile diabetes education service 

on a group of 107 children living in rural areas in the United States. At both 6- and 12-

month followups there was a statistically significant improvement in QOL using the 

KINDL® quality of life questionnaire. The methodological quality of this study was 

moderate based on the Thomas assessment tool. 

Cognitive Behavioral Therapy—Quality of Life 

 General population of children with diabetes. Grey et al.21 randomly assigned 77 

adolescents to receive intensive diabetes management as described in the Diabetes 

Control and Complications Trial or intensive diabetes management plus a behavioral 

program of coping-skills training intervention. At 10-months post-intervention, the 

intervention group experienced less negative impact on QOL as measured by the 

Diabetes Quality of Life: Youth tool. The methodological quality of this study was 

moderate (2/5 on the Jadad scale; unclear concealment of allocation; blinding of outcome 

assessors). 

Family Therapy—Quality of Life 

 

 General population of children with diabetes. Laffel et al.38 randomly assigned 105 

families to a family-focused teamwork intervention, or to standard care (i.e., routine 

multidisciplinary clinical care). QOL was assessed using the PedsQL, which was 

administered to both children and parents. At 12-months post-intervention, there was no 

difference in the QOL scores between the intervention and standard care groups. The 

methodological quality of this study was assessed as low (2/5 on the Jadad scale; unclear 

concealment of allocation). 

Skills Training—Quality of Life 

 General population of children with diabetes. In an uncontrolled before-and-after 

study by Caravalho and Saylor,11 56 children and their parents were taught insulin 

adjustment procedures and received group support and education to improve selfmanagement. QOL was assessed using the Quality of Life Parent Questionnaire (adapted 

from the Diabetes Quality of Life instrument). QOL scores improved from pre- to postintervention (12 months) assessment, but the improvement was not statistically 
124

significant (p = 0.07). The methodological quality of this study was weak based on the 

Thomas instrument. 

Summary of Results—Quality of Life 

Overall, there was limited evidence for the QOL outcome and the results were mixed 

(Table 20). One moderate quality RCT (Grey et al.21) found that adolescents who 

received coping skills training along with intensive diabetes management experienced 

less negative impact on QOL compared with those who received intensive management 

only. Similarly, the moderate quality uncontrolled before-and-after study by von 

Sengbusch et al.77 reported a statistically significant improvement in QOL scores at 12 

months. The RCT by Laffel et al.38 found no difference in QOL scores between the 

family therapy group and control group. Caravalho and Saylor11 reported improved 

scores for parents of children with diabetes, but the change from baseline was not 

statistically significant. 

Table 20. Summary of results of studies assessing the effect of diabetes education on quality of life 

Author Year Intervention Study design 

Sample size 

Quality Conclusion 

General population of children with diabetes 

Caravalho11 2000 Skills Before-after 

56 

Low Parents had improved QOL scores 

at 12 mo.; difference was NS 

Grey21 2000 Cognitive 

behavioral 

therapy 

RCT 

77 

Moderate IG experienced less negative QOL 

than CG at 10 mo. 

Laffel38 2003 Family therapy RCT 

105 

Low No significant differences in QOL 

between groups at 12 mo. 

von Sengbusch77

2006 

General 

diabetes 

education 

Before-after 

107 

Moderate Significant improvement in QOL 

scores at 6 mo. and 12 mo. 

CG = control group, IG = intervention group; NS = not significant 

School Performance 

Overall there were two RCTs that assessed the effect of diabetes education on school 

performance. One examined the general population of children with diabetes and one 

focused on children with newly diagnosed diabetes (Table 21). 

General Diabetes Education—School Performance 

 Children with newly diagnosed diabetes. Dougherty et al.18 randomly assigned 63 

newly diagnosed patients to a 24-month home-based diabetes education program or to a 

traditional hospitalization and outpatient followup. Treatment differences between the 

groups consisted of duration of initial hospital stay, timing of initial teaching, and the 

nature and extent of subsequent nursing followup. During the course of the 2-year study, 

there was no difference in absences from school between the groups (28.3±36.4 days for 
125

the hospital-based group and 29.7±28.7 days for the home-based group. The 

methodological quality of this study was moderate (2/5 on the Jadad scale; unclear 

allocation of concealment; blinding of outcome assessors). 

Diabetes Camp—School Performance 

 General population of children with diabetes. Pichert et al.59 randomly assigned 84 

patients to either a control group, which participated in two 45-minute sessions where 

traditional teaching methods were employed to review 9 guidelines for sick-day 

management; or, to an intervention group, which participated in two 45-minute sessions 

using a video tape and discussion to review nine guidelines for sick-day management. At 

8-month followup there was no significant difference between groups for the number of 

sick days in the past 10 weeks. The methodological quality of this study was moderate 

(2/5 on the Jadad scale; unclear allocation of concealment; blinding of outcome 

assessors). 

Summary of Results—School Performance 

Overall, there was limited evidence relating to this outcome (Table 21). In the two 

studies assessing this outcome, diabetes education programs did not have a significant 

effect on school absence or sick days. 

Table 21. Summary of results of studies assessing the effect of diabetes education on school 

performance 

Author Year Intervention Study design 

Sample size 

Quality Conclusion 

General population of children with diabetes 

Pichert59 1994b Diabetes camp RCT 

84 

Moderate No significant difference in number of 

school absences between groups at 

8 mo. 

Children with newly diagnosed diabetes 

Dougherty18 1999 General 

diabetes 

education 

RCT 

63 

Moderate No significant difference in sick days 

between groups at 24 mo. 
127

Chapter 4. Discussion 

Grading the Body of Evidence 

We assessed the body of evidence for six key outcomes based on five domains: study 

design, study quality, consistency of effect estimates across studies, precision of effect 

estimates, and directness of the link between interventions and outcomes (Table 22). For 

each outcome, the majority of the studies used an RCT design, which is considered the 

strongest design; however, the quality of the studies was generally low. There was no 

consistency of effect estimates across studies for the outcomes. Precision was difficult to 

evaluate as confidence intervals or exact p values were not reported. The link between 

interventions and outcomes was often difficult to determine. Most interventions had 

multiple components and, while there may be a correlation between the entire 

intervention and the outcome, the association between specific intervention components 

and the outcomes was not evident. We classified the strength of evidence as low, 

meaning that there is low confidence in the estimate of effect and further research is 

likely to change our confidence in the estimate of effect. 

Table 22. Grading the strength of evidence 

Outcome Design Quality Consistency Precision Directness GRADE 

HbA1c (n = 52) RCT = 33 

CCT = 7 

Cohort = 4 

B-A = 8 

Low No significant effect in 22/52 studies 

Effect for both IG and CG; change or 

difference NS in 13/52 

IG improved more in 17/52 

Unable to 

evaluate 

Uncertainty 

about 

directness 

Low 

Short-term 

complications 

(n = 15) 

RCT = 6 

CCT = 1 

Cohort = 2 

B-A = 6 

Low No significant effect in 7/15 

Effect for both IG and CG; change or 

difference NS in 1/15 

IG improved more in 5/15 

Improvement made post intervention 

in 2/15 (B-A) 

Unable to 

evaluate 

Uncertainty 

about 

directness 

Low 

Knowledge (n = 

29) 

RCT = 10 

CCT = 6 

Cohort = 2 

B-A = 11 

Low No significant effect in 8/29 

Intervention group improved more in 

4/29 

Effect for both IG and CG; change or 

difference NS in 2/29 

Improvements made post 

intervention in 9/29 (B-A) 

Results vary between outcome or 

time point 6/29 

Unable to 

evaluate 

Uncertainty 

about 

directness 

Low 

Selfmanagement 

skills (n = 21) 

RCT = 15 

CCT = 3 

Cohort = 1 

B-A = 2 

Low No significant effect in 11/21 

Intervention group improved more in 

7/21 

Results vary between outcome or 

time point in 3/21 

Unable to 

evaluate 

Uncertainty 

about 

directness 

Low 

Coping (n = 14) RCT = 7 

CCT = 1 

Cohort = 2 

B-A = 4 

Low No significant effect in 10/14 studies 

Intervention group improved more in 

2/14 

Results varied between outcomes in 

2/14 

Unable to 

evaluate 

Uncertainty 

about 

directness 

Low 

Quality of Life (n 

= 4) 

RCT = 2 

B-A = 2 

Low No significant effect in 1/4 

IG improved more in 1/4 

Improvements made post 

intervention in 2/4 (B-A) 

Unable to 

evaluate 

Uncertainty 

about 

directness 

Low 

B-A = uncontrolled before and after study; CG = control group; CCT = controlled clinical trial; IG = 

intervention group; NS = not significant; RCT = randomized controlled trial 
128

Quality of the Evidence 

Although the majority of included studies were RCTs or CCTs, all but four RCTs 

obtained a low methodological score of 0, 1 or 2 of a possible 5 points on the Jadad scale, 

or 0 or 1 out of a possible 3 on the modified Jadad scale. These studies were considered 

of poor quality with serious threats to internal validity. The primary reason for the low 

scores was the lack of double blinding in these trials. It is important to recognize that it 

may not be appropriate to evaluate non-pharmacological interventions by the same 

standards applied to pharmacological interventions. Although there has been some debate 

as to whether the lack of double blinding is a serious flaw in studies that examine 

behavioral interventions,121,122 research has shown that there is a potential for 

performance bias in outcome assessment and studies that are not double blinded can 

overestimate treatment effects by 17 percent.102 Notwithstanding the evidence confirming 

the importance of double blinding in trials, we conducted a post hoc assessment to 

identify trials that used single blinding, in particular the blinding of outcome assessors. In 

27 percent of the trials, steps had been taken to reduce the potential for measurement 

bias. While implementing blinding in an RCT of non-pharmacological interventions often 

requires creative solutions, approaches such as blinding participants to the hypothesis of 

the study or blinding of outcome assessors have been increasingly adopted. The 

approaches are ethically justified provided that stringent criteria for protecting research 

participants are satisfied. Further research in this domain is warranted. 

Additionally, 25 percent of included studies were uncontrolled-before-and-after 

studies, which is not considered to be a rigorous study design because of the difficulty in 

determining whether any observed effects are solely accounted for by the intervention. 

Consistency of the Evidence 

Many of the interventions did not have consistent effects across the intervention (for 

example, all cognitive behavioral therapy studies did not display the same effect ) or 

coherent effects across all outcomes (e.g., all studies that showed a statistically 

significant effect in HbA1c did not necessarily find an effect in any other outcome). 

 Types of interventions. Diabetes education is a general term that encompasses a wide 

variety of interventions. Even within categories of the same type of intervention (e.g., 

cognitive behavioral therapy) there were many differences among studies in the focus of 

the intervention (e.g., stress management, coping strategies), the mode of delivery, the 

intensity of the intervention, whether the program was delivered to parents, children or 

both, and the times at which endpoints were measured. Although we were able to assign 

interventions to broad categories, there was still a high level of heterogeneity within 

categories. For example, the general diabetes education category included interventions 

delivered in such diverse formats as phone calls, small group sessions, educational 

leaflets, or video games. In addition to considerable heterogeneity, many of the studies 

had short study length (1 day to 2 weeks) and/or followup, which may not have been 

enough time to see significant changes. In some studies that showed positive effects, 

more intense followup of participants or the presence of an experienced team and an 

intensive management protocol may have been a factor in their success. 
129

 Types of control groups. Most of the trials that used control groups described the 

comparison intervention as “standard care”. Although some studies provided a 

description of standard care, the content of the education delivered to the control group 

was rarely detailed. Because the control group would be unlikely to receive “no 

education”, it is important to understand how the intervention and control interventions 

differed. Only then will we be able to isolate the factors that make education effective. 

Furthermore, if standard care is the comparison, researchers should be encouraged to 

change only one or two elements of an education program during their trial in order to 

better assess which components are effective and which are not. For example, this was 

successful, in the coping skills training intervention by Grey et al. 

 Types of populations. We considered three main population groups: the maintenance 

population of children with diabetes, which was our “general” category; children with 

newly diagnosed diabetes receiving their first diabetes treatment and education; and 

children who had problems achieving optimal metabolic control. In the general 

population, only a small number of interventions were shown to be effective. Many of 

these studies took place in academic settings where the patient population may be better 

educated and established educational programs may already exist. It is possible that these 

studies did not have sufficient statistical power to detect differences. Furthermore, if 

children entering these studies already had a certain level of education and motivation, 

there may be a ceiling effect and the additional education intervention may not have a 

noticeable impact on knowledge, behavior, or metabolic control. It is possible that these 

interventions may be effective in different study settings. 

In the population of children who were newly diagnosed, a small number of studies 

compared the delivery of education in inpatient and outpatient settings. While this review 

did not find that the setting of the education program had an impact on outcomes, the 

number of studies was small, and there were substantial differences in terms of the 

specific outpatient setting (e.g., training apartment, day care program) and intensity of 

intervention. Therefore, it is difficult to state that outpatient settings are as effective as 

inpatient settings for the delivery of education interventions. Further research controlling 

for these factors is required. 

For children with poorly controlled diabetes, we included studies in this category if 

the researchers specified that the study population was children with poor metabolic 

control. However, this allowed for some variability in clinical indicators. For example, 

the mean HbA1c levels in these studies ranged from 8.2 percent to 14.9 percent. 

Generally, results in this population were inconclusive, with a small number of studies 

showing improvement in HbA1c, knowledge and adherence and almost none showing 

changes in psychosocial outcomes. For the studies that reported improvement in 

outcomes, there were no common factors; the education interventions fell into different 

categories and the target populations were defined differently. 

 Types of outcomes. Our main clinical outcome, HbA1c, was standard across studies. 

However, for knowledge and psychosocial outcomes there was a wide range assessment 

tools, ranging from self-designed questionnaires to instruments that were developed and 

validated for people with diabetes. The use of different tools and metrics, even when 

measuring the same outcome was an additional factor that made it difficult to pool the 

results of studies or to generalize the effectiveness of interventions. Use of standardized 
130

instruments in studies evaluating outcomes in children with diabetes should alleviate this 

issue. 

Discussion of Key Questions 

There were 80 studies included in this review of diabetes education. Although over 65 

percent of the studies were RCTs or CCTs, their methodological quality was generally 

low. There was considerable heterogeneity with regard to the study population, the 

educational intervention and the outcomes measured. Furthermore, because most control 

groups also received some level of education, the studies may not have had sufficient 

power to detect a clinically or statistically significant difference in the various outcomes 

examined. These factors make it difficult to draw definitive conclusions and 

recommendations on the benefits of diabetes education. However, the discussion to 

follow will address the key questions based on the evidence obtained from the available 

research. 

1. What is the evidence that diabetes education on day-to-day management of 

diabetes improves metabolic control as determined by: 

 HbA1c. HbA1c is the gold standard for assessing diabetes control. The DCCT clearly 

showed that lower HbA1c leads to a decreased rate of microvascular complications. 

Therefore, the goal of all diabetes education interventions is to provide the knowledge, 

skills, and attitude to achieve the lowest HbA1c possible without frequent hypoglycemia. 

Unfortunately, the results of this review do not indicate that any specific educational 

intervention leads to consistent and sustained improvement in HbA1c over that achieved 

with “standard care” education. Cognitive behavioral and family therapy interventions 

appear to have a clinically significant benefit in some studies, although this was 

somewhat inconsistent with some studies showing a benefit while others did not. This can 

be explained in part by the heterogeneity within the intervention categories. Further 

research should be conducted to confirm these results and test their robustness in other 

settings. 

Although diabetes camps are frequently touted as venues in which education can 

occur to positively change practices, the main function of these camps seems to be as a 

vacation and as a support for children and parents. Studies set in diabetes camps are 

usually of short duration. While they may be successful in terms of participant 

satisfaction, the results do not suggest any short- or long-term improvement in metabolic 

control. 

Initial management and education of newly diagnosed patients has moved from an 

inpatient to an outpatient setting in many centers. The results of studies comparing the 

same education provided in these settings indicate there is no difference in HbA1c up to 2 

years after the diagnosis; however, the settings and the interventions were not consistent 

across the studies and these results should be interpreted cautiously. There are a few 

individual studies with newly diagnosed patients that demonstrated that education 

provided by a multidisciplinary team at the time of diagnosis results in improved HbA1c 
131

compared to education provided by fewer individuals or at a later time. This comparison 

needs to be replicated to determine if the benefit is significant. 

Patients with poorly controlled diabetes can be major consumers of diabetes health 

care resources. Numerous studies have examined different interventions to improve 

HbA1c. Unfortunately, only a few have shown a benefit. More intensive general diabetes 

education, interventions teaching stress management and coping skills, and family 

therapy have not been shown to improve diabetes control. Frequent (weekly) contact with 

motivational interviewing and goal-setting, and individual psychotherapy are 

interventions that have shown benefit but need to be studied further. 

It has been hypothesized that changes in HbA1c may be mediated by changes in 

knowledge, skills, attitudes and/or behavior. In the 16 studies that measured both 

knowledge and HbA1c, most groups exhibited improved knowledge after the educational 

intervention. However, improvements in knowledge did not translate into improved 

diabetes control. This suggests that lack of knowledge in itself is not necessarily a barrier 

to improving control. 

There were only two studies that measured both skills acquisition and HbA1c and 

neither showed a correlation between the two outcomes. Likewise, studies that measured 

psychosocial outcomes and HbA1c (n=24) did not show coherence across outcomes. 

Results spanned the spectrum from one of the outcomes improving but not the other, to 

neither outcome improving, and to both outcomes improving. In the studies that showed 

improvement in both outcomes, two were cognitive behavioral therapy interventions that 

looked at both self-efficacy and HbA1c, one was a family systems therapy intervention 

that looked at family relationships and HbA1c, and one was a skills training intervention 

that examined anxiety and HbA1c. In studies that examined both regimen adherence and 

HbA1c (n=21), there was little correlation between the outcomes. The two studies that 

showed improvement in both outcomes were family systems therapy trials. Finally, there 

was no correlation between outcomes in the four studies that measured quality of life and 

HbA1c. Based on these results, it is difficult to gain any insight into what is mediating 

metabolic control. It may be that different issues gain precedence in different families, for 

example adherence may be important for one family and psychosocial issues for another. 

Therefore, interventions may need to be targeted to more uniform study populations with 

similar underlying issues in order to assess the effect of the intervention. 

 Diabetes-related hospitalizations. Diabetes education appears to be effective in 

decreasing health care utilization (duration of hospital stay after diagnosis, rate of 

hospitalization, and ED and physician visits). The education interventions used to achieve 

this were more intensive, were provided by specialists and multidisciplinary teams, and 

involved some form of psychotherapy or psychosocial focus. The setting of the 

intervention (inpatient vs. outpatient) did not have an effect on outcome. Intensive, 

multidisciplinary interventions may be time- and labor-intensive, but their effect on 

decreasing health care utilization by patients and families may be quite cost-effective. 

This would be an interesting and worthwhile future research focus. 

 Frequency of DKA and hypoglycemia. Results were not as clear in the area of 

diabetes-related short-term complications. Most studies did not have high enough rates of 

DKA to show significant differences. Studies reporting on hypoglycemia covered the 

spectrum of possible outcomes. A possible explanation for this may be that hypoglycemia 

has so many potential causes. For example, an intervention may target nocturnal 
132

hypoglycemia, but not physical activity-related hypoglycemia. It is also possible that 

standard care and standard diabetes education effectively reduce the incidence of 

hypoglycemia, making it difficult to demonstrate differences between types of 

educational interventions. 

2. What is the evidence that medical nutrition therapy education in day-to-day 

management of diabetes improves HbA1c values and results in less variability in 

blood glucose levels? 

There is no clear evidence indicating that nutrition therapy education either improves 

or does not improve diabetes control. We identified only one uncontrolled before-andafter study12 that specifically assessed the effect of medical nutrition therapy education on 

HbA1c. The intervention was delivered to children attending a diabetes camp. The 

participants’ ability to meal-plan and carbohydrate count improved and the improvement 

in carbohydrate counting correlated with a lower pre-intervention HbA1c. However, none 

of the other nutrition knowledge scores were correlated with changes in? HbA1c. There 

were several other studies that described a nutritional education component or module as 

part of their intervention.6,9,16,17,24,34,35 Two of these studies found improved nutritional 

knowledge or behavior after the intervention24,35 but this did not correlate with a lowering 

of HbA1c in the intervention group. Three studies found improved metabolic control 

alone.6,17,34 The other studies showed no significant changes in HBA1c or regimen 

adherence. 

Studies that reported improvement in HbA1c are disparate in their interventions and 

designs, and it is difficult to know whether to attribute the improvement to the nutritional 

therapy component or to the overall change in management34 or other components of the 

intervention.6

 Because of this heterogeneity, there is no clear evidence indicating that 

medical nutrition therapy education either improves or does not improve diabetes control 

and studies are needed to address this question. 

3. What is the evidence that diabetes education results in improved long-term 

management of diabetes? 

 In this review, all but three studies followed participants for 2 years or less. The study 

with the longest followup tracked hospitalizations for 4 years. Long-term followup in 

diabetes would generally be considered 5 to 10 years. Therefore, there are no data to 

determine if a particular educational approach improves long-term control and reduces 

long-term diabetes complications. Since diabetes management has changed over the years 

covered by this review and will continue to evolve as more research becomes available, it 

is unlikely that any study will be able to separate the effect of the educational 

intervention from the change in diabetes management on the rate of complications. It 

would be possible, however, for a future review to address the question of which diabetes 

management strategies improve long-term diabetes control and reduce complications.

4. What is the evidence that diabetes education programs improve knowledge 

about diabetes management? 
133

a. What is the evidence that this knowledge increases the child’s self-confidence 

in his or her ability to handle the disease and has a positive impact on the 

child’s quality of life (QOL) and other psychosocial issues (e.g., school 

absences, school performance, adherence to a medical regimen)? 

In answering this question we have broken the discussion into sections which will 

discuss interventions for improving knowledge, skills, and adherence separately from 

those addressing QOL and other psychosocial issues. 

In the majority of studies that were controlled and assessed knowledge there was no 

difference in knowledge scores between those who received the intervention vs. those 

who received standard care education. In most studies, patients in both the intervention 

and control groups demonstrated improved knowledge. A minority of studies using either 

a cognitive behavioral intervention or general diabetes education delivered at diabetes 

camp showed a significant difference in knowledge scores in favor of the intervention. 

Only a few studies addressed interventions to improve skills needed for day-to-day 

diabetes management. Most interventions in this area resulted in an improvement over 

standard care. However, the number of studies was small and the interventions and 

specific skills assessed differed. Several studies addressed issues of self-management and 

adherence behavior; however, the type of interventions and the measured outcomes were 

not uniform making it difficult to draw conclusions. It appears that cognitive behavioral 

therapy may be effective in improving self-care behaviors. In patients with poorly 

controlled diabetes, there was no specific intervention that was consistently effective, but 

further studies utilizing family based therapy should be considered. In summay, no clear 

recommendation can be made regarding a specific educational approach, beyond that as 

part of standard care, to improve knowledge, skills or self-management behavior. 

Most research assessing the effect of diabetes education on psychosocial aspects of 

diabetes has used controlled study designs (75 percent RCTs and CCTs). However, the 

heterogeneity in study setting, duration and frequency of intervention, followup period, 

assessment tools, and primary outcomes, makes it impossible to pool the data. The study 

results mirror this heterogeneity and span the full spectrum of clinical and statistical 

significance. There is no particular study design or intervention that demonstrates a 

consistently positive effect of diabetes education on psychosocial outcomes, including 

QOL and school performance. However, it is likewise impossible to rule out certain 

intervention types as ineffective. For instance, cognitive behavioral therapy was effective 

in improving coping skills in two studies, but was not effective in four others. There are 

very few studies demonstrating negative effects of education on psychosocial outcomes, 

but this should be interpreted in light of the known low rate of reporting of negative 

findings. Even among newly diagnosed children, interventions did not result in 

significantly improved family and social relationships or support, coping, self-perception, 

or self-efficacy. Similarly, in children with poor metabolic control, only one of two 

studies showed a significant improvement in self-efficacy, and one more study showed 

initial, but not sustained improvement in family and social relationships. The education 

intervention had no significant effect on family or social support, coping or selfperception among this cohort. Although it seems intuitive that working with patients and 

families through educational interventions is important, the research does not show a 

clear effect. One possible explanation for this lack of evidence is that standard care and 
134

standard diabetes education used in the control groups may effectively improve 

psychosocial outcomes, making it difficult to demonstrate differences between groups 

receiving different types of educational intervention. There are no clear recommendations 

regarding interventions that are likely to improve psychosocial outcomes. 

b. What is the evidence that this knowledge improves long-term metabolic 

control (i.e., decreases or prevents diabetes-related complications), as shown 

in the Diabetes Control and Complications Trial (DCCT) (as measured by 

retinal, renal, cardiovascular, and neurological evaluations), in children of 

families who receive these diabetes education or medical nutrition therapy 

program services compared to children of families who do not receive these 

services? 

We did not identify any studies that addressed this question. There are no studies 

correlating knowledge and/or a specific educational intervention with long-term diabetes 

complications. In terms of short-term metabolic control, there were 16 studies that 

measured some aspect of diabetes knowledge as well as changes in metabolic control as 

on outcome. In five studies14,22,34,61,75 knowledge increased and HbA1c levels decreased 

post intervention. However, in two of these studies61,75 the improvements in metabolic 

control were not sustained at six and 12 months, respectively. In one study14 both HbA1c 

levels and child’s knowledge were not sustained at the 12-month followup. In another 

study18 the intervention group had superior metabolic control. While knowledge 

increased in both groups and was stable over time, there was no significant difference 

between the groups. In five studies9,24,35,72,77 the significant increase in knowledge did not 

translate into an improvement in metabolic control. There were five studies31,32,55,62,69 in 

which the intervention did not significantly affect either knowledge or metabolic control. 

From the studies that measured both these outcomes, one can conclude that an increase in 

knowledge is not sufficient to bring about behavior changes that improve metabolic 

control. 

5. What is the evidence that training in intensive diabetes management (consistent 

with DCCT, including blood glucose monitoring at least four times a day, three 

or more daily insulin injections or use of an insulin pump and education on 

when and how to adjust insulin doses) conducted in the practitioner setting 

yields: 

a. Improved metabolic control, (as determined by HbA1c values, numbers of 

diabetes-related hospitalizations, frequency of DKA, and numbers of 

episodes of hypoglycemia)? 

Although several studies have reported improved diabetes control in children and 

adolescents following initiation of intensive diabetes management, only three studies 

described the educational component or compared different educational interventions 

among children undergoing intensive diabetes management. Therefore, the majority 

of intensive diabetes therapy studies in children did not meet the inclusion criteria for 

this review. All three studies that met our inclusion criteria21,34,39 reported improved 

metabolic control after initiation of the intensive treatment which persisted up to 1 
135

year later. Two of the studies compared refinements to the education provided as a 

component of intensive diabetes management.21,39 The results of both studies suggest 

that educational interventions may support the effects of intensive diabetes 

management in reducing HbA1c. 

All three studies reported on frequency of DKA and hypoglycemia. Grey et al.21

found that the overall rate of severe hypoglycemia was higher than the rate reported 

in the adolescent cohort of the DCCT of 88/100 patient-years. In the cohort study by 

Lawson et al.39 there were two severe hypoglycemic reactions in the individualized 

education group. In the camp study,34 intensive diabetes management had no effect on 

the frequency of mild to moderate hypoglycemia, and there were no severe episodes 

of hypoglycemia. Among the three studies, there was only one episode of DKA. 

Therefore, in terms of short-term acute complications, the studies show mixed results 

with one study reporting an unacceptably high level of severe hypoglycemia 

suggesting that further educational interventions need to be explored. 

b. A decrease in or prevention of diabetes-related complications (as measured 

by retinal, renal, cardiovascular and neurological evaluations), as 

demonstrated by DCCT? 

No evidence was available to answer this question as none of the studies reported on 

long-term diabetes complications and all followed patients for less than 2 years. Although 

the Lawson study included patients who had nephromegaly, the progression of this 

complication was not monitored and patients were followed for only 15 months.39

Limitations 

Several limitations of this review need to be discussed. They are associated with weak 

study designs, potential for publication bias, and heterogeneity in interventions, outcome 

measurements, and control group definitions. 

Although the majority of included studies were RCTs or CCTs, all but four RCTs 

received a low methodological score of 1 or 2 of a possible 5 points. These studies were 

considered weak in quality, mainly due to educational interventions not lending 

themselves to double blinding. Although there has been some debate as to whether this is 

a serious flaw in studies that examine behavioral outcomes,121,122 it still indicates that 

there is a potential for performance bias in outcome assessment. In the majority of the 

RCTs, the method by which the randomization code was derived, concealed, and 

allocated was also not reported, thereby leaving the studies open to the question of 

selection bias. Additionally, 25 percent of included studies were uncontrolled-before-andafter studies, which are not considered a rigorous a design as it is difficult to determine 

whether any effects are solely accounted for by the intervention. 

Potential for publication bias is an issue relevant to all systematic reviews. To 

minimize publication bias, an experienced research librarian conducted a comprehensive 

search of the published literature for potentially relevant studies using a systematic 

strategy. We also searched conference proceedings, theses and dissertations, and grey 

literature, including professional websites in order to obtain additional relevant studies. In 
136

addition, we handsearched reference lists of reviews and included studies. We restricted 

the search to English language articles because we felt the majority of relevant research 

would be published in English language reports. Selection bias was minimized via the use 

of a priori inclusion criteria which were applied by two reviewers independently. Any 

discrepancies were resolved with a third party who had clinical expertise in diabetes 

management. 

A particular limitation of this review was the variety of interventions and outcome 

measures across studies, which meant that we were not able to pool results. Although we 

combined interventions under broad categories, there was still significant heterogeneity 

within these categories. Moreover, some interventions were targeted to the child, the 

parent, or the family or peers, and some interventions were single component while 

others were multifaceted. Likewise, there were a wide variety of endpoints and outcome 

measurement instruments. Similarly, control groups were not defined the same way in all 

studies; some studies specified no intervention, while others specified standard care, 

which may not be consistent across different regions. Due to lack of time and resources, 

we did not contact authors directly to determine the breakdown of components in control 

groups. 

Conclusions 

Overall, the studies included in this review did not show consistent and coherent 

effects over the examined outcomes. Therefore, we have limited confidence in our ability 

to identify one particular intervention above another to improve diabetes control, reduce 

short-term acute complications, or improve quality of life. 

Although we had a number of higher quality trials, disparate interventions, 

populations, and outcomes made it difficult to determine whether one form of diabetes 

education was more effective than another. Furthermore, because most control groups 

also received some level of education, the studies may not have had sufficient power to 

detect a clinically or statistically significant difference in the various outcomes examined. 

It is also important to remember that trials often take place in tertiary settings where the 

patient population may be better educated, and where established educational programs 

may exist; the studies may not have had power to find differences between study groups. 

Further testing using strong study designs (e.g., cluster RCTs), clearly defined study 

populations and interventions, and standard and validated measurement instruments may 

help to elucidate this. 

Future Research Opportunities 

To date, research in diabetes education is characterized by a great deal of 

heterogeneity and few long-term studies. 

• Data from this review suggest there is a need for appropriately powered RCTs 

assessing cognitive behavioral therapy, family systems therapy, motivational 

interviewing, and frequency of contact with health care professionals on HbA1c 
137

and short-term complications, particularly in a population with poorly controlled 

diabetes. 

• Future RCTs should specify the components of their “standard care” education 

and followup. A survey of standard education programs for diabetes so that 

researchers are aware of the diversity of standard care would be a useful addition 

to the literature. 

• Nutrition therapy is a significant component of diabetes management. This review 

documents that very few studies have assessed specifically this component of 

diabetes education, and even fewer have assessed its effect on metabolic control. 

Additional research is needed in this area. For example, different educational 

formats for providing nutritional information may be more effective in improving 

knowledge, practice and metabolic control than others. 

• The effect of interventions on quality of life was difficult to assess in this review 

because of the small number of studies that assessed this outcome and the use of a 

multitude of outcome tools. Future studies should include quality of life as an 

outcome measure and researchers in this area should work toward adopting a 

common validated instrument. 

• Since diabetes-related complications develop over many years, longer term cohort 

studies and trials with longer followup will be essential to assess the effect of 

education on long-term complications of diabetes. 

• Well-designed studies that address the challenges of conducting research on 

behavioral interventions are needed. Strong study designs such as cluster 

randomized trials should be used and steps should be taken to minimize the risks 

of bias. Although blinding may be difficult to achieve with educational and 

behavioral interventions, it should be possible to perform RCTs with the practice 

of using blinded outcome assessors. Concealment of allocation is always possible 

and should be reported. 

• The DCCT and several subsequent reports have shown the benefit of intensive 

diabetes management on HbA1c in children and adolescents. Studies are needed 

to examine the aspects of education that improve outcomes with this management 

approach. Followup of the previous DCCT cohort (EDIC study) has found that 

the HbA1c rises over time. Studies are needed to explore education interventions 

that might lessen this deterioration in control. 

 
139 

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Appendixes 
 

A-1 

Appendix A. Technical Expert Panel and Peer 

Reviewers 

Technical Expert Panel 

In designing the study questions and methodology at the outset of this report, the EPC consulted 

several technical and content experts. Broad expertise and perspectives are sought. Divergent and 

conflicting opinions are common and perceived as health scientific discourse that results in a 

thoughtful, relevant systematic review. Therefore, in the end, study questions, design and/or 

methodologic approaches do not necessarily represent the views of individual technical and 

content experts. 

Technical Expert Affiliations/Location 

Denis Daneman, M.B., B.Ch., F.R.C.P.C. University of Toronto and Hospital for Sick Children 

Toronto, ON 

Alison B. Evert, M.S., R.D., C.D.E. Diabetes Care Center, University of Washington Medical Center 

Seattle, WA 

Jeffrey Johnson, B.S.P., M.S., Ph.D. University of Alberta 

Edmonton, AB 

Richard A. Justman, M.D. United HealthCare 

Edina, MN 

Lori M. B. Laffel, B.S., M.D., M.P.H. Joslin Diabetes Center 

Boston, MA 

Gabriela Ramírez-Garnica, Ph.D., M.P.H. Nemours Children’s Clinic 

Orlando, FL 

Janet Silverstein, M.D. University of Florida 

Gainesville, FL 
 

A-2 

Peer Reviewers 

Peer reviewer comments on a preliminary draft of this report were considered by the EPC in 

preparation of this final report. Synthesis of the scientific literature presented here does not 

necessarily represent the views of individual reviewers. 

Technical Expert Affiliations/Location 

William L. Clarke, M.D., F.A.A.P. University of Virginia Health System 

Charlottesville, VA 

Nathaniel Clark, M.D., F.A.A.P. Novo Nordisk, Inc. 

Princeton, NJ 

Debra Counts, M.D., F.A.A.P. University of Maryland 

Baltimore, MD 

Marion J. Franz, M.S., R.D., L.D., C.D.E. Nutrition Concepts by Franz, Inc. 

Minneapolis, MN 

Stephen J. Spann, M.D., M.B.A. Baylor College of Medicine 

Houston, TX 

Randi Streisand, Ph.D., C.D.E. Children's National Medical Center 

Washington, DC 

Dorothy Becker, M.B., B.Ch. Children’s Hospital of Pittsburgh 

Pittsburgh, PA 
 B-1 

Appendix B. Exact Search Strings 

Table B1. MEDLINE®—OVID Version: rel10.4.1 

Years/issue searched: 1950 to February Week 3 2007 

Search date: March 4, 2007 

Results: study design 4,219; no study design 6,615

1. exp Infant/ 

2. exp Child/ 

3. exp Adolescent/ 

4. exp Parents/ 

5. exp Family/ 

6. exp Caregivers/ 

7. infan$.mp. 

8. (baby or babies).mp. 

9. child$.mp. 

10. toddler$.mp. 

11. adolescen$.mp. 

12. (young adj3 (person? or people or adult?)).mp. 

13. (teen$ or teen ager?).mp. 

14. youth?.mp. 

15. juvenil$.mp. 

16. pube$.mp. 

17. parent$.mp. 

18. famil$.mp. 

19. (caregiv$ or care giv$ or care-giv$ or caretak$ or 

care tak$ or care-tak$ or carer?).mp. 

20. or/1-19 

21. Diabetes Mellitus/ 

22. Diabetes Mellitus, Type 1/ 

23. exp hypoglycemia/ 

24. ((type 1 or type I) adj (diabetes mellitus or DM)).mp. 

25. ((diabetes mellitus or DM) adj (type 1 or type I)).mp. 

26. diabet$.mp. 

27. IDDM.mp. 

28. DM.mp. 

29. ((insulin-dependent or insulindependent) adj3 

(diabetes mellitus or DM)).mp. 

30. ((earl$ or juvenil$ or child$ or labil$ or keto$) adj3 

(diabetes mellitus or DM)).mp. 

31. ((autoimmun$ or auto-immun$ or auto immun$ or 

sudden onset) adj3 (diabetes mellitus or DM)).mp. 

32. (insulin defic$ adj3 absolut$).mp. 

33. hypoglyc?emi$.mp. 

34. or/21-33 

35. exp Diabetes Insipidus/ 

36. (diabet$ adj3 (insipidus not mellitus)).mp. 

37. or/35-36 

38. 34 not 37 

39. Self Help Groups/ 

40. Health Education/ 

41. Patient Education/ 

42. Patient Care/ 

43. Adolescent Psychology/ 

44. Child Psychology/ 

45. Behavior Therapy/ 

46. Cognitive Therapy/ 

47. Family Therapy/ 

48. Counseling/ 

49. exp patient care management/ and diabet$.mp. 

50. exp Nutrition Therapy/ 

51. exp Home Care Services/ 

52. exp School Health Services/ 

53. (behav$ adj3 (therap$ or modif$)).mp. 

54. (family adj3 therap$).mp. 

55. ed.fs. 

56. (video$ or gam$).mp. 

57. (phone or telephon$).mp. 

58. program$.mp. 

59. interven$.mp. 

60. inform$.mp. 

61. educat$.mp. 

62. teach$.mp. 

63. train$.mp. 

64. instruct$.mp. 

65. ((diet or nutrition$) adj2 therap$).mp. 

66. (diabet$ adj diet$).mp. 

67. ((education$ or home) adj2 (meeting? or session? or 

strateg$ or workshop? or visit?)).mp. 

68. ((psycho-$ or psycho$) and diabet$).mp. 

69. or/39-68 

70. Hemoglobin A, Glycosylated/ 

71. Blood Glucose/ 

72. Diabetic Ketoacidosis/ 

73. (ketoacido$ or keto-acido$).mp. 

74. DKA.mp. 

75. SMBG.mp. 

76. (blood glucose or BG).mp. 

77. ((metabolic or diabet$ or glyc?emic or glucose) adj 

control).mp. 

78. ((glycosylated or glycated) adj3 (hemoglobin or 

haemoglobin)).mp. 

79. (HbA1c or A1c or HbA1 or GHb or hemoglobin A1c 

or haemoglobin A1c).mp. 

80. exp Self Care/ 

81. Self efficacy/ 

82. (self adj (care or regulat$ or monitor$ or manage$ or 

efficacy)).mp. 

83. "Outcome Assessment (Health Care)"/ 

84. Program Evaluation/ 

85. Treatment Outcome/ 

86. exp Attitude to Health/ 

87. exp Health Behavior/ 

88. Problem Solving/ 

89. ((effect? or impact or evaluat$ or compar$) adj2 

(treatment or care) adj program$).mp. 

90. attitud$.mp. 

91. behavio?r$.mp. 

92. complian$.mp. 

93. adheren$.mp. 

94. improv$.mp. 

95. chang$.mp. 

96. (cope or coping).mp. 

97. skill?.mp. 

98. (knowledge or learn$ or cognition).mp. 
 B-2 

99. Quality of Life/ 

100. "quality of life".mp.
 B-3 

Table B1. MEDLINE®—OVID Version: rel10.4.1 (continued) 

101. exp Hospitalization/ 

102. hospitali?ation?.mp. 

103. admission?.mp. 

104. service utilization.mp. 

105. or/70-104 

106. clinical trial.pt. 

107. randomi?ed.ti,ab. 

108. placebo.ti,ab. 

109. dt.fs. 

110. randomly.ti,ab. 

111. trial.ti,ab. 

112. groups.ti,ab. 

113. or/106-112 

114. animals/ 

115. humans/ 

116. 114 not (114 and 115) 

117. 113 not 116 

118. exp controlled clinical trials/ 

119. exp cohort studies/ 

120. Intervention Studies/ 

121. evaluation studies/ or program evaluation/ 

122. random allocation/ 

123. (pre test$ or pretest$ or (post test$ or 

posttest$)).mp. 

124. (observation$ or prospectiv$ or cohort$ or control$ 

or volunteer$ or evaluat$ or compar$ or longitudinal 

or long term or long-term or longterm or case control$ 

or case-control$ or case referrent or case-referrent or 

time series or time-series or followup or follow up or 

follow-up or before-and-after or before-after).mp. and 

(study or studies or trial$).ti,ab,sh. 

125. or/118-124 

126. 125 not 116 

127. 117 or 126 

128. (letter$ or editorial$ or comment$ or lecture$).pt. 

129. 127 not 128 

130. and/20,38,69,105,129 

131. limit 130 to english language 

132. limit 131 to yr="1983-2007" 
 B-4 

Table B2. Ovid MEDLINE® In-Process and Other Non-Indexed Citations—OVID Version: rel10.4.1

Years/issue searched: March 02, 2007 

Search date: March 4, 2007 

Results: study design 68; no study design 122

1. infan$.mp. 

2. (baby or babies).mp. 

3. child$.mp. 

4. toddler$.mp. 

5. adolescen$.mp. 

6. (young adj3 (person? or people or adult?)).mp. 

7. (teen$ or teen ager?).mp. 

8. youth?.mp. 

9. juvenil$.mp. 

10. pube$.mp. 

11. parent$.mp. 

12. famil$.mp. 

13. (caregiv$ or care giv$ or care-giv$ or caretak$ or 

care tak$ or care-tak$ or carer?).mp. 

14. or/1-13 

15. ((type 1 or type I) adj (diabetes mellitus or DM)).mp. 

16. ((diabetes mellitus or DM) adj (type 1 or type I)).mp. 

17. diabet$.mp. 

18. IDDM.mp. 

19. DM.mp. 

20. ((insulin-dependent or insulindependent) adj3 

(diabetes mellitus or DM)).mp. 

21. ((earl$ or juvenil$ or child$ or labil$ or keto$) adj3 

(diabetes mellitus or DM)).mp. 

22. ((autoimmun$ or auto-immun$ or auto immun$ or 

sudden onset) adj3 (diabetes mellitus or DM)).mp. 

23. (insulin defic$ adj3 absolut$).mp. 

24. hypoglyc?emi$.mp. 

25. or/15-24 

26. (diabet$ adj3 (insipidus not mellitus)).mp. 

27. 25 not 26 

28. (patient adj (care or management)).mp. 

29. health services.mp. 

30. ((child or adolescent) adj3 psychology).mp. 

31. counsel?ing.mp. 

32. ((behav$ or cognitiv$) adj3 (therap$ or modif$)).mp. 

33. (family adj3 therap$).mp. 

34. (video$ or gam$).mp. 

35. (phone or telephon$).mp. 

36. program$.mp. 

37. interven$.mp. 

38. inform$.mp. 

39. educat$.mp. 

40. teach$.mp. 

41. train$.mp. 

42. instruct$.mp. 

43. ((diet or nutrition$) adj2 therap$).mp. 

44. (diabet$ adj diet$).mp. 

45. ((education$ or home) adj2 (meeting? or session? or 

strateg$ or workshop? or visit?)).mp. 

46. ((psycho-$ or psycho$) and diabet$).mp. 

47. or/28-46 

48. (blood glucose or BG).mp. 

49. (ketoacido$ or keto-acido$).mp. 

50. DKA.mp. 

51. SMBG.mp. 

52. ((metabolic or diabet$ or glyc?emic or glucose) adj 

control).mp. 

53. ((glycosylated or glycated) adj3 (hemoglobin or 

haemoglobin)).mp. 

54. (HbA1c or A1c or HbA1 or GHb or hemoglobin A1c 

or haemoglobin A1c).mp. 

55. (self adj (care or regulat$ or monitor$ or manage$ or 

efficacy)).mp. 

56. "Outcome and Assessment (Health Care)".mp. 

57. treatment outcome$.mp. 

58. problem solving.mp. 

59. ((effect? or impact or evaluat$ or compar$) adj2 

(treatment or care) adj program$).mp. 

60. attitud$.mp. 

61. behavio?r$.mp. 

62. complian$.mp. 

63. adheren$.mp. 

64. improv$.mp. 

65. chang$.mp. 

66. (cope or coping).mp. 

67. skill?.mp. 

68. (knowledge or learn$ or cognition).mp. 

69. "quality of life".mp. 

70. hospitali?ation?.mp. 

71. admission?.mp. 

72. service utilization.mp. 

73. or/48-72 

74. clinical trial.pt. 

75. randomi?ed.ti,ab. 

76. placebo.ti,ab. 

77. randomly.ti,ab. 

78. trial.ti,ab. 

79. groups.ti,ab. 

80. (pre test$ or pretest$ or (post test$ or 

posttest$)).mp. 

81. (observation$ or prospectiv$ or cohort$ or control$ 

or volunteer$ or evaluat$ or compar$ or longitudinal 

or long term or long-term or longterm or case control$ 

or case-control$ or case referrent or case-referrent or 

time series or time-series or followup or follow up or 

follow-up or before-and-after or before-after).mp. and 

(study or studies or trial$).ti,ab,sh. 

82. or/74-81 

83. (letter$ or editorial$ or comment$ or lecture$).pt. 

84. and/14,27,47,73,82 

85. 84 not 83 

86. limit 85 to (english language and yr="1983 - 2007") 
 B-5 

Table B3. EMBASE—OVID Version: rel10.4.1 

Years/issues searched: 1988 to 2007 Week 09 

Search date: March 4, 2007 

Results: study design 5,824; no study design 7,805

1. exp child/ 

2. exp childhood/ 

3. exp adolescent/ 

4. exp adolescence/ 

5. exp family/ 

6. caregiver/ 

7. infan$.mp. 

8. (baby or babies).mp. 

9. child$.mp. 

10. toddler$.mp. 

11. adolescen$.mp. 

12. (young adj3 (person? or people or adult?)).mp. 

13. (teen$ or teen ager?).mp. 

14. youth?.mp. 

15. juvenil$.mp. 

16. pube$.mp. 

17. parent$.mp. 

18. famil$.mp. 

19. (caregiv$ or care giv$ or care-giv$ or caretak$ or 

care tak$ or care-tak$ or carer?).mp. 

20. or/1-19 

21. diabetes mellitus/ 

22. exp hypoglycemia/ 

23. ((type 1 or I) adj (diabetes mellitus or DM)).mp. 

24. ((diabetes mellitus or DM) adj (type 1 or type I)).mp. 

25. diabet$.mp. 

26. IDDM.mp. 

27. DM.mp. 

28. ((insulin-dependent or insulindependent) adj3 

(diabetes mellitus or DM)).mp. 

29. ((earl$ or juvenil$ or child$ or labil$ or keto$) adj3 

(diabetes mellitus or DM)).mp. 

30. (insulin defic$ adj3 absolut$).mp. 

31. hypogly?emi$.mp. 

32. ((autoimmun$ or auto-immun$ or auto immun$ or 

sudden onset) adj3 (diabetes mellitus or DM)).mp. 

33. or/21-32 

34. exp diabetes insipidus/ 

35. (diabet$ adj3 (insipidus not mellitus)).mp. 

36. or/34-35 

37. 33 not 36 

38. exp health service/ 

39. health education/ 

40. diabetes education/ 

41. nutrition education/ 

42. patient education/ 

43. child psychology/ 

44. behavior therapy/ 

45. cognitive therapy/ 

46. family therapy/ 

47. exp counseling/ 

48. exp diet therapy/ 

49. (behav$ adj3 (therap$ or modif$)).mp. 

50. (family adj3 therap$).mp. 

51. (video$ or gam$).mp. 

52. (phone or telephon$).mp. 

53. program$.mp. 

54. interven$.mp. 

55. inform$.mp. 

56. educat$.mp. 

57. teach$.mp. 

58. train$.mp. 

59. instruct$.mp. 

60. ((diet or nutrition$) adj2 therap$).mp. 

61. (diabet$ adj diet$).mp. 

62. ((education$ or home) adj2 (meeting? or session? 

or strateg$ or workshop? or visit?)).mp. 

63. ((psycho-$ or psycho$) and diabet$).mp. 

64. or/38-63 

65. exp Hemoglobin/ 

66. glucose blood level/ 

67. (ketoacido$ or keto-acido$).mp. 

68. DKA.mp. 

69. SMBG.mp. 

70. (blood glucose or BG).mp. 

71. ((metabolic or diabet$ or glyc?emic or glucose) adj 

control).mp. 

72. (self adj (care or regulat$ or monitor$ or manage$ 

or efficacy)).mp. 

73. ((glycosylated or glycated) adj3 (hemoglobin or 

haemoglobin)).mp. 

74. (HbA1c or A1c or HbA1 or GHb or hemoglobin A1c 

or haemoglobin A1c).mp. 

75. exp Self Care/ 

76. exp self concept/ 

77. exp treatment outcome/ 

78. attitude to health/ 

79. exp Health Behavior/ 

80. Problem Solving/ 

81. decision making/ 

82. ((effect? or impact or evaluat$ or compar$) adj2 

(treatment or care) adj program$).mp. 

83. attitud$.mp. 

84. behavio?r$.mp. 

85. complian$.mp. 

86. adheren$.mp. 

87. improv$.mp. 

88. chang$.mp. 

89. (cope or coping).mp. 

90. skill?.mp. 

91. (knowledge or learn$ or cognition).mp. 

92. Quality of Life/ 

93. "quality of life".mp. 

94. hospitalization/ 

95. hospitali?ation?.mp. 

96. admission?.mp. 

97. service utilization.mp. 

98. or/65-97 

99. exp clinical trial/ 

100. randomi?ed.ti,ab. 

101. placebo.ti,ab. 

102. (ae or dt or to).fs. 

103. randomly.ti,ab. 

104. trial.ti,ab. 
 B-6 

105. groups.ti,ab. 

106. cohort analysis/
 B-7 

Table B3. EMBASE—OVID Version: rel10.4.1 (continued)

107. time Series Analysis/ 

108. (pre test$ or pretest$ or (post test$ or 

posttest$)).mp. 

109. (observation$ or prospectiv$ or cohort$ or control$ 

or volunteer$ or evaluat$ or compar$ or longitudinal 

or long term or long-term or longterm or case control$ 

or case-control$ or case referrent or case-referrent or 

time series or time-series or followup or follow up or 

follow-up or before-and-after or before-after).mp. and 

(study or studies or trial$).ti,ab,sh. 

110. or/99-109 

111. ANIMAL/ 

112. Human/ 

113. 111 not (111 and 112) 

114. 110 not 113 

115. and/20,37,64,98,114 

116. (letter$ or editorial$ or note$).pt. 

117. 115 not 116 

118. limit 117 to (english language and yr="1983 - 

2007")
 B-8 

Table B4. EBM Reviews—Cochrane Central Register of Controlled Trials 

Years/issue searched: 1st Quarter 2007 

Search date: March 4, 2007

Results: 741

1. exp Infant/ 

2. exp Family/ 

3. exp Caregiver/ 

4. infan$.mp. 

5. (baby or babies).mp. 

6. child$.mp. 

7. toddler$.mp. 

8. adolescen$.mp. 

9. (young adj3 (person? or people or adult?)).mp. 

10. (teen$ or teen ager?).mp. 

11. youth?.mp. 

12. juvenil$.mp. 

13. pube$.mp. 

14. parent$.mp. 

15. famil$.mp. 

16. (caregiv$ or care giv$ or care-giv$ or caretak$ or 

care tak$ or care-tak$ or carer?).mp. 

17. or/1-16 

18. exp Diabetes Mellitus/ 

19. exp Hypoglycemia/ 

20. diabetes mellitus type 1.sh. 

21. ((type 1 or type I) adj (diabetes mellitus or DM)).mp. 

22. ((diabetes mellitus or DM) adj (type 1 or type I)).mp. 

23. diabet$.mp. 

24. IDDM.mp. 

25. DM.mp. 

26. ((insulin-dependent or insulindependent) adj3 

(diabetes mellitus or DM)).mp. 

27. ((earl$ or juvenil$ or child$ or labil$ or keto$) adj3 

(diabetes mellitus or DM)).mp. 

28. ((autoimmun$ or auto-immun$ or auto immun$ or 

sudden onset) adj3 (diabetes mellitus or DM)).mp. 

29. (insulin defic$ adj3 absolut$).mp. 

30. hypoglyc?emi$.mp. 

31. or/18-30 

32. exp Diabetes Insipidus/ 

33. (diabet$ adj3 (insipidus not mellitus)).mp. 

34. or/32-33 

35. 31 not 34 

36. Self Help Groups/ 

37. health education/ 

38. patient education/ 

39. exp patient care/ 

40. exp health services/ 

41. Adolescent Psychology/ 

42. Child Psychology/ 

43. Behavior Therapy/ 

44. Family Therapy/ 

45. Counseling/ 

46. exp patient care management/ and diabet$.mp. 

47. (behav$ adj3 (therap$ or modif$)).mp. 

48. (family adj3 therap$).mp. 

49. ed.fs. 

50. (video$ or gam$).mp. 

51. (phone or telephon$).mp. 

52. program$.mp. 

53. interven$.mp. 

54. inform$.mp. 

55. educat$.mp. 

56. teach$.mp. 

57. train$.mp. 

58. instruct$.mp. 

59. ((diet or nutrition$) adj2 therap$).mp. 

60. (diabet$ adj diet$).mp. 

61. ((education$ or home) adj2 (meeting? or session? or 

strateg$ or workshop? or visit?)).mp. 

62. ((psycho-$ or psycho$) and diabet$).mp. 

63. or/36-62 

64. Hemoglobin A, Glycosylated/ 

65. Blood Glucose/ 

66. diabetic ketoacidosis/ 

67. DKA.mp. 

68. SMBG.mp. 

69. ((metabolic or diabet$ or glyc?emic or glucose) adj 

control).mp. 

70. ((glycosylated or glycated) adj3 (hemoglobin or 

haemoglobin)).mp. 

71. (HbA1c or A1c or HbA1 or GHb or hemoglobin A1c 

or haemoglobin A1c).mp. 

72. exp Self Care/ 

73. Self efficacy/ 

74. (self adj (care or regulat$ or monitor$ or manage$ or 

efficacy)).mp. 

75. exp "Outcome and Process Assessment (Health 

Care)"/ 

76. exp Attitude to Health/ 

77. exp Health Behavior/ 

78. Problem Solving/ 

79. ((effect? or impact or evaluat$ or compar$) adj2 

(treatment or care) adj program$).mp. 

80. attitud$.mp. 

81. behavio?r$.mp. 

82. complian$.mp. 

83. adheren$.mp. 

84. improv$.mp. 

85. chang$.mp. 

86. (cope or coping).mp. 

87. skill?.mp. 

88. (knowledge or learn$ or cognition).mp. 

89. "quality of life".mp. 

90. exp hospitalization/ 

91. hospitali?ation?.mp. 

92. admission?.mp. 

93. service utilization.mp. 

94. or/64-93 

95. Intervention Studies/ 

96. evaluation studies/ or program evaluation/ 

97. (pre test$ or pretest$ or (post test$ or 

posttest$)).mp. 

98. (observation$ or prospectiv$ or cohort$ or control$ 

or volunteer$ or evaluat$ or compar$ or longitudinal 

or long term or long-term or longterm or case control$ 

or case-control$ or case referrent or case-referrent or 

time series or time-series or followup or follow up or 
 B-9 

follow-up or before-and-after or before-after).mp. and 

(study or studies or trial$).ti,ab,sh.
 B-10 

Table B4. EBM Reviews—Cochrane Central Register of Controlled Trials (continued) 

99. or/95-98 

100. animals/ 

101. 99 not 100 

102. and/17,35,63,94,101 

103. (letter$ or editorial$ or comment$ or lecture$ or 

note$).pt. 

104. 102 not 103 

105. limit 104 to yr="1983 - 2006" 
 B-11 

Table B5. EBM Cochrane Database of Systematic Reviews (CDSR) and EBM Database of Reviews and 

Abstracts (DARE)—OVID Version: rel10.4.1

Years/issue searched: 1st Quarter 2007

Search date: March 4, 2007 

Results: CDSR 490; DARE 106 

1. infan$.mp. 

2. (baby or babies).mp. 

3. child$.mp. 

4. toddler$.mp. 

5. adolescen$.mp. 

6. (young adj3 (person? or people or adult?)).mp. 

7. (teen$ or teen ager?).mp. 

8. youth?.mp. 

9. juvenil$.mp. 

10. pube$.mp. 

11. parent$.mp. 

12. famil$.mp. 

13. (caregiv$ or care giv$ or care-giv$ or caretak$ or 

care tak$ or care-tak$ or carer?).mp. 

14. or/1-13 

15. ((type 1 or type I) adj (diabetes mellitus or DM)).mp. 

16. ((diabetes mellitus or DM) adj (type 1 or type I)).mp. 

17. diabet$.mp. 

18. IDDM.mp. 

19. DM.mp. 

20. ((insulin-dependent or insulindependent) adj3 

(diabetes mellitus or DM)).mp. 

21. ((earl$ or juvenil$ or child$ or labil$ or keto$) adj3 

(diabetes mellitus or DM)).mp. 

22. ((autoimmun$ or auto-immun$ or auto immun$ or 

sudden onset) adj3 (diabetes mellitus or DM)).mp. 

23. (insulin defic$ adj3 absolut$).mp. 

24. hypoglyc?emi$.mp. 

25. or/15-24 

26. (diabet$ adj3 (insipidus not mellitus)).mp. 

27. 25 not 26 

28. (patient adj (care or management)).mp. 

29. health services.mp. 

30. ((child or adolescent) adj3 psychology).mp. 

31. counsel?ing.mp. 

32. ((behav$ or cognitiv$) adj3 (therap$ or modif$)).mp. 

33. (family adj3 therap$).mp. 

34. (video$ or gam$).mp. 

35. (phone or telephon$).mp. 

36. program$.mp. 

37. interven$.mp. 

38. inform$.mp. 

39. educat$.mp. 

40. teach$.mp. 

41. train$.mp. 

42. instruct$.mp. 

43. ((diet or nutrition$) adj2 therap$).mp. 

44. (diabet$ adj diet$).mp. 

45. ((education$ or home) adj2 (meeting? or session? or 

strateg$ or workshop? or visit?)).mp. 

46. ((psycho-$ or psycho$) and diabet$).mp. 

47. or/28-46 

48. (blood glucose or BG).mp. 

49. (ketoacido$ or keto-acido$).mp. 

50. DKA.mp. 

51. SMBG.mp. 

52. ((metabolic or diabet$ or glyc?emic or glucose) adj 

control).mp. 

53. ((glycosylated or glycated) adj3 (hemoglobin or 

haemoglobin)).mp. 

54. (HbA1c or A1c or HbA1 or GHb or hemoglobin A1c 

or haemoglobin A1c).mp. 

55. (self adj (care or regulat$ or monitor$ or manage$ or 

efficacy)).mp. 

56. "Outcome and Assessment (Health Care)".mp. 

57. treatment outcome$.mp. 

58. problem solving.mp. 

59. ((effect? or impact or evaluat$ or compar$) adj2 

(treatment or care) adj program$).mp. 

60. attitud$.mp. 

61. behavio?r$.mp. 

62. complian$.mp. 

63. adheren$.mp. 

64. improv$.mp. 

65. chang$.mp. 

66. (cope or coping).mp. 

67. skill?.mp. 

68. (knowledge or learn$ or cognition).mp. 

69. "quality of life".mp. 

70. hospitali?ation?.mp. 

71. admission?.mp. 

72. service utilization.mp. 

73. or/48-72 

74. and/14,27,47 
 B-12 

Table B6. OVID Healthstar—OVID Version: rel10.4.1 

Years/issues searched: 1966 to January 2007 

Search date: March 4, 2007 

Results: study design 3,631; no study design 5,591

1. exp Infant/ 

2. exp Child/ 

3. exp Adolescent/ 

4. exp Parents/ 

5. exp Family/ 

6. exp Caregivers/ 

7. infan$.mp. 

8. (baby or babies).mp. 

9. child$.mp. 

10. toddler$.mp. 

11. adolescen$.mp. 

12. (young adj3 (person? or people or adult?)).mp. 

13. (teen$ or teen ager?).mp. 

14. youth?.mp. 

15. juvenil$.mp. 

16. pube$.mp. 

17. parent$.mp. 

18. famil$.mp. 

19. (caregiv$ or care giv$ or care-giv$ or caretak$ or 

care tak$ or care-tak$ or carer?).mp. 

20. or/1-19 

21. Diabetes Mellitus/ 

22. Diabetes Mellitus, Type 1/ 

23. exp hypoglycemia/ 

24. ((type 1 or type I) adj (diabetes mellitus or DM)).mp. 

25. ((diabetes mellitus or DM) adj (type 1 or type I)).mp. 

26. diabet$.mp. 

27. IDDM.mp. 

28. DM.mp. 

29. ((insulin-dependent or insulindependent) adj3 

(diabetes mellitus or DM)).mp. 

30. ((earl$ or juvenil$ or child$ or labil$ or keto$) adj3 

(diabetes mellitus or DM)).mp. 

31. ((autoimmun$ or auto-immun$ or auto immun$ or 

sudden onset) adj3 (diabetes mellitus or DM)).mp. 

32. (insulin defic$ adj3 absolut$).mp. 

33. hypoglyc?emi$.mp. 

34. or/21-33 

35. exp Diabetes Insipidus/ 

36. (diabet$ adj3 (insipidus not mellitus)).mp. 

37. or/35-36 

38. 34 not 37 

39. Self Help Groups/ 

40. Health Education/ 

41. Patient Education/ 

42. Patient Care/ 

43. Adolescent Psychology/ 

44. Child Psychology/ 

45. Behavior Therapy/ 

46. Cognitive Therapy/ 

47. Family Therapy/ 

48. Counseling/ 

49. exp patient care management/ and diabet$.mp. 

50. exp Nutrition Therapy/ 

51. exp Home Care Services/ 

52. exp School Health Services/ 

53. (behav$ adj3 (therap$ or modif$)).mp. 

54. (family adj3 therap$).mp. 

55. ed.fs. 

56. (video$ or gam$).mp. 

57. (phone or telephon$).mp. 

58. program$.mp. 

59. interven$.mp. 

60. inform$.mp. 

61. educat$.mp. 

62. teach$.mp. 

63. train$.mp. 

64. instruct$.mp. 

65. ((diet or nutrition$) adj2 therap$).mp. 

66. (diabet$ adj diet$).mp. 

67. ((education$ or home) adj2 (meeting? or session? 

or strateg$ or workshop? or visit?)).mp. 

68. ((psycho-$ or psycho$) and diabet$).mp. 

69. or/39-68 

70. Hemoglobin A, Glycosylated/ 

71. Blood Glucose/ 

72. Diabetic Ketoacidosis/ 

73. (ketoacido$ or keto-acido$).mp. 

74. DKA.mp. 

75. SMBG.mp. 

76. (blood glucose or BG).mp. 

77. ((metabolic or diabet$ or glyc?emic or glucose) adj 

control).mp. 

78. ((glycosylated or glycated) adj3 (hemoglobin or 

haemoglobin)).mp. 

79. (HbA1c or A1c or HbA1 or GHb or hemoglobin A1c 

or haemoglobin A1c).mp. 

80. exp Self Care/ 

81. Self efficacy/ 

82. (self adj (care or regulat$ or monitor$ or manage$ 

or efficacy)).mp. 

83. "Outcome Assessment (Health Care)"/ 

84. Program Evaluation/ 

85. Treatment Outcome/ 

86. exp Attitude to Health/ 

87. exp Health Behavior/ 

88. Problem Solving/ 

89. ((effect? or impact or evaluat$ or compar$) adj2 

(treatment or care) adj program$).mp. 

90. attitud$.mp. 

91. behavio?r$.mp. 

92. complian$.mp. 

93. adheren$.mp. 

94. improv$.mp. 

95. chang$.mp. 

96. (cope or coping).mp. 

97. skill?.mp. 

98. (knowledge or learn$ or cognition).mp. 

99. Quality of Life/ 

100. "quality of life".mp. 

101. exp Hospitalization/ 

102. hospitali?ation?.mp. 

103. admission?.mp. 

104. service utilization.mp. 
 B-13 

105. or/70-104 106. clinical trial.pt.

Table B6. OVID Healthstar—OVID Version: rel10.4.1 (continued) 

107. randomi?ed.ti,ab. 

108. placebo.ti,ab. 

109. dt.fs. 

110. randomly.ti,ab. 

111. trial.ti,ab. 

112. groups.ti,ab. 

113. exp controlled clinical trials/ 

114. exp cohort studies/ 

115. Intervention Studies/ 

116. evaluation studies/ or program evaluation/ 

117. random allocation/ 

118. (pre test$ or pretest$ or (post test$ or 

posttest$)).mp. 

119. (observation$ or prospectiv$ or cohort$ or control$ 

or volunteer$ or evaluat$ or compar$ or longitudinal 

or long term or long-term or longterm or case control$ 

or case-control$ or case referrent or case-referrent or 

time series or time-series or followup or follow up or 

follow-up or before-and-after or before-after).mp. and 

(study or studies or trial$).ti,ab,sh. 

120. or/106-119 

121. animals/ not human/ 

122. 120 not 121 

123. and/20,38,69,105,122 

124. (letter$ or editorial$ or comment$ or lecture$).pt. 

125. 123 not 124 

126. limit 125 to english language 

127. limit 126 to yr="1983-2007" 
 B-14 

Table B7. ERIC (Educational Resources Information Center)—OVID Version: rel10.4.1

Years/issue searched: 1966 to January 2007 

Search date: March 4, 2007 

Results: study design 220; no study design 222

1. infants/ 

2. Toddlers/ 

3. exp children/ 

4. early adolescents/ 

5. adolescents/ 

6. late adolescents/ 

7. preadolescents/ 

8. exp youth/ 

9. exp "family (sociological unit)"/ 

10. exp parents/ 

11. exp caregivers/ 

12. infan$.mp. 

13. (baby or babies).mp. 

14. toddler$.mp. 

15. child$.mp. 

16. adolescen$.mp. 

17. (young adj3 (person? or people or adult?)).mp. 

18. (teen$ or teen ager?).mp. 

19. youth?.mp. 

20. juvenil$.mp. 

21. pube$.mp. 

22. parent$.mp. 

23. famil$.mp. 

24. (caregiv$ or care giv$ or care-giv$ or caretak$ or 

care tak$ or care-tak$ or carer?).mp. 

25. or/1-24 

26. diabetes/ 

27. ((type 1 or type I) adj (diabetes mellitus or DM)).mp. 

28. ((diabetes mellitus or DM) adj (type 1 or type I)).mp. 

29. diabet$.mp. 

30. IDDM.mp. 

31. DM.mp. 

32. ((insulin-dependent or insulindependent) adj3 

(diabetes mellitus or DM)).mp. 

33. ((earl$ or juvenil$ or child$ or labil$ or keto$) adj3 

(diabetes mellitus or DM)).mp. 

34. hypoglyc?emi$.mp. 

35. or/26-34 

36. (diabet$ adj3 (insipidus not mellitus)).mp. 

37. 35 not 36 

38. exp health education/ 

39. Health Behavior/ 

40. health programs/ 

41. health promotion/ 

42. patient education/ 

43. Nutrition Instruction/ 

44. exp behavior modification/ 

45. exp counseling/ 

46. exp intervention/ 

47. self help programs/ 

48. social support groups/ 

49. cognitive restructuring/ 

50. exp health services/ 

51. school health services/ 

52. exp therapy/ and diabet$.mp. 

53. child psychology/ 

54. exp educational methods/ 

55. exp instructional methods/ 

56. (behav$ adj3 (therap$ or modif$)).mp. 

57. (family adj3 therap$).mp. 

58. (video$ or gam$).mp. 

59. (phone or telephon$).mp. 

60. program$.mp. 

61. interven$.mp. 

62. inform$.mp. 

63. educat$.mp. 

64. teach$.mp. 

65. train$.mp. 

66. instruct$.mp. 

67. ((diet or nutrition$) adj2 therap$).mp. 

68. (diabet$ adj diet$).mp. 

69. ((education$ or home) adj2 (meeting? or session? 

or strateg$ or workshop? or visit?)).mp. 

70. ((psycho-$ or psycho$) and diabet$).mp. 

71. or/38-70 

72. (hemoglobin or haemoglobin).mp. 

73. (HbA1c or A1c or HbA1 or GHb).mp. 

74. (blood glucose or BG).mp. 

75. (ketoacido$ or keto-acido$).mp. 

76. ((metabolic or diabet$ or glyc?emic or glucose) adj 

control).mp. 

77. self management/ 

78. self efficacy/ 

79. (self adj (care or regulat$ or monitor$ or manage$ 

or efficacy)).mp. 

80. medical care evaluation/ 

81. program evaluation/ 

82. "outcomes of treatment"/ 

83. Behavior Change/ 

84. problem solving/ 

85. ((effect? or impact or evaluat$ or compar$) adj2 

(treatment or care) adj program$).mp. 

86. attitud$.mp. 

87. behavio?r$.mp. 

88. complian$.mp. 

89. adheren$.mp. 

90. improv$.mp. 

91. chang$.mp. 

92. (cope or coping).mp. 

93. skill?.mp. 

94. (knowledge or learn$ or cognition).mp. 

95. exp "quality of life"/ 

96. "quality of life".mp. 

97. hospitali?ation?.mp. 

98. admission?.mp. 

99. service utilization.mp. 

100. motivation/ 

101. or/72-100 

102. control?ed clinical trial?.mp. 

103. randomi?ed.ti,ab. 

104. placebo.ti,ab. 

105. randomly.ti,ab. 

106. trial.ti,ab. 

107. groups.ti,ab. 
 B-15 

108. Evaluation Methods/ or Program Evaluation/
 B-16 

Table B7. ERIC (Educational Resources Information Center)—OVID Version: rel10.4.1 

(continued) 

109. (pre test$ or pretest$ or (post test$ or 

posttest$)).mp. 

110. (observation$ or prospectiv$ or cohort$ or control$ 

or volunteer$ or evaluat$ or compar$ or longitudinal 

or long term or long-term or longterm or case control$ 

or case-control$ or case referrent or case-referrent or 

time series or time-series or followup or follow up or 

follow-up or before-and-after or before-after).mp. and 

(study or studies or trial$).ti,ab,sh. 

111. Cohort Analysis/ 

112. exp longitudinal studies/ 

113. or/101-112 

114. exp animals/ 

115. 113 not 114 

116. and/25,37,71,101,115 

117. (letter$ or editorial$ or commentary or 

lecture$).ti,ab. 

118. 116 not 117 

119. limit 118 to (english language and yr="1983 - 

2007") 
 B-17 

Table B8. PsycINFO®—OVID Version: rel10.4.1 

Years/issue searched: 1985 to February Week 4 2007

Search date: March 4, 2007 

Results: study design 468; no study design 1,141

1. infan$.mp. 

2. (baby or babies).mp. 

3. toddler$.mp. 

4. child$.mp. 

5. adolescen$.mp. 

6. (young adj3 (person? or people or adult?)).mp. 

7. (teen$ or teen ager?).mp. 

8. youth?.mp. 

9. juvenil$.mp. 

10. pube$.mp. 

11. parent$.mp. 

12. famil$.mp. 

13. (caregiver? or care-taker or care giver$? or 

caretaker? or care-taker? or care caker? or 

carer?).mp. 

14. infancy 2 23 mo.ag. 

15. childhood birth 12 yrs.ag. 

16. preschool age 2 5 yrs.ag. 

17. school age 6 12 yrs.ag. 

18. adolescence 13 17 yrs.ag. 

19. exp parents/ 

20. exp Family/ 

21. exp Caregivers/ 

22. or/1-21 

23. diabetes/ 

24. diabetes mellitus/ 

25. hypoglycemia/ 

26. ((type 1 or I) adj (diabetes mellitus or DM)).mp. 

27. ((diabetes mellitus or DM) adj (type 1 or I)).mp. 

28. diabet$.mp. 

29. IDDM.mp. 

30. DM.mp. 

31. ((insulin-dependent or insulindependent) adj3 

(diabetes mellitus or DM)).mp. 

32. ((earl$ or juvenil$ or child$ or labil$ or keto$) adj3 

(diabetes mellitus or DM)).mp. 

33. ((autoimmun$ or auto-immun$ or auto immun$ or 

sudden onset) adj3 (diabetes mellitus or DM)).mp. 

34. (insulin defic$ adj3 absolut$).mp. 

35. hypoglyc?emi$.mp. 

36. or/23-35 

37. exp Diabetes Insipidus/ 

38. (diabet$ adj (insipidus not mellitus)).mp. 

39. 36 not 38 

40. health education/ 

41. health promotion/ 

42. client education/ 

43. behavior modification/ 

44. behavior therapy/ 

45. cognitive therapy/ 

46. cognitive behavior therapy/ 

47. exp counseling/ 

48. interdisciplinary treatment approach/ 

49. Multimodal Treatment Approach/ 

50. exp health care delivery/ 

51. exp Health Care Services/ 

52. exp case management/ 

53. support groups/ 

54. exp intervention/ 

55. health behavior/ 

56. exp psychotherapy/ and diabet$.mp. 

57. (behav$ adj3 (therap$ or modif$)).mp. 

58. (family adj3 therap$).mp. 

59. (video$ or gam$).mp. 

60. (phone or telephon$).mp. 

61. program$.mp. 

62. interven$.mp. 

63. inform$.mp. 

64. educat$.mp. 

65. teach$.mp. 

66. train$.mp. 

67. instruct$.mp. 

68. ((diet or nutrition$) adj2 therap$).mp. 

69. (diabet$ adj diet$).mp. 

70. ((education$ or home) adj2 (meeting? or sesion? or 

strateg$ or workshop? or visit?)).mp. 

71. child psychology/ and diabet$.mp. 

72. adolescent psychology/ and diabet$.mp. 

73. ((psycho-$ or psycho$) and diabet$).mp. 

74. "Psychoanalytic Therapy".cc. 

75. "Behavioral & Psychological Treatment of Physical 

Illness".cc. 

76. or/40-75 

77. blood sugar/ 

78. hemoglobin/ 

79. self monitoring/ 

80. DKA.mp. 

81. (ketoacido$ or keto-acido$).mp. 

82. SMBG.mp. 

83. (self adj (care or regulat$ or monitor$ or manage$ 

or efficacy)).mp. 

84. (blood glucose or BG).mp. 

85. ((metabolic or diabet$ or glyc?emic or glucose) adj 

control).mp. 

86. ((glycosylated or glycated) adj3 (hemoglobin or 

haemoglobin)).mp. 

87. (HbA1c or A1c or HbA1 or GHb or hemoglobin A1c 

or haemoglobin A1c).mp. 

88. self efficacy/ 

89. exp self management/ 

90. exp treatment outcomes/ 

91. Treatment Effectiveness Evaluation/ 

92. exp program evaluation/ 

93. health attitudes/ 

94. "physical illness (attitudes toward)"/ 

95. problem solving/ 

96. treatment compliance/ 

97. ((effect? or impact? or evaluat$ or compar$) adj2 

(treatment or care) adj program$).mp. 

98. attitud$.mp. 

99. behavio?r.mp. 

100. complian$.mp. 

101. adheren$.mp. 

102. improv$.mp. 
 B-18 

103. chang$.mp. 

104. (cope or coping).mp.
 B-19 

Table B8. PsycINFO®—OVID Version: rel10.4.1 (continued) 

105. skill?.mp. 

106. (knowledge or learn$ or cognition).mp. 

107. "quality of life"/ 

108. "quality of life".mp. 

109. exp hospitalization/ 

110. hospitali?ation?.mp. 

111. admission?.mp. 

112. health care utilization/ 

113. service utilization.mp. 

114. or/77-113 

115. clinical trials/ 

116. randomi?ed.ti,ab. 

117. placebo.ti,ab. 

118. randomly.ti,ab. 

119. trial.ti,ab. 

120. groups.ti,ab. 

121. "research design$".mp. 

122. cohort analysis/ 

123. Followup Studies/ 

124. exp Longitudinal Studies/ 

125. exp program evaluation/ 

126. random sampling/ 

127. (pre test$ or pretest$ or (post test$ or 

posttest$)).mp. 

128. (observation$ or prospectiv$ or cohort$ or control$ 

or volunteer$ or evaluat$ or compar$ or longitudinal 

or long term or long-term or longterm or case control$ 

or case-control$ or case referrent or case-referrent or 

time series or time-series or followup or follow up or 

follow-up or before-and-after or before-after).mp. and 

(study or studies or trial$).ti,ab,sh. 

129. or/115-128 

130. exp Animals/ 

131. 129 not 130 

132. and/22,39,76,114,131 

133. (letter$ or editorial$ or lecture$ or 

commentary).ti,ab. 

134. 132 not 133 

135. limit 134 to (english language and yr="1983 - 

2007") 
 B-20 

Table B9. CINAHL Plus with Full Text—EBSCOhost 

Years/issue searched: 1937 to present 

Search date: March 5, 2007 

Limits: not applied (not working day searches were run) 

Results: study design 646; no study design 2,383

1. ( MH "Child+" or MH "Adolescence+" or MH 

"Family+" or MH "Caregivers" or infan* or baby or 

babies or child* or toddler* or adolescent* or young 

w3 person? or young w3 adult? or young w3 people 

or teen* or teen ager? or teen-ager? or youth? or 

juvenil* or pube* or parent* or family or families or 

caregiv* or care giv* or care-giv* or caretak* or care 

tak* or care-tak* or carer? ) and ( MH "Diabetes 

Mellitus" or MH "Diabetes Mellitus, InsulinDependent" or MH "Hypoglycemia+" or type 1 

diabetes or type I diabetes or diabet* or iddm or dm 

or earl* w3 diabetes or juvenil* w3 diabetes or 

child* w3 diabetes or labil* w3 diabetes or keto* w3 

diabetes or auto immun* w3 diabetes or autoimmun* w3 diabetes or autoimmun* w3 diabetes or 

sudden onset w3 diabetes or insulin defic* n3 

absolut* or hypoglyc?emi* ) and ( MH "Support 

Groups" or MH "Health Education+" or MH "Patient 

Care+" or MH "Child Psychology" or MH 

"Adolescent Psychology" or MH "Behavior Therapy" 

or MH "Cognitive Therapy" or MH "Family Therapy" 

or MH "Counseling" or behav* n3 therap* or 

behave* n3 modif* or family n3 therap* or family n3 

modif* or MW "Education" or video* or game? or 

gaming or phone or telephon* or program* or 

interven* or inform* or educat* or teach* or train* or 

instruct* or psycho* or diet w2 therap* or nutrition 

w2 therap* or diabet* diet* ) and ( HbA1c or A1c or 

HbA1 or GHb or hemoglobin A1c or haemoglobin 

A1c or MH "Self Care+" or MH "Self-Efficacy" or 

MH "Outcomes (Health Care)+" or MH "Program 

Evaluation" or MH "Attitude to Health+" or MH 

"Health Behavior+" or MH "Problem Solving" or MH 

"Quality of Life" or MH "Institutionalization+" or self 

w2 care or self w2 regulat* or self w2 monitor* or 

self w2 manage* or self w2 efficacy or effect? or 

impact or evaluat* or compar* n2 treatment or care 

w1 program* or attitud* or behavio?r* or complian* 

or adheren* or improv* or cope or coping or skill? or 

knowledge or learn* or cognition or "quality of life" 

or hospitali?ation? or admission? or service 

utilization or MH "Coping+" or MH "Adaptation, 

Psychological" or MH "Health Resource Utilization" 

or MH "Health Services+/UT" ) 

2. ( MH "Clinical Trials+" or MH "Case Control 

Studies" or MH "Multiple Time Series" or MH "Time 

series" or MH "Concurrent Prospective Studies" or 

MH "Prospective Studies" or MH "Research 

Methodology" or MH "Pretest-Posttest Design+" or 

MH "Experimental studies" or MH "Comparative 

Studies" or MH "Evaluation Research+" or MH 

"Program Evaluation" or MH "Evaluation" or MH 

"Random Assignment" ) 

3. #1 and #2 
 B-21 

Table B10. LILACS (Latin American and Caribbean Health Science Literature) (via OCLC WorldCat) 

Search date: February 28, 2007

Limits: 1983-2007; English 

Results: 800

1. (kw: diabetes w mellitus OR kw: Diabetes w 

Mellitus, w Type w 1 OR kw: Diabetic w 

Ketoacidosis OR kw: DM OR kw: IDDM OR ((kw: 

diabetes w mellitus OR kw: DM) AND (kw: type and 

kw: 1) OR (kw: type and kw: I))) OR ((kw: insulindepend* OR kw: insulindepend* OR kw: keto* OR 

kw: earl* OR kw: juvenil* OR kw: child* OR kw: 

labil* OR kw: autoimmun* OR kw: auto-immun* OR 

(kw: sudden and kw: onset)) AND (kw: diabet* OR 

kw: DM)) OR (((kw: insulin and kw: def*) AND kw: 

absolut*) OR kw: hypoglycemi*) and yr: 1983-2007 

and la= "eng" and li: lilac 
 B-22 

Table B11. OCLC ProceedingsFirst—OCLC First Search 

Limits: 1983-2007; English 

Search date: February 28, 2007 

Results: 14

1. kw: infant+ OR kw: baby OR kw: babies OR kw: 

toddler+ OR kw: child* OR kw: adolescent+ OR kw: 

teen* OR kw: teenager+ OR kw: youth+ OR kw: 

juvenile+ OR kw: parent+ OR kw: family OR kw: 

families OR kw: caregiver+ OR kw: caretaker+ OR 

kw: carer+ and yr: 1983-2007 and ln= "english") 

and ((kw: diabetes w mellitus OR kw: Diabetes w 

Mellitus, w Type w 1 OR kw: Diabetic w 

Ketoacidosis OR kw: DM OR kw: IDDM OR ((kw: 

diabetes w mellitus OR kw: DM) AND (kw: type and 

kw: 1) OR (kw: type and kw: I))) OR ((kw: insulindepend* OR kw: insulindepend* OR kw: keto* OR 

kw: earl* OR kw: juvenil* OR kw: child* OR kw: 

labil* OR kw: autoimmun* OR kw: auto-immun* OR 

(kw: sudden and kw: onset)) AND (kw: diabet* OR 

kw: DM)) OR (((kw: insulin and kw: def*) AND kw: 

absolut*) OR kw: hypoglycemi*) and yr: 1983-2007 

and ln= "english") 
 B-23 

Table B12. OCLC PapersFirst—OCLC First Search 

Limits: 1983-2007 

Search date: February 28, 2007 

Results: 10 

1. kw: infant+ OR kw: baby OR kw: babies OR kw: 

toddler+ OR kw: child* OR kw: adolescent+ OR kw: 

teen* OR kw: teenager+ OR kw: youth+ OR kw: 

juvenile+ OR kw: parent+ OR kw: family OR kw: 

families OR kw: caregiver+ OR kw: caretaker+ OR 

kw: carer+ and yr: 1983-2007 and ln= "english") 

and ((kw: diabetes w mellitus OR kw: Diabetes w 

Mellitus, w Type w 1 OR kw: Diabetic w 

Ketoacidosis OR kw: DM OR kw: IDDM OR ((kw: 

diabetes w mellitus OR kw: DM) AND (kw: type and 

kw: 1) OR (kw: type and kw: I))) OR ((kw: insulindepend* OR kw: insulindepend* OR kw: keto* OR 

kw: earl* OR kw: juvenil* OR kw: child* OR kw: 

labil* OR kw: autoimmun* OR kw: auto-immun* OR 

(kw: sudden and kw: onset)) AND (kw: diabet* OR 

kw: DM)) OR (((kw: insulin and kw: def*) AND kw: 

absolut*) OR kw: hypoglycemi*) and yr: 1983-2007 
 B-24 

Table B13. PubMed®—U.S. National Library of Medicine 

Search date: March 6, 2007 

Limits: articles published and/or entered within last 180 days 

Results: 218

1. Search infant[MeSH] OR child[MeSH] OR 

adolescent[MeSH] OR parents[MeSH] OR 

family[MeSH] OR caregivers[MeSH]) OR (infan* 

OR baby OR babies OR toddler* OR child* OR 

adolescen* OR "young person*" OR "young people" 

OR "young adult*" OR teen* OR "teen-ager*" OR 

youth* OR juvenil* OR pube* OR parent* OR famil* 

OR caregiv* OR care-giv* OR caretak* OR "caretak*" OR carer*) 

2. Search ("diabetes mellitus"[MeSH] OR "Diabetes 

Mellitus, Type 1"[MeSH] OR "Diabetic 

Ketoacidosis"[MeSH] OR DM OR IDDM OR 

(("diabetes mellitus" OR DM) AND type 1 OR type 

I)) OR ((insulin-depend* OR insulindepend* OR 

keto* OR earl* OR juvenil* OR child* OR labil* OR 

autoimmun* OR auto-immun* OR sudden onset) 

AND (diabet* OR DM)) OR ((insulin def* AND 

absolut*) OR hypoglycemi*) 

3. Search diabetes insipidus[MeSH] 

4. Search ((#2)) NOT (#3) 

5. Search self help groups[MeSH] OR health 

education[MeSH] OR patient education[MeSH] OR 

patient care[MeSH] OR adolescent 

psychology[MeSH] OR child psychology[MeSH] OR 

behavior therapy[MeSH] OR cognitive 

therapy[MeSH] OR family therapy[MeSH] OR 

counseling[MeSH] OR (exp patient care 

management[MeSH] AND diabet*) OR exp nutrition 

therapy[MeSH] OR exp home care services[MeSH] 

OR (behav* AND (therap* OR modif*)) OR (family 

AND therap*) OR video OR videos OR game OR 

games OR phone OR telphon* OR program* OR 

interven* OR inform* OR educat* OR teach* OR 

train* OR instruct* 

6. Search ((Patient AND (Care OR management)) OR 

"Self-help group*" OR ((Health OR patient) AND 

education) OR Counsel* OR ((adolescent OR child) 

AND psychology) OR (behavio* OR cognit* OR 

psychotherap* OR family OR nutrition* OR diet*) 

AND (therap* OR (modif*)) OR "Home care 

service* OR school health service* OR diabet* 

diet*) 

7. Search ((#5)) OR (#6) 

8. Search Hemoglobin A, glycosylated[MeSH] OR 

blood glucose[MeSH] OR diabetic 

ketoacidosis[MeSH] OR ketoacido* OR keto-acido* 

OR DKA OR SMBG OR "blood glucose" OR BG 

OR ((metabolic OR diabet* OR glycemic OR 

glycaemic OR glucose) AND control) OR (HbA1c 

OR A1c OR HbA1 OR GHb OR hemoglobin OR 

haemoglobin) 

9. Search Self care[MeSH] OR self efficacy[MeSH] 

OR (self AND (care OR regulat* OR monitor* OR 

manage* OR efficacy)) OR (attitud* OR behavior* 

OR complian* OR adheren* OR improv* OR chang* 

OR cope OR coping OR skill* OR knowledge OR 

learn* OR cognition)) 

10. Search Program evaluation[MeSH] OR treatment 

outcome[MeSH] OR attitude to health[MeSH] OR 

health behavior[MeSH] OR problem solving[MeSH] 

OR ((effect* OR impact OR evaluat* OR compar*) 

AND (treatment OR care) AND program*) OR 

"outcome assessment (health care)"[MeSH] OR 

quality of life[MeSH] OR hospitalization[MeSH] OR 

admission* OR "service utilization" 

11. Search (((#8)) OR (#9)) OR (#10) 

12. Search clinical trial[PT] OR randomized[TIAB] OR 

placebo[TIAB] OR randomly[TIAB] OR trial[TIAB] 

OR groups[TIAB] OR controlled clinical 

trials[MeSH] OR cohort studies[MeSH] OR 

intervention studies[MeSH] OR evaluation 

studies[MeSH] OR program evaluation[MeSH] OR 

random allocation[MeSH] 

13. Search pre-test* OR pretest* OR post-test* OR 

posttest* 

14. Search (observation*[TIAB] OR prospectiv*[TIAB] 

OR cohort*[TIAB] OR control*[TIAB] OR 

volunteer*[TIAB] OR evaluat*[TIAB] OR 

compar*[TIAB] OR longitudinal[TIAB] OR longterm[TIAB] OR longterm[TIAB] OR casecontrol*[TIAB] OR case control*[TIAB] OR case 

referrent*[TIAB] OR case-referrent*[TIAB] OR time 

series[TIAB] OR time-series[TIAB] OR 

followup[TIAB] OR follow up[TIAB] OR followup[TIAB] OR before-and-after[TIAB] OR beforeafter[TIAB]) AND (study[TIAB] OR studies[TIAB] 

OR trial*[TIAB])) 

15. Search (((#12)) OR (#13)) OR (#14) 

16. Search (((((#1)) AND (#4)) AND (#7)) AND (#11)) 

AND (#15) 
 B-25 

Table B14. Science Citation Index Expanded (via Web of Science®)—ISI Web of Knowledge ver 3.0 

Years/issue searched: 1900-present 

Limits: 1983-2007; English 

Search date: February 22, 2007 

Results: 938

1. TS=(infan* OR (baby OR babies) OR toddler* OR 

child* OR adolescen* OR youth* OR juvenil* OR 

teen* OR (teen SAME ager*) OR (young SAME 

person*) OR (young SAME people) OR (young 

SAME adult*)) OR TS=(pube* OR parent* OR 

famil* OR caregiv* OR (care SAME giv*) OR 

caretak* OR (care SAME tak*) OR carer*) 

2. TS=((Diabetes SAME mellitus) OR DM) AND 

TS=((Type SAME 1) OR (Type SAME I)) OR 

TS=(diabet* OR IDDM) OR TS=((insulin SAME 

dependent) OR insulindependent OR earl* OR 

juvenil* OR child* OR labil* OR keto* OR 

autoimmun* OR (auto SAME immun*) OR 

(sudden SAME onset)) AND TS=((diabetes SAME 

mellitus) OR DM) 

3. #2 NOT TS=(diabetes SAME insipidus) 

4. TS=((education* OR home) SAME (meeting* OR 

session* OR strateg* OR workshop*OR visit*)) OR 

TS=(video* OR gam* OR phone OR telephon* OR 

program* OR interven* OR inform* OR educat*OR 

teach* OR train* OR instruct*) 

5. TS=((Home SAME care) OR TS=(school SAME 

health) SAME TS=Service*) OR TS=(diabet* 

SAME diet) 

6. TS=(Behav* OR cognit* OR psycho*OR family OR 

nutrition* OR diet*) AND TS=(therap* OR modif*) 

7. TS=Counse?ling OR (TS=(Adolescent OR child) 

AND TS=psychology) 

8. TS=(Patient SAME (Care OR management)) OR 

TS=(Self SAME help SAME group*) OR 

TS=(Health OR patient) AND TS=education 

9. #8 OR #7 OR #6 OR #5 OR #4 

10. TS=(ketoacido* OR keto same acido*) OR 

TS=DKA OR TS=SMBG OR TS=(blood SAME 

glucose) OR TS=BG OR TS=((metabolic OR 

diabet* OR glyc?emic OR glucose) SAME control) 

OR TS=(HbA1c OR A1c OR HbA1 OR GHb OR 

hemoglobin OR haemoglobin) 

11. TS=(self SAME (care OR regulat* OR monitor* 

OR manage* OR efficacy)) OR TS=(attitud* OR 

behavior* OR complian* OR adheren* OR improv* 

OR chang* OR cope OR coping OR skill* OR 

knowledge OR learn* OR cognition) 

12. TS=(Program SAME evaluation) OR 

TS=(Treatment SAME Outcome) OR TS=(problem 

SAME solving) OR TS=((effect* OR impact OR 

evaluat* OR compar*) SAME (treatment OR care) 

SAME program*) OR TS="quality of life" OR 

TS=hospitali?ation OR TS=admission* OR 

TS=(service SAME utilization) 

13. #12 OR #11 OR #10 

14. TS=(randomized controlled trial* OR controlled 

clinical trial* OR research design OR placebo* OR 

random* OR pre test* OR prettest* OR post test* 

OR posttest* ) OR TS=(observation* OR 

prospectiv* OR cohort* OR control* OR volunteer* 

OR evaluat* OR compar* OR intervention OR 

longitudinal OR long term OR long-term OR 

longterm OR "case control*" OR case-control* OR 

"time series" OR time-series OR "case referent" OR 

case-referent OR before-and-after OR before-after 

OR followup OR "follow up" OR follow-up) AND 

TS=(study OR studies OR trial*) NOT TS=animal* 

15. #9 AND #3 AND #1 

16. #15 AND #14 AND #13 
 B-26 

Table B15. SSCI-Expanded (Social Science Citation Index) (Expanded via Web of 

Science®

)—ISI Web of Knowledge ver 3.0 

Years/issue searched: 1956-present 

Limits: English; 1983-present 

Search date: February 22, 2007 

 Results: 250

1. TS=(infan* OR (baby OR babies) OR toddler* OR 

child* OR adolescen* OR youth* OR juvenil* OR 

teen* OR (teen SAME ager*) OR (young SAME 

person*) OR (young SAME people) OR (young 

SAME adult*)) OR TS=(pube* OR parent* OR 

famil* OR caregiv* OR (care SAME giv*) OR 

caretak* OR (care SAME tak*) OR carer*) 

2. TS=((Diabetes SAME mellitus) OR DM) AND 

TS=((Type SAME 1) OR (Type SAME I)) OR 

TS=(diabet* OR IDDM) OR TS=((insulin SAME 

dependent) OR insulindependent OR earl* OR 

juvenil* OR child* OR labil* OR keto* OR 

autoimmun* OR (auto SAME immun*) OR 

(sudden SAME onset)) AND TS=((diabetes SAME 

mellitus) OR DM) 

3. #2 NOT TS=(diabetes SAME insipidus) 

4. TS=((education* OR home) SAME (meeting* OR 

session* OR strateg* OR workshop*OR visit*)) OR 

TS=(video* OR gam* OR phone OR telephon* OR 

program* OR interven* OR inform* OR educat*OR 

teach* OR train* OR instruct*) 

5. TS=((Home SAME care) OR TS=(school SAME 

health) SAME TS=Service*) OR TS=(diabet* 

SAME diet) 

6. TS=(Behav* OR cognit* OR psycho*OR family OR 

nutrition* OR diet*) AND TS=(therap* OR modif*) 

7. TS=Counse?ling OR (TS=(Adolescent OR child) 

AND TS=psychology) 

8. TS=(Patient SAME (Care OR management)) OR 

TS=(Self SAME help SAME group*) OR 

TS=(Health OR patient) AND TS=education 

9. #8 OR #7 OR #6 OR #5 OR #4 

10. TS=(ketoacido* OR keto same acido*) OR 

TS=DKA OR TS=SMBG OR TS=(blood SAME 

glucose) OR TS=BG OR TS=((metabolic OR 

diabet* OR glyc?emic OR glucose) SAME control) 

OR TS=(HbA1c OR A1c OR HbA1 OR GHb OR 

hemoglobin OR haemoglobin) 

11. TS=(self SAME (care OR regulat* OR monitor* 

OR manage* OR efficacy)) OR TS=(attitud* OR 

behavior* OR complian* OR adheren* OR improv* 

OR chang* OR cope OR coping OR skill* OR 

knowledge OR learn* OR cognition) 

12. TS=(Program SAME evaluation) OR 

TS=(Treatment SAME Outcome) OR TS=(problem 

SAME solving) OR TS=((effect* OR impact OR 

evaluat* OR compar*) SAME (treatment OR care) 

SAME program*) OR TS="quality of life" OR 

TS=hospitali?ation OR TS=admission* OR 

TS=(service SAME utilization) 

13. #12 OR #11 OR #10 

14. TS=(randomized controlled trial* OR controlled 

clinical trial* OR research design OR placebo* OR 

random* OR pre test* OR prettest* OR post test* 

OR posttest* ) OR TS=(observation* OR 

prospectiv* OR cohort* OR control* OR volunteer* 

OR evaluat* OR compar* OR intervention OR 

longitudinal OR long term OR long-term OR 

longterm OR "case control*" OR case-control* OR 

"time series" OR time-series OR "case referent" OR 

case-referent OR before-and-after OR before-after 

OR followup OR "follow up" OR follow-up) AND 

TS=(study OR studies OR trial*) NOT TS=animal* 

15. #9 AND #3 AND #1 

16. #15 AND #14 AND #13 
 B-27 

Table B16. Dissertations and Theses Full Text ProQuestTM 

Search date: March 1, 2007 

Results: 130

(diabet* AND (type 1 OR type I))) AND (infan* OR 

child* OR adolescen* OR famil* OR parent* OR 

caregiv* OR carer) AND NOT (mouse OR mice OR 

rat* OR cow*) 

OVID databases 

RCT filter adapted from: 

Cochrane Highly Sensitive Search Strategy (2005) Revision from 

Glanville JM, Lefebvre C, Miles JNV, Camosso-Stefinovic J. How to identify randomized 

controlled trials in Medline: ten years on. J Med Libr Assoc 2006; 94(2):130-6 

Science Citation Index and Social Science Citation Index databases 

RCT filter from Lisa Tjosvold (ARCHE) located at 

http://www.ualberta.ca/ARCHE/filters.html#rctwos 

At the recommendation of the TEP panel, the searches were rerun without the study design 

component. Studies found previously (with the study design filter) were then removed from the 

search before importing into ProCite. The numbers for “no study design” are the raw results from 

the search, before removing duplicate studies from the study design results. 
 B-28 

Gray Literature 

Table B17. Diabetes organizations and societies 

Website URL 

Alberta (Canada) Foundation for 

Diabetes Research 

http://www.afdr.ab.ca 

American Association of Diabetes 

Educators (AADE) 

http://www.aadenet.org 

American Diabetes Association http://www.diabetes.org 

American Dietetic Association http://www.eatright.org/cps/rde/xchg/ada/hs.xsl/index.h

tml 

American Public Health Association http://www.apha.org 

Australian Diabetes Educators 

Association (ADEA) 

http://www.adea.com.au/index.aspx 

Australian Diabetes Society (ADS) http://www.racp.edu.au/ads 

Barbara Davis Center for Childhood 

Diabetes 

http://www.uchsc.edu/misc/diabetes 

British Society for Paediatric 

Endocrinology and Diabetes 

http://www.bsped.org.uk 

Canadian Diabetes Association 

(CDA) 

http://www.diabetes.ca 

Center for Disease Control and 

Prevention. Diabetes Public Health 

Resource 

http://www.cdc.gov/diabetes 

Children's Diabetes Foundation at 

Denver 

http://www.childrensdiabetesfdn.org 

Diabetes Action Research and 

Education Foundation 

http://www.diabetesaction.org 

Diabetes Education and Camping 

Association 

http://www.diabetescamps.org 

Diabetes Care and Education http://www.dce.org 

Diabetes Australia http://www.diabetesaustralia.com.au 

Diabetes India http://diabetesindia.com 

Diabetes New Zealand http://www.diabetes.org.nz 

Diabetes Technology Society http://www.clinicaldiabetestechnology.org 

Diabetes UK http://www.diabetes.org.uk 

Diabetes Exercise and Sports 

Association 

http://www.diabetes-exercise.org 

Diabetes Institutes Foundation http://www.dif.org 

Diabetes Research and Wellness 

Foundation 

http://www.diabeteswellness.net 

Diabetes Research Institute http://www.drinet.org 

Diabetes Technology Society http://www.diabetestechnology.org 

Dietitians of Canada http://www.dietitians.ca 

European Association for the Study 

of Diabetes 

http://www.easd.org 
 B-29 

Federation of European Nurses in 

Diabetes 

http://www.fend.org 

Finnish Diabetes Association http://www.diabetes.fi 

Joslin Diabetes Center http://www.joslin.harvard.edu 

International Diabetes Institute http://www.idi.org.au 

International Diabetes Federation http://www.idf.org 

International Society for Pediatric and 

Adolescent Diabetes (ISPAD) 

http://www.ispad.org 

Juvenile Diabetes Research 

Foundation Australia 

http://www.jdrf.org.au 

Juvenile Diabetes Research 

Foundation International 

http://www.jdf.org 

Table B17. Diabetes organizations and societies (continued) 

Website URL 

Juvenile Diabetes Research 

Foundation Canada 

http://www.jdfc.ca 

Naomi Berrie Diabetes Center http://nbdiabetes.org 

National Diabetes Education 

Initiative (NDEI) 

http://www.ndei.org 

Pediatric Endocrinology Nursing 

Society 

http://www.pens.org/all.php?l=home&w=1280 
 B-30 

Table B18. Medical professional websites 

Website URL 

American Association of Clinical 

Endocrinologists 

http://www.aace.com 

American Medical Association http://www.ama-assn.org 

Canadian Medical Association http://www.cma.ca/index.cfm/ci_id/121/la_id/1.htm 

Diabetes for Professionals http://www.d4pro.com/HomeDefault.asp 

Diabetes Prevention and Control 

Branch 

http://www.ncdiabetes.org 

Diabetes Research in Children 

Network (DirecNet) 

http://public.direc.net/index.htm 

DiabetesIndia.com http://www.diabetesindia.com 

Endocrineindia.com http://www.endocrineindia.com 

Healthcare Professionals (Canadian 

Diabetes Association) 

http://www.diabetes.ca/Section_Professionals/index.as

p 

National Diabetes Support Team http://www.diabetes.nhs.uk/ 

National Institute for Health and 

Clinical Excellence (NICE) 

http://www.nice.org.uk 

National Institute of Diabetes and 

Digestive and Kidney Diseases 

http://www2.niddk.nih.gov 

ndei (National Diabetes Education 

Initiative) 

http://www.ndei.org 

National Glycohemoglobin 

Standardization Program (NGSP) 

http://www.ngsp.org/ngsp.html 

Royal College of Nursing http://www.rcn.org.uk/resources/improvingcare/diabete

s/ 

index.php 

SEARCH For Diabetes in Youth http://www.searchfordiabetes.org/public/provider/index

.cfm 

The Endocrine Society http://www.endo-society.org 

Type 1 Diabetes TrialNet http://www.diabetestrialnet.org 

U.S. Department of Health and 

Human Services—National Institutes 

of Health 

http://health.nih.gov 

U.S. Food and Drug Administration 

Diabetes Information 

http://www.fda.gov/diabetes/ 

World Health Organization http://www.who.org 
 B-31 

Table B19. Journal websites 

Website URL 

Acta Diabetologia http://link.springer.de/link/service/journals/00592 

Annals of Nutrition and Metabolism http://www.karger.ch/journal/anm 

Annual Review of Nutrition http://nutr.annualreviews.org 

Asia Pacific Journal of Clinical 

Nutrition 

http://www.healthyeatingclub.com/APJCN/index.htm 

Australian Journal of Nutrition and 

Dietetics 

http://www.ajnd.org.au 

British Journal of Nutrition http://journals.cambridge.org/action/displayJournal?jid

=BJN 

Canadian Journal of Diabetes http://www.diabetes.ca/Section_Professionals/pub_cjd.

asp 

Canadian Journal of Dietetic Practice 

and Research 

http://dcjournal.metapress.com/home/main.mpx 

Clinical Diabetes http://clinical.diabetesjournals.org 

Clinical Nutrition http://www.harcourt-international.com/journals/clnu 

Current Diabetes Reports http://www.biomedcentral.com/currdiabetesrep 

Current Opinion in Clinical Nutrition 

and Metabolic Care 

http://www.co-clinicalnutrition.com 

Diabetes http://diabetes.diabetesjournals.org 

Diabetes http://www.diabetes.org/Diabetes 

Diabetes and Primary Care http://www.sbcommunicationsgroup.com/publications/

diabetesprimarycare/archive.htm 

Diabetes Care http://care.diabetesjournals.org 

Diabetes Digest http://www.diabetesdigest.com 

Diabetes Forecast http://www.diabetes.org/DiabetesForecast 

Diabetes Metabolism Research and 

Reviews 

http://www3.interscience.wiley.com/ 

cgi-bin/jhome/10009394 

Diabetes Research and Clinical 

Practice 

http://www.sciencedirect.com/science/journal/0168822

7 

Diabetes Self-Management Magazine http://www.diabetes-self-mgmt.com 

Diabetes Spectrum http://www.diabetes.org/DiabetesSpectrum 

Diabetes Technology and 

Therapeutics 

http://www.liebertonline.com/dia?cookieSet=1 

Diabetes, Obesity and Metabolism http://www.blackwellpublishing.com/journal.asp 

Diabetes/Metabolism Reviews http://www3.interscience.wiley.com/cgibin/jhome/3666?CRETRY=1&SRETRY=0 

Diabetic Medicine http://www.blackwellpublishing.com/journal.asp?ref=0

742-3071&site=1 

Diabetologia http://link.springer.de/link/service/journals/00125/inde

x.htm 

Disease Management http://www.liebertonline.com/dis 

DOC News http://docnews.diabetesjournals.org 

eCMAJ http://www.collectionscanada.ca/eppparchive/100/201/300/cdn_medical_association/cmaj/in

dex.asp 
 B-32 

European Journal of Clinical 

Nutrition 

http://www.nature.com/ejcn/index.html 

European Journal of Nutrition http://www.steinkopff.springer.de/journal/394 

Indian Journal of Biochemistry and 

Biophysics 

http://www.niscair.res.in/ScienceCommunication/ 

ResearchJournals/rejour/ijbb/ijbb0.asp 

Indian Journal of Medical Research http://www.icmr.nic.in/ijmr/ijmr.htm 

Indian Journal of Medical Sciences http://www.bioline.org.br/ms 

International Journal of Diabetes and 

Metabolism 

http://ijod.uaeu.ac.ae 

Journal of Diabetes and its 

Complications 

http://www.sciencedirect.com/science/journal/1056872

7 

Journal of Diabetes Science and 

Technology 

http://www.journalofdst.org 

Table B19. Journal websites (continued) 

Website URL 

Journal of Diabetic Nursing http://www.sbcommunicationsgroup.com/publications/

diabetesnursing/archive.htm 

Journal of the American Dietetic 

Association 

http://www.adajournal.org 

Journal of the Association of 

Physicians of India 

http://japi.org/index.asp 

Pediatric Diabetes http://www.blackwell-synergy.com/loi/PDI 

Public Health Nutrition http://www.cabi-publishing.org/journals.phn 

Review of Diabetic Studies http://www.soc-bdr.org/content/e4/e887/ 

volRdsVolumes4215/issRdsIssues4216/index_en.html 

The American Journal of Clinical 

Nutrition 

http://www.ajcn.org 

Tufts University Health and Nutrition 

Letter 

http://healthletter.tufts.edu/ 
C-1

Appendix C. Sample Data Abstraction Forms 

Inclusion Criteria Worksheet: Diabetes & Medical Nutrition Therapy Education for 

Families with Children Who Have Type 1 Diabetes Mellitus 

Reviewer: Date: ______________ Record ID: _______________ 

Yes No Unclear/Comments 

Population: Patients with type 1 diabetes (If both type 1 and type 2 diabetes 

patients are included, results for type 1 must be explicit)

Exclude Type 2 diabetes, gestational diabetes 

Yes No 

Population: Patients ≤ 18 yr. (or <20% of population over 18 yr.) OR families of 

patients ≤ 18 years 

Yes No 

Study design: RCT, CCT, cohort studies, interrupted time series, before-after 

study with concurrent controls, case control studies, uncontrolled before and 

after studies, case series [make a note of those that are <10 participants] 

Exclude secondary research, case reports 

Yes No 

Intervention: Education program that incorporates at least one of the following 

content areas: 

1) Diabetes disease process and treatment options; 

2) Nutritional management; 

3) Physical activity; 

4) Monitoring blood glucose, urine ketones (when appropriate), and using 

the results to improve control; 

5) Utilizing medications; 

6) Preventing, detecting, and treating acute complications; 

7) Preventing (through risk reduction behavior), detecting, and treating 

chronic complications; 

8) Goal setting to promote health and problem solving for daily living; 

9) Psychosocial adjustment. 

Yes No 

Comparator: Education program vs. usual care OR another education 

program. NOTE: do not exclude based on this item; just make note of whether 

there is or isn’t a comparison group. 

Yes No 

Is the description of intervention sufficient to reproduce? 

Note: Must include topics or content. Other characteristics: provider, length 

and # sessions, target audience, mode of delivery (e.g., in person or distance), 

group or individual, didactic/interactive, changes in treatment. 

Yes No 
C-2

Inclusion Criteria Worksheet: Diabetes & Medical Nutrition Therapy Education for 

Families with Children Who Have Type 1 Diabetes Mellitus (continued) 

Outcomes: One or more of the following: 

1) Metabolic control (as measured by HbA1c); 

2) Hospitalization or ED utilization; 

3) Complications (short & long term; e.g., diabetic ketoacidosis, episodes 

of hypoglycemia, retinal, renal, cardiovascular, neurological); 

4) Knowledge; 

5) Quality of life; 

6) School attendance and performance; 

7) Self confidence in ability to cope with disease; 

8) Psychosocial outcomes 

Exclude life style outcomes (e.g., smoking, use of recreational drugs, 

participation in extracurricular activities) 

Yes No 

Final decision: Should this study be included? Yes No Unclear (Discuss) 

Results of discussion: 
C-3

Quality Assessment Form: (Jadad Scale for RCTs) 

Study number _______________ Initials of assessor: _____ 

Part 1 (from: Jadad AR, Moore RA, Carroll D, Jenkinson C, Reynolds DJ, Gavaghan DJ, et al. 

Assessing the quality of reports of randomized clinical trials: is blinding necessary? Control 

Clin Trials 1996;17(1):1-12.) 

1. Was the study described as randomized (this includes the use of words such 

as randomly, random, and randomization)? _______ 

Yes=1 No=0 

2. Was the study described as double-blind? _______ 

Yes=1 No=0 

3. Was there a description of withdrawals and drop-outs? _______ 

Yes=1 No=0 

Add one point if: 

Method to generate the sequence of randomization was described, and was 

appropriate (e.g., table of random numbers, computer-generated, coin-tossing) _______ 

Method of double-blinding was described, and was appropriate (identical 

placebo, active placebo, dummy) _______ 

Subtract one point if: 

Method of randomization was described, and was inappropriate (allocated 

alternately, according to date of birth, hospital number) _______ 

Method of double-blinding described, but was inappropriate (comparison of 

tablet versus injection with no double dummy) _______ 

OVERALL SCORE (maximum 5) 

Score ___________ 

Part 2 (from Schulz – JAMA 1995; 273:408-12) 

 

Concealment of treatment allocation:  Adequate 

 Inadequate 

 Unclear 

 

Adequate: e.g., central randomization; numbered/coded containers; drugs prepared by 

pharmacy; serially numbered, opaque, sealed envelopes 

 Inadequate: e.g., alternation, use of case record numbers, dates of birth or day of week; 

open lists 

 Unclear: Allocation concealment approach not reported or fits neither above category 
C-4
C-5
C-6
C-7
C-8

Data Extraction Form: Diabetes Education for Children with Type 1 Diabetes 

Description of Study 

 Reviewer name: 

 Date entered: 

Verifier’s name: 

Consensus reached: 

Data updated: 

Procite ID: 

Author: Year:

 Study ID: Reviewer Name: Date entered:

Type of publication: 

Funding:

Country: 

 Study setting: 

Single-centre 5

Multi-centre 5

Urban 5

Rural 5

Mixed 5

Camp 5

Unclear 5

Study design:

Objective or hypothesis of study:

Author's primary outcome:

Measure of primary outcome:

Secondary outcomes: 

Inclusion criteria for study:

Exclusion criteria for study:
C-9

Procite ID:

Author: Year:

Number Eligible: Number of withdrawals: 

Number Enrolled:

Number Completed: 

Number Excluded: Out of how:

How many excluded were from treatment group (n/N): How many from treatment group (n/N):

How many excluded were from control group (n/N): How many from control group (n/N):

Reasons for Exclusion: Reasons Withdrawn:

From where were subjects recruited?: (Drop down menu) 

 Hospital 

 Clinic 

 Home 

 Community 

 Existing support program 

 Diabetes centre 

 School 

How were they recruited?: (Drop down menu) 

 Volunteers 

 Referrals 

 Existing patients 

 Poster/flyer 

 Administrative data 

 Chart review/Medical records 

How was the control group selected?:

Authors' Conclusions: 

 Reviewer's Comments: Verifier's Comments:
C-10

Baseline Characteristics 

 

Verifier’s name: 

Consensus reached: 

Data updated: 

Population ID: 

 Procite ID: 

 Reviewer Initials: 

 Group Name: Name of Group: 

 Number in Group: 

 Age Mean: Standard deviation: Reported 5

 Age- other measure: Other variance: Calculated 5

 Percent Male: Reported 5

 Calculated 5

 Weight or BMI: 

 BMI Mean: BMI SD: 

 Weight Mean: Weight SD: 

 HbA1C Unit of Measurement: 

 

 HbA1C Mean: HbA1C SD: 

 HbA1C Other Measure: HBA1C Other Variance: 

 Diabetes Duration: Standard deviation: 

 Percent Newly Diagnosed: 

 Comments: 

Pop 

categorica

l 

Populatio

n ID 

Measure

s 

Categor

y 

Numerato

r 

Denominato

r 

% Mea

n 

S

D 

Comment

s 

(Auto 

Number) 

 
C-11

Interventions

Verifier’s name: 

Consensus reached: 

Data updated: 

Procite ID:

Group Name: Short Name:

Setting Content

Hospital 5 Diabetes disease process and treatment options 5

Doctor's office 5 Nutritional management 5

Home 5 Physical activity 5

Community 5 Monitoring (e.g. blood glucose, urine ketones) 5

Support Program 5 Medication use 5

School 5 Preventing, detecting, treating acute complications 5

Diabetes Center 5 Preventing, detecting, treating chronic complications 5

Other 5 Relationship Skills 

Goal setting to promote health and problem solving for 5

 daily living

Specify other:

Psychosocial adjustment 5

Description of Intervention:

Theoretical Framework:

Enter the page number where this description is located:
C-12

Interventions 

Procite ID:

Group Name: Short Name: 

Study Duration: 

Recruitment period: 

Follow-up period: 

Duration of program delivery: 

Component 1:

Frequency of intervention component 1 (ie 2x/week):

Duration of component 1 (i.e. length of session):

 

Frequency of component 2: 

Frequency of intervention component 2 (ie 2x/week):

Duration of component 2 (i.e. length of session):

Frequency of component 3: 

Frequency of intervention component 3 (ie 2x/week):

Duration of component 3 (i.e. length of session):

Who delivered the intervention? Primary deliverer (select one) 

 Diabetes educator 

 Physician 

 Pediatric endocrinologist 

 Nurse 

 Nurse practitioner 

 Psychologist 

 Social worker 

 Exercise physiologist 

 Paramedic 

 Camp counsellor 

 Multidisciplinary team 

 Research staff 

 Peer group 

 Lay person 

 Computer game 

 Video game 

 Dietician 

 Other (specify) 

 NR 

 N/A 

Secondary deliverers: 

 

If other, please specify: 

What was the mode of delivery? 

Primary mode of delivery (select 

one) 

 Literature 

 Meetings 

 Clinic visits 

 Personal counselling 

 Club 

 Computer game 

 Presentation 

 Class 

 Support group 

 Workbooks 

 Phone calls 

 Other (specify) 

 NR 

 N/A 

Secondary mode(s) of delivery: 

 

If other, please specify: 

To whom was the intervention 

delivered? 

 

Parents 

 Child 

 Family 

 Other 

 Other (specify) 

 NR 

 N/A 

 

Other recipient: 

 

Specify other: 
C-13

Outcomes 

Verifier’s name: 

Consensus reached: 

Data updated: 

Procite ID:

Reviewer Initials: 

Category (drop down menu): 

 Knowledge 

 Metabolic control 

 Short-term complications 

 Long-term complications 

 Health care utilization 

 Quality of life 

 School attendance and performance 

 Self-confidence in ability to cope with disease 

 Psychosocial outcomes 

 Adherence 

 

Description of outcome: 

Instrument used: 

Method of Measurement (drop down menu): 

 Patient self-report 

 Parent self-report 

 Observation 

 24 hr food frequency questionnaires 

 Pill count 

 Skill demonstration 

 Laboratory records 

 Medical records 

 Other Specify Other:

Frequency of Measurement: 

Unit of Measurement (e.g. mg, score):

Outcome 

group 

ID 

Outcome 

ID 

Group Timepoint Number Mean SD Other 

Measure

Other 

Variance 

Page 

Number 

Comments 

(Auto 

number) 

 
D-1

Appendix D. Excluded Studies 

After screening the full-text of studies that were potentially relevant to this review, 327 were 

excluded from this review. The studies are grouped by reason for exclusion. In addition, there 

were 46 studies that were unavailable for retrieval. 

Topic 

The purpose of this review was to answer questions regarding the effectiveness of diabetes and 

medical nutrition therapy education for children with type 1 diabetes mellitus and their families. 

The following 50 studies were excluded because they addressed different topics. 

1. Diabetes Care Centre at Texas Children’s Hospital. 

Effect of intensive diabetes treatment on the 

development and progression of long-term 

complications in adolescents with insulin-dependent 

diabetes-mellitus—diabetes control and 

complications trial. J Pediatr 1994;125(2):177-88. 

 2. IHS getting healthy returns in statewide diabetes 

initiative: early emphasis on education produces 

solid improvement. Dis Manag Advis 2002;8(6):85-

9. 

 3. Aguilar MI, Hart R. Oral anticoagulants for 

preventing stroke in patients with non-valvular 

atrial fibrillation and no previous history of stroke 

or transient ischemic attacks. Cochrane Database of 

Systematic Reviews. 2005(3):CD001927. 

 4. Allen HF, Yarnie S, Murray MA, et al. Is telephone 

care an effective tool for management of children 

with Type 1 diabetes? [abstract]. Diabetes 

2000;49(Suppl 1):A215. 

 5. Brandt P, Watts G. Bridging science and practice: 

four collaborative clinical projects: a clinic based 

protocol for teens with diabetes and their parents. 

Commun Nurs Res 2006;39:99. 

 6. Briery BG. Psychosocial sequelae of relaxation 

training and peer interaction for children with 

diabetes [dissertation]. Hattiesburg, MS: 

University of Southern Mississippi; 2000. 

 7. Campaigne BN, Gilliam TB, Spencer ML, et al. The 

effects of a physical-activity program on children 

with insulin dependent diabetes-mellitus [abstract]. 

Med Sci Sports Exerc 1983;15(2):149. 

 8. Carson C. Educating adolescents with type 1 

diabetes about drug use. Journal of Diabetes 

Nursing 2002;6(1):6-8. 

 9. Challener J, Ozen S, Barnes ND. The memory 

blood glucose reflectance meter: a useful 

educational tool for the diabetic adolescent? 

Practical Diabetes 1989;6(5):219-22. 

 10. Charron Prochownik D, Sereika SM, Hannan MF, 

et al. Reproductive health education for adolescent 

girls with diabetes (Ready-Girls): sustaining longrange outcomes [abstract]. Diabetes 2006;55(Suppl 

1):A416. 

 11. Diabetes Control and Complications Trial Research 

Group. Effect of intensive diabetes treatment on the 

development and progression of long-term 

complications in adolescents with insulin-dependent 

diabetes mellitus: Diabetes Control and 

Complications Trial. J Pediatr 1994;125(2):177-88. 

 12. Diabetes Control and Complications Trial Research 

Group. Progression of retinopathy with intensive 

versus conventional treatment in the Diabetes 

Control and Complications Trial. Ophthalmology 

1995;102(4):647-61. 

 13. George CK. Video in pediatric patient education: 

the role of formal features in the relationship of 

intervention, knowledge, and anxiety [dissertation]. 

Austin, TX: University of Texas at Austin; 1992. 

 14. Hanauer D, Wentzell K, Tovar A, et al. Parent and 

youth assessments of a handheld wireless device to 

enhance diabetes mellitus management. Arch 

Pediatr Adolesc Med 2006;160(3):321. 

 15. Herskowitz RD. Outward bound, diabetes and 

motivation: experiential education in a wilderness 

setting. Diabet Med 1990;7(7):633-8. 

 16. Hillson RM. Diabetes outward bound mountain 

course, Eskdale, Cumbria. Diabet Med 1984;1(1): 

59-63. 
D-2

 17. Huttunen NP, Lankela SL, Knip M, et al. Effect of 

once-a-week training program on physical fitness 

and metabolic control in children with IDDM. 

Diabetes Care 1989;12(10):737-40. 

 18. Jones EM. The efficacy of intensive individual play 

therapy for children diagnosed with insulindependent diabetes mellitus [dissertation]. Denton, 

TX: University of North Texas; 2000. 

 19. Kerr D, Kerr S. Diabetic camps for children—

effects on control and hypoglycaemia. Practical 

Diabetes 1988;5(2):74-6. 

 20. Kuno T, Tasaki H, Miyazaki S. [Continuous 

subcutaneous insulin injection for self-care of 

young patients with insulin-dependent diabetes 

mellitus]. Acta Paediatr Jpn 1996;38(5):464-9 (Jap). 

 21. Laffel LM, Brackett J, Ho J, et al. Changing the 

process of diabetes care improves metabolic 

outcomes and reduces hospitalizations. Qual Manag 

Health Care 1998;6(4):53-62. 

 22. Landt KW, Campaigne BN, James FW, et al. 

Effects of exercise training on insulin sensitivity in 

adolescents with type I diabetes. Diabetes Care 

1985;8(5):461-5. 

 23. Lawson ML, Cohen N, Richardson C, et al. A 

randomized trial of regular standardized telephone 

contact by a diabetes nurse educator in adolescents 

with poor diabetes control. Pediatr Diabetes 

2005;6(1):32-40. 

 24. Lee PD. An outpatient-focused program for 

childhood diabetes: design, implementation, and 

effectiveness. Tex Med 1992;88(7):64-8. 

 25. Lieberman D. Management of chronic pediatric 

diseases with interactive health games: theory and 

research findings. J Ambulatory Care Manage 

2001;24(1):26-38. 

 26. Mackowiak L. Education record for new-onset 

pediatric diabetes. Diabetes Educ 1996;22(4):345, 

347, 349-50 passim. 

 27. Mann LH. Effects of biofeedback-assisted deep 

muscle relaxation training on blood glucose levels 

in female adolescents with type I diabetes 

[dissertation]. Amherst, MA: University of 

Massachusetts; 1991. 

 28. Marrero DG, Kronz KK, Golden MP, et al. Clinical 

evaluation of computer-assisted self-monitoring of 

blood glucose system. Diabetes Care 

1989;12(5):345-50. 

 29. Melchionne FM. Children with diabetes mellitus: 

health and education teams. Holist Nurs Pract 

1993;7(4):11-9. 

 30. Miller SG. Family therapy for recurrent diabetic 

ketoacidosis: treatment guidelines. Fam Syst Health 

1996;14(3):303-14. 

 31. Orr PM, McGinnis M, Hudson LR, et al. A focused 

telephonic nursing intervention delivers improved 

adherence to A1c testing. Dis Manag 

2006;9(5):277-83. 

 32. Pinosa C, Marchand C, Tubiana Rufi N, et al. The 

use of concept mapping to enlighten the knowledge 

networks of diabetic children: a pilot study. 

Diabetes Metab 2004;30(6):527-34. 

 33. Price KJ, Lang JD, Eiser C, et al. Prescribed versus 

unrestricted carbohydrate diets in children with type 

1 diabetes. Diabet Med 1993;10(10):962-7. 

 34. Roberts L, Jones TW, Fournier P. Exercise training 

and glycemic control in adolescents with poorly 

controlled type 1 diabetes mellitus. J Pediatr 

Endocrinol Metab 2002;15(5):621-7. 

 35. Rogers DG. The effect of intensive treatment of 

diabetes on the development and progression of 

long-term complications in insulin-dependent 

diabetes mellitus. Clin Pediatr (Phila) 

1994;33(6):378. 

 36. Romanian Young Diabetics Study Team (RYDST). 

Mixtard 30 HM Penfill insulin treatment in selected 

young insulin-dependent diabetes mellitus patients. 

Romanian Young Diabetics Study Team (RYDST). 

Rom J Intern Med 1997;35(1-4):99-113. 

 37. Rosenfalck AM, Bendtson I. The Diva(TM) system, 

a computerized diary, used in young type 1 diabetic 

patients. Diabetes Metab 1993;19(1):25-9. 

 38. Ryden O, Nevander L, Johnsson P, et al. Family 

therapy in poorly controlled juvenile IDDM: effects 

on diabetic control, self-evaluation and behavioural 

symptoms. Acta Paediatr 1994;83(3):285-91. 

 39. Sar V, Akyuz G, Kugu N, et al. Axis I dissociative 

disorder comorbidity in borderline personality 

disorder and reports of childhood trauma. J Clin 

Psychiatry 2006;67(10):1583-90. 

 40. Schafer LC, McCaul KD, Glasgow RE. Supportive 

and nonsupportive family behaviors: relationships 

to adherence and metabolic control in persons with 

type I diabetes. Diabetes Care 1986;9(2):179-85. 
D-3

 41. Siarkowski AK, Pidgeon V. Documentation of 

discharge teaching before and after use of a 

discharge teaching tool. J Pediatr Nurs 

1991;6(5):296-301. 

 42. Smith CA, Kennedy DM, Lahoz MR, et al. Creating 

an academic and rural community network to 

improve diabetes care. In: Issues Affecting Rural 

Communities (II). Proceedings of the International 

Conference [on] Rural Communities & Identities in 

the Global Millennium; 2000 May 1-5; Nanaimo, 

BC. Nanaimo (BC): Rural Communities Research 

and Development Centre, Malaspina University 

College; 2000. 

 43. Smith LJ. Type I diabetes mellitus: dependent care 

agents' participation in decision making compared 

to their participation in diabetes education [master’s 

thesis]. Columbia, OH: University of Missouri; 

1991. 

 44. The Diabetes Control and Complications Trial. The 

effect of intensive diabetes treatment on the 

progression of diabetic retinopathy in insulindependent diabetes mellitus. Arch Ophthalmol 

1995;113(1):36-51. 

 45. The Diabetes Control and Complications 

Trial/Epidemiology of Diabetes Interventions and 

Complications Research Group. Retinopathy and 

nephropathy in patients with type 1 diabetes four 

years after a trial of intensive therapy [erratum 

appears in N Engl J Med 2000;342(18):1376]. N 

Engl J Med 2000;342(6):381-9 . 

 46. The Diabetes Control and Complications Trial 

Research Group. The effect of intensive treatment 

of diabetes on the development and progression of 

long-term complications in insulin-dependent 

diabetes mellitus. N Engl J Med 1993;329(14):977-

86. 

 47. Vanelli M, Chiari G, Ghizzoni L, et al. 

Effectiveness of a prevention program for diabetic 

ketoacidosis in children: an 8-year study in schools 

and private practices. Diabetes Care 1999;22:7-9.

 48. Ward J. Kid stuff. Teaching children about diabetes 

management. Adv Nurse Pract 1999;7(10):49-52. 

 49. Warpeha J. Design and implementation of an 

outdoor forestry program for children with diabetes 

[dissertation]. Orono, ME: The University of 

Maine; 1998. 

 50. Yopp JM. The impact of family functioning on 

treatment adherence and metabolic control for 

adolescents with poorly controlled type 1 diabetes 

[dissertation]. Mount Pleasant, MI: Central 

Michigan University; 2004. 
D-4

Study Design 

The review included studies that had the following study designs: randomized controlled trial (parallel or 

crossover), clinical controlled trial, cohort study, case-control study, interrupted time series, before-after 

study with concurrent control group, case series, and uncontrolled before-after study. The following 93 

studies were systematic reviews, descriptive studies, or case reports. 

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Diabetologia 1983;25(6):470-6. 

 65. Neumann L, Weitzman S, Gross J. Improved 

knowledge of diabetic patients through education of 

primary care staff. Health Policy 1989;13(2):103-8. 

66. Nusbaum NJ, Gant L. Focused nutritional 

intervention in the home care setting. Home Health 

Care Management & Practice 1999;11(2):53-7. 

 67. O'Connor PJ, Crabtree BF, Abourizk NN. 

Longitudinal study of a diabetes education and care 

intervention: predictors of improved glycemic 

control. J Am Board Fam Pract 1992;5(4):381-7. 

 68. Pagliari C, Clark D, Hunter K, et al. DARTS 2000 

online diabetes management system: formative 

evaluation in clinical practice. J Eval Clin Pract 

2003;9(4):391-400. 

 69. Piaggesi A, Giampietro O, Picaro L, et al. 

Individual teaching as a first-step intervention for 

the education of diabetic subjects. Acta Diabetol Lat 

1989;26(3):225-35. 

 70. Pichert JW, Hanson SL, Pechmann C. Modifying 

dietitians' use of patient time. Diabetes Educ 

1984;10(1):43-6,72. 
D-11

 71. Pichert JW, Hanson SL, Pechmann C. A system for 

assessing use of patients' time. Eval Health Prof 

1985;8(1):39-54. 

 72. Pieber TR, Brunner GA, Schnedl WJ, et al. 

Evaluation of a structured outpatient group 

education program for intensive insulin therapy. 

Diabetes Care 1995;18(5):625-30. 

 73. Ramalho A, de Lourdes C, Lima M, et al. The effect 

of resistance versus aerobic training on metabolic 

control in patients with type-1 diabetes mellitus. 

Diabetes Res Clin Pract 2006;72(3):271-6. 

 74. Rettig BA, Shrauger DG, Recker RR, et al. A 

randomized study of the effects of a home diabetes 

education program. Diabetes Care 1986;9(2):173-8. 

 75. Rowe AB. The use of biofeedback assisted 

relaxation training as a method to improve blood 

glucose control in type i diabetics [dissertation]. 

Cincinnati, OH: Union for Experimenting Colleges 

and Universities; 1986. 

 76. Schiel R, Muller U, Ulbrich S. Long-term efficacy 

of a 5-day structured teaching and treatment 

programme for intensified conventional insulin 

therapy and risk for severe hypoglycemia. Diabetes 

Res Clin Pract 1997;35(1):41-8. 

 77. Sheard CM. How effective is our advice to 

diabetics? A preliminary evaluation. Hum Nutr 

Appl Nutr 1984;38(2):138-41. 

 78. Sidorov J, Gabbay R, Harris R, et al. Disease 

management for diabetes mellitus: impact on 

hemoglobin A1c. Am J Manag Care 

2000;6(11):1217-26. 

 79. Simmons D. Diabetes self help facilitated by local 

diabetes research: The Coventry Asian Diabetes 

Support Group. Diabet Med 1992;9(9):866-9. 

 80. Simmons D, Gamble GD, Foote S, et al. The New 

Zealand Diabetes Passport Study: a randomized 

controlled trial of the impact of a diabetes passport 

on risk factors for diabetes-related complications. 

Diabet Med 2004;21(3):214-7. 

 81. Smith KE, Dickerson P, Saylor CF, et al. Issues of 

managing diabetes in children and adolescents: a 

multifamily group approach. Child Health Care 

1989;18(1):49-52. 

 82. Spiess K, Sachs G, Pietschmann P, et al. A program 

to reduce onset distress in unselected type-I 

diabetic-patients—effects on psychological 

variables and metabolic control. Eur J Endocrinol 

1995;132(5):580-6. 

 83. Starostina EG, Antsiferov M, Galstyan GR, et al. 

Effectiveness and cost-benefit analysis of intensive 

treatment and teaching programmes for Type 1 

(insulin-dependent) diabetes mellitus in Moscow–

blood glucose versus urine glucose self-monitoring. 

Diabetologia 1994;37(2):170-6. 

 84. Stegmayer P, Lovrien FC, Smith M, et al. 

Designing a diabetes nutrition education program 

for a Native American community. Diabetes Educ 

1988;14(1):64-6. 

 85. Sullivan ED, Joseph DH. University/community 

partnership to improve the lives of people with 

diabetes. Practical Diabetes International 

2000;17(1):26-30. 

 86. Sullivan ED, Joseph DH. University/community 

partnership to improve the lives of people with 

diabetes. Practical Diabetes International 

2000;17(1):26-30. 

 87. Sutherland JE, Hoehns JD, O'Donnell B, et al. 

Diabetes management quality improvement in a 

family practice residency program. J Am Board 

Fam Pract 2001;14(4):243-51. 

 88. Temple AJS. The effects of diabetes selfmanagement education on diabetes self-care, 

diabetes self-efficacy, and psychological adjustment 

to diabetes [dissertation]. New Orleans, LA: 

Louisiana State University Health Sciences Center 

School of Nursing; 2003. 

 89. Terent A, Hagfall O, Cederholm U. The effect of 

education and self-monitoring of blood glucose on 

glycosylated hemoglobin in type I diabetes. A 

controlled 18-month trial in a representative 

population. Acta Med Scand 1985;217(1):47-53. 

 90. The Diabetes Control and Complications Trial. 

Effect of intensive diabetes management on 

macrovascular events and risk factors in the 

Diabetes Control and Complications Trial. Am J 

Cardiol 1995;75(14):894-903. 

 91. The Diabetes Control and Complications Trial 

Research Group. Effect of intensive therapy on 

residual beta-cell function in patients with type 1 

diabetes in the diabetes control and complications 

trial. A randomized, controlled trial. Ann Intern 

Med 1998;128(7):517-23. 

 92. The Diabetes Control and Complications Trial 

Research Group. Hypoglycemia in the Diabetes 

Control and Complications Trial. Diabetes 

1997;46(2):271-86. 
D-12

 93. Thorell B, Olsson L, Svardsudd K. Implementation 

of a structured care programme for diabetes 

mellitus in a defined population in mid-Sweden. 

Diabet Med 1994;11(5):458-64. 

 94. Toth EL, James I. Description of a diabetes support 

group: lessons for diabetes caregivers. Diabet Med 

1992;9(8):773-8. 

 95. Turnin MC, Bolzonella PC, Dumoulin S, et al. 

[Multicenter evaluation of the Nutri-Expert 

Telematic System in diabetic patients]. Diabete 

Metab 1995;21(1):26-33. (Fre). 

 96. Uchigata Y, Asao K, Matsushima M, et al. Impact 

on mortality and incidence of end-stage renal 

disease of education and treatment at a diabetes 

center among patients with type 1 diabetes: 

comparison of two subgroups in the Japanese DERI 

cohort. J Diabetes Complications 2004;18(3):155-9. 

 97. Uddin I, Ahmad TJ, Kurkuman AR, et al. Diabetes 

education: its effects on glycemic control. Ann 

Saudi Med 2001;21(1-2):120-2. 

 98. Verlato G, Muggeo M, Bonora E, et al. Attending 

the diabetes center is associated with increased 5-

year survival probability of diabetic patients: The 

Verona Diabetes Study. Diabetes Care 

1996;19(3):211-3. 

 99. Viinamaki H, Niskanen L. Psychotherapy in 

patients with poorly controlled type 1 (insulindependent) diabetes. Psychother Psychosom 

1991;56(1-2):24-9. 

 100. Wdowik MJ, Kendall P, Harris M, et al. 

Development and evaluation of an intervention 

program: “Control on Campus.” Diabetes Educ 

2000;26(1):95-104. 

 101. Webb KL, Dobson AJ, O'Connell DL, et al. Dietary 

compliance among insulin-dependent diabetics. J 

Chronic Dis 1984;37(8):633-43. 

 102. Werdier D, Jesdinsky HJ, Helmich P. A 

randomized, controlled study on the effect of 

diabetes counseling in the offices of 12 general 

practitioners. Rev Epidemiol Sante Publique 

1984;32(3-4):225-9. 

 103. Whitlock WL, Brown A, Moore K, et al. 

Telemedicine improved diabetic management. Mil 

Med 2000;165(8):579-84. 

 104. Wilson E, Wardle EV, Chandel P, et al. Diabetes 

education: an Asian perspective. Diabet Med 

1993;10(2):177-80. 

 105. Wolever TM, Hamad S, Chiasson JL, et al. Day-today consistency in amount and source of 

carbohydrate associated with improved blood 

glucose control in type 1 diabetes. J Am Coll Nutr 

1999;18(3):242-7. 

 106. Yan C, Miao FY. Summer camps for diabetic 

children in Beijing of China. Indian J Pediatr 

1989;56(Suppl 1):S125-7. 

 107. Yong A, Power E, Gill G. Improving glycaemic 

control of insulin-treated diabetic patients—a 

structured audit of specialist nurse intervention. J 

Clin Nurs 2002;11(6):773-6. 

 108. Zador I, Meyer LJ, Scheets DR, et al. Hemoglobin 

A1c in obese children and adolescents who 

participated in a weight management program. Acta 

Paediatr 2006;95(1):105-7. 

.
D-13

Intervention 

For key questions pertaining to diabetes education programs, at least one of the following topics 

had to be included in the intervention: 1) diabetes disease process and treatment options; 2) nutritional 

management; 3) physical activity; 4) monitoring blood glucose, urine ketones (when appropriate), and 

using the results to improve control; 5) utilizing medications; 6) preventing, detecting, and treating acute 

complications; 7) preventing (through risk reduction behaviour), detecting, and treating chronic 

complications; 8) goal setting to promote health and problem solving for daily living; and 9) psychosocial 

adjustment. The control/comparison group could be no treatment or standard care. The following 13 

studies did not meet the inclusion criteria.

1. Achenbach P, Warncke K, Reiter J, et al. Type 1 

diabetes risk assessment: improvement by followup measurements in young islet autoantibodypositive relatives. Diabetologia 2006;49(12):2969-

76. 

 2. Campaigne BN, Gilliam TB, Spencer ML, et al. 

Effects of a physical activity program on metabolic 

control and cardiovascular fitness in children with 

insulin-dependent diabetes mellitus. Diabetes Care 

1984;7(1):57-62. 

 3. DiMeglio L, Pottorff TM, Boyd SR, et al. A 

randomized, controlled study of insulin pump 

therapy in diabetic preschoolers. J Pediatr 

2004;145(3):380-4. 

 4. Eastman BG, Johnson SB, Silverstein J, et al. 

Understanding of hypo- and hyperglycemia by 

youngsters with diabetes and their parents. J Pediatr 

Psychol 1983;8(3):229-43. 

 5. Lowes L. Specialist nursing. Evaluation of a 

paediatric diabetes specialist nurse post. Br J Nurs 

1997;6(11):625-6, 628-33. 

 6. Mortweet S, Robinson J, Howard C. What do you 

know? The impact of information on the 

management of type-1 diabetes in children 

[abstract]. Diabetes 2000;49(Suppl 1):A78. 

 7. Oliver CM, Johnston CC, Winkler SJ. Problemsolving and adjustment to life with diabetes among 

adolescents with insulin-dependent diabetes 

mellitus. In: King K, Prodrick E, Bauer B, eds. 

Proceedings of the 10th National Research 

Conference: Nursing Research: Science for Quality 

Care; 1985 April; Toronto, Ontario. Toronto, ON: 

University of Toronto; 1986. p. 329-32. 

 8. Rami B, Popow C, Horn W, et al. Telemedical 

support to improve glycemic control in adolescents 

with type 1 diabetes mellitus. Eur J Pediatr 

2006;165(10):701-5. 

 9. Stratton R, Wilson DP, Endres RK, et al. Improved 

glycemic control after supervised 8-wk exercise 

program in insulin-dependent diabetic adolescents. 

Diabetes Care 1987;10(5):589-93. 

 10. Vanelli M, Chiarelli F, Chiari G, et al. Metabolic 

control in children and adolescents with diabetes: 

experience of two Italian regional centers. J Pediatr 

Endocrinol Metab 1999;12(3):403-9. 

 11. Villagra VG, Ahmed T. Effectiveness of a disease 

management program for patients with diabetes. 

Health Aff (Millwood) 2004;23(4):255-66. 

 12. Whittemore RU, Tamborlane RD, William V, et al. 

Quality of life in school-aged children with type 1 

diabetes on intensive treatment and their parents. 

Diabetes Educ 2003;29(5):847-54. 

 13. Wolters C, Yu SL, Hagen JW, et al. Short-term 

memory and strategy use in children with insulindependent diabetes mellitus. J Consult Clin Psychol 

1996;64(6):1397-405.
D-14

Ongoing 

The following three studies were not yet completed and no outcome data were available. 

1. Muir AB, Geffken GR, McKnight M, et al. Feasibility 

of computer assisted training (CAT) in families of 

newly diagnosed type I diabetes [abstract]. Diabetes 

2004;53(Suppl 2):A225. 

 2. Streisand R, Hilliard M, Mednick L, et al. Preliminary 

results of an RCT to prevent nonadherence among 

preadolescents with T1 diabetes [web page]. Available 

at: http://professional.diabetes.org/ 

Abstracts_Display.aspx?TYP=1&CID=48746. 

Accessed 2007. 

 3. Streisand R, Mednick L. Development of the diabetes 

education, counseling, information delivery and 

evaluation (DECIDE) program: a health promotion 

intervention for preadolescents with type 1 diabetes. J 

Clin Psychol Med Settings 2006;13(2):180-90. 
D-15

Outcome 

Studies were included if they reported the following outcomes: metabolic control (as measured by 

HbA1c), hospitalization, ED utilization, short term complications (e.g., diabetic ketoacidosis, episodes of 

hypoglycemia), long term complications (retinal, renal, cardiovascular, neurological), quality of life; 

school attendance and performance, self confidence in ability to cope with disease, or psychosocial 

outcomes. The following 14 studies did not report any of the appropriate outcomes or reported lifestyle 

outcomes (e.g., smoking, use of recreational drugs, participation in extracurricular activities). 

 1. Aoki N, Ohta S, Okada T, et al. INSULOT: a 

cellular phone-based edutainment learning tool for 

children with type 1 diabetes. Diabetes Care 

2005;28(3):760. 

 2. Can G, Okten A, Kaya G. The effects of the local 

camps on children with type I diabetes mellitus. 

Annals of Medical Sciences 2001;10(2):68-70. 

 3. Daley B. The use of activities in the approach to 

non-compliance in the treatment of juvenile 

diabetes. Int J Adolesc Med Health 1985;1(3-

4):255-63. 

 4. Deris-Atassi S. A program design for Hispanic 

caregivers of children with newly diagnosed type 1 

diabetes mellitus [dissertation]. Miami, FL: Carlos 

Albizu University; 2002. 

 5. Krause ER. Influence of self-monitoring and visual 

discrimination training on children's accuracy in 

blood glucose monitoring (diabetes, teaching 

straegies, error analysis) [dissertation]. Denver, CO: 

University of Denver; 1984. 

 6. Lavalle F, De la Garza N, Martinez I, et al. 

Forgetfulness curve, exposure to an educational 

program for youths with type 1 diabetes [abstract]. 

Diabetes 1998;47(Suppl 1):A382. 

 7. Malasanos TH, Burlingame JB, Youngblade L, et 

al. Improved access to subspecialist diabetes care 

by telemedicine: cost savings and care measures in 

the first two years of the FITE diabetes project. J 

Telemed Telecare 2005;11(Suppl 1):74-6. 

 8. Nurick M, Johnson SB. Enhancing blood glucose 

awareness in adolescents and young adults with 

IDDM. Diabetes Care 1991;14(1):1-7. 

 9. Razeghi S, Renner C, Schafer S, et al. Project D: 

computer-mediated communication as a tool for 

self-help in children and adolescents with diabetes. 

Diabetes Educ 1998;24(5):577-80. 

 10. Salvatoni A, Pompili V, Biasoli R, et al. 

[“Governare il diabete” (“to steer diabetes”): a new 

proposal for diabetic camps]. Acta Biomed Ateneo 

Parmense 2003;74(Suppl 1):29-31. (Ital). 

 11. Silverstein JH, Bandyopadhyay R. Camping with a 

friend. Helping adolescents cope with diabetes. J 

Fla Med Assoc 1995;82(12):817-20. 

 12. Solowiejczyk J. The family approach to diabetes 

management: theory into practice toward the 

development of a new paradigm. Diabetes Spectrum 

2004;17(1):31-6. 

 13. Wangberg SC, Arsand E, Andersson N. Diabetes 

education via mobile text messaging. J Telemed 

Telecare 2006;12(Suppl 1):55-6. 

 14. Waszak LC. The effects of parent education on 

adherence and metabolic control of children with 

insulin-dependent diabetes mellitus [dissertation]. 

Pittsburgh, PA: University of Pittsburgh; 1987.
D-16

Reporting 

The following 37 studies were excluded because they did not provide a description of the 

intervention that was sufficient to reproduce it, or they did not provide measurable data for 

outcomes relevant to this review. 

1. Ahern J, Ramchandani N, Cooper J, et al. Using a 

primary nurse manager to implement DCCT 

recommendations in a large pediatric program. 

Diabetes Educ 2000;26(6):990-4. 

 2. Arraya G, Trave D, Benavent M. [The influence of 

education for metabolic control in infant-youth 

diabetes patients]. Revista ROL de Enfermeria 

1998;21(235):51-4. (Span). 

 3. Auslander WF. Brief family interventions to 

improve family communication and co-operation 

regarding diabetes management. Diabetes Spectrum 

1993;6:330-3. 

 4. Basso R. A structured-fantasy group experience in a 

children's diabetic education program. Patient Educ 

Couns 1991;18(3):243-51. 

 5. Codner DE, Mericq GV, Garcia BH, et al. Results 

of a multidisciplinary and intensified treatment 

program for type 1 diabetes mellitus in a Chilean 

public hospital. Rev Med Chil 2003;131(8):857-64. 

 6. Dammacco F, Torelli C, Frezza E, et al. Computer 

based instruction of diabetic children and 

adolescents. Techniques and results. J Endocrinol 

Invest 1989;12(8 suppl 3):141-2. 

 7. Delamater AM, Smith J, Kurtz SM, et al. Dietary 

skills and adherence in children with type I diabetes 

mellitus. Diabetes Educ 1988;14(1):33-6. 

 8. Follansbee DJ , Lagreca AM, Citrin WS. Coping 

skills training for adolescents with diabetes 

[abstract]. Diabetes 1983;32(Suppl 1):A37. 

 9. Hansson K, Ryden O, Johnsson P. Parent-rated 

family climate: a concomitant to metabolic control 

in juvenile IDDM. Fam Syst Med 1994;12(4):405-

13. 

 10. Hardway D, Weatherly KS, Bonheur B. Diabetes 

education on wheels. J Nurs Staff Dev 

1993;9(3):122-6. 

 11. Hedbrant J, Ludvigsson J. Use of computer 

simulator training in the education of diabetic 

teenagers. Practical Diabetes International 

1995;12(1):18-21. 

 12. Heidgerken AD, Adkins J, Storch E, et al. 

Telehealth intervention for adolescents with type 1 

diabetes. J Pediatr 2006;148(5):707-8. 

 13. Hunter HL, Rosnov DL, Koontz D, et al. Camping 

programs for children with chronic illness as a 

modality for recreation, treatment, and evaluation: 

an example of a mission-based program evaluation 

of a diabetes camp. J Clin Psychol Med Settings 

2006;13(1):67-80. 

 14. Jones E, Murphy LG. The efficacy of intensive 

individual play therapy for chronically ill children. 

International Journal of Play Therapy 

2002;11(1):117-40 . 

 15. Kaufman FR, Costin G, Roe TF, et al. The efficacy 

of a residential-treatment program (RTP) for 

childhood diabetes-mellitus (JDM) [abstract]. 

Diabetes 1986;35(Suppl 1):A79. 

 16. Keeter EL, Linehan MS. Affecting children's 

attitudes toward diabetes through camp. Nurse Pract 

1993;18 (8):25-6. 

 17. Kieren DK, Hurlbut NL, Looney T, et al. Designing 

a family problem solving training program with an 

adolescent diabetic. Paper presented at the 

Conference of the National Council on Family 

Relations; 1987 November 3-7; Atlanta, GA. 

 18. Knight KM, Bundy C, Morris R, et al. The effects 

of group motivational interviewing and 

externalizing conversations for adolescents with 

type-1 diabetes. Psychol Health Med 

2003;8(2):149-57. 

 19. Koplatadze K, Koplatadze M, Kacharava L, et al. 

Diabetes camps: an international experience. Mo 

Med 2003;100(2):145-7. 

 20. Kurmacheva N, Svinaryov MY, Kireev R, et al. 

Self-control teaching and its influence on insulindependent diabetes mellitus complications 

incidence in children [abstract]. Diabetes Nutr 

Metab 1999;12(3):229. 

 21. Lorini R, Ciriaco O, Salvatoni A, et al. The 

influence of dietary education in diabetic children. 

Diabetes Res Clin Pract 1990;9(3):279-85. 
D-17

 22. MacDonald MJ , Kerouz N, Hayek R, et al. Early 

referral of children with IDDM to a specialized 

program correlates with better long-term metabolic 

control. Diabetes Care 1993;16(9):1310-1. 

 23. Malasanos TH , Patel BD, Stein JM, et al. FITE 

Diabetes: improved access to sub-specialist care by 

telemedicine; no detrimental effect on A1c over 3 

years [web page]. 2006; Available at: 

http://scientificsessions.diabetes.org/Abstracts/ 

index.cfm?fuseaction=Locator.SearchAbstracts. 

Accessed 2007. 

 24. Maryniuk MD, Kauwell GPA, Thomas RG. A test 

of instructional approaches designed to influence 

food selection...children and adolescents with 

diabetes. Diabetes Educ 1986;12(1):34-6. 

 25. McKelvey J, Borgersen M. Family development 

and the use of diabetes groups: experience with a 

model approach. Patient Educ Couns 

1990;16(1):61-7. 

 26. Misuraca A, Di Gennaro M, Lioniello M, et al. 

Summer camps for diabetic children: an experience 

in Campania, Italy. Diabetes Res Clin Pract 

1996;32(1-2):91-6. 

 27. Nordfeldt S, Ludvigsson J. Prevention of severe 

hypoglycaemia in type 1 diabetes children. A 

prospective intervention study 1995-98 [abstract]. 

Diabetologia 1999;42(Suppl 1):A256. 

 28. Opipari AL, Kichler J, Fredericks E, et al. The Kids 

Project: medical and psychosocial outcomes of an 

intervention to kick in diabetes support for 

economically disadvantaged adolescents with type 1 

diabetes mellitus [abstract]. Pediatr Res 

2004;55(4):137A. 

 29. Scharf LS. Efficacy of diabetes camp in improving 

psychological adjustment of adolescents 

[dissertation]. Detroit, MI: Wayne State University; 

1985. 

 30. Shaltout A, Qabazard M, Khawari M, et al. 

Towards improving care for children with diabetes 

in Kuwait. Int J Health Care Qual Assur 

1995;8(7):4-8. 

 31. Spevack M, Johnson S, Bennett R, et al. The effect 

of diabetes summer camp on adherence behaviors 

and glycemic control. In: Johnson JH, Johnson SB, 

eds. In: Advances in child health psychology. 

Gainesville, FL: J Hillis Miller Health Science 

Center; 1991. p. 285-92. 

 32. Stinchfield PA. Evaluation of an education program 

for Type I diabetics [dissertation]. Salt Lake City, 

UT: University of Utah College of Nursing; 1987. 

 33. Strickland BR. Management of diabetic children by 

behavior-modification and blood-glucose 

monitoring [abstract]. Drug Intell Clin Pharm 

1983;17(6):438. 

 34. von Sengbusch S, Wagner V, Muller GE, et al. 

[Mobile Diabetes Education Programme SchleswigHolstein (Mdsh). A new training concept and model 

for diabetes care for children and adolescents with 

type 1 diabetes and its effects on the family burden]. 

Kindheit Und Entwicklung 2005;14(2):96-102. 

(Ger). 

 35. Weist MD, Finney JW, Barnard MU, et al. 

Empirical selection of psychosocial treatment 

targets for children and adolescents with diabetes. J 

Pediatr Psychol 1993;18(1):11-28. 

 36. Zhou YH, Lin CL, Zhou M, et al. [Interventional 

effect of cognitive education on the quality of life in 

227 patients with diabetes mellitus from 4 hospitals 

in Meizhou city.] Chinese Journal of Clinical 

Rehabilitation [Zhongguo Linchuang Kangfu] 

2005;9(24):40-1. (Chinese). 

 37. Zimmerman E, Carter MC, Sears JH, et al. Diabetic 

camping: effect on knowledge, attitude, and selfconcept. Issues Compr Pediatr Nurs 1987;10(2):99-

111. 
D-18

Small Sample Size (n≤10) 

The following nine studies were excluded because there were < 10 participants enrolled in the 

study. 

1. Albrecht SJ. Increasing blood glucose monitoring in 

adolescents with type 1 diabetes: effects of a prompt 

[dissertation]. Kalamazoo, MI: Western Michigan 

University; 2005. 

 2. Hains A, Davies WH, Parton E, et al. Brief report: a 

cognitive behavioral intervention for distressed 

adolescents with type I diabetes. J Pediatr Psychol 

2001;26(1):61-6. 

 3. Hains AA, Davies W, Hobart P, et al. A cognitive 

behavioral intervention for distressed adolescents with 

Type I diabetes. J Pediatr Psychol 2001;26(1):61-6. 

 4. Lasecki KL. Normalizing blood glucose levels in 

children with type I diabetes: mystery motivators used 

within the context of behavioral consultation models 

[dissertation]. Salt Lake City, UT: University of Utah; 

2000. 

 5. Marrero DG, Fremion AS, Golden MP. Improving 

compliance with exercise in adolescents with insulindependent diabetes mellitus: results of a selfmotivated home exercise program. Pediatrics 

1988;81(4):519-25. 

 6. Oksol EM. A treatment development study: a 

preliminary analysis of a new treatment for parents of 

diabetic children in poor glycemic control 

[dissertation]. Reno, NV: University of Nevada; 2004. 

 7. Rose MI, Firestone P, Heick HM, et al. The effects of 

anxiety management training on the control of 

juvenile diabetes mellitus. J Behav Med 

1983;6(4):381-95. 

 8. Silverman AH. Increasing regimen adherence in 

adolescents with type I diabetes [dissertation]. 

Milwaukee, WI: University of Wisconsin; 2002. 

 9. Silverman AH, Hains A, Davies WH, et al. A 

cognitive behavioral adherence intervention for 

adolescents with type 1 diabetes. J Clin Psychol Med 

Settings 2003;10(2):119-27. 
D-19

Studies Unavailable 

The following 46 studies were requested through our interlibrary loan service but did not arrive 

within the 7-month cut-off that we established for article retrieval.
D-20

 1. Diabetes program teaches kids to be case managers. Dis State Manag 1997;3(11):138-40. 

 2. Ambrosino J, Fennie K, Hendrickson K, et al. Coping skills training with parents of school-aged youth with 

type 1 diabetes (T1d) improves family functioning [abstract]. Diabetes 2005;54(Suppl 1):A18. 

 3. Assaad-Khalil SH, El Siwy F, Kamel KF, et al. Impact of an educational video film: “The Jinn's Party” on the 

knowledge, practices and attitudes of school children and adolescents with type 1 diabetes and their parents. 

Diabetologia 2003;46(Suppl 2):A91. 

 4. Bartus B, Hecker W. Age-adapted hypoglycemia awareness training for children and adolescents with insulindependent diabetes-mellitus (Iddm) [abstract]. Diabetologia 1994;37(Suppl 1):A19. 

 5. Bellando BJ. Changes in short-term and long-term control of diabetes after participation in Blood Glucose 

Awareness Training [dissertation]. Lubbock, TX: Texas Tech University; 1989. 

 6. British Diabetic Association. Education and Professional Care Section and Medical and Scientific Section 1995 

Oct 4-6; Harrogate. Diabet Med 1995;12(10 Number Sup 2):S1-56. 

 7. British Diabetic Association. Education and Professional Care section annual conference 1994 Sep 7-9 and 

Medical and Scientific Section autumn meeting 1994 Sep 8-9; Lancaster. 1994;11(Suppl 2):S1-51. 

 8. British Dietetic Association. Conference of the Community Nutrition Group and Health Education Authority; 

1991 March; London. In: Hurren CA, Black AE, eds. The food network: achieving a healthy diet by the year 

2000. London: Smith-Gordon; 1991. 

 9. Campaigne B. The effects of a physical activity program on children ages 5 to 11 years with insulin-dependent 

diabetes mellitus [dissertation]. Ann Arbor, MI: University of Michigan; 1982. 

 10. Charron Prochownik D, Becker D, Sereika S, et al. The impact of a newly developed CD-ROM reproductive 

health education program on teens with diabetes [abstract]. Diabetes 2001;50(Suppl 2):A25-A26. 

 11. Clawson E, Kade D, Dickens M. Efficacy of a rehabilitation program for children and adolescents who are 

chronically noncompliant with diabetes management [abstract]. Diabetes 1996;45(Suppl 2):38. 

 12. Cook S, McNabb WL. Problem-solving program for adolescents with diabetes: choices [abstract]. Diabetes 

1999;48(Suppl 2):A158. 

 13. Dammacco F, Frezza E, Torelli C, et al. Computerized mastery learning instruction of diabetic children 

[abstract]. Diabetologia 1984;27(2):A266-A267. 

 14. Etzwiler DD. Education and participation of patients and their families. Pediatr Ann 1983;12(9):638-40,642. 

 15. Fekete D, Guare J, Marrero D, et al. Self-management of ''off diet'' food intake by adolescents and young adults 

with insulin-dependent diabetes mellitus (Iddm). Diabetes 1997;46(Suppl 1):1016. 

 16. Follansbee DJ. Coping skills training for adolescents with insulin dependent diabetes mellitus [dissertation]. 

Miami, FL: University of Miami; 1984. 

 17. Franzen I, Ludvigsson J. Specific instructions gave reduction of lipomas and improved metabolic control in 

diabetic children [abstract]. Diabetologia 1997;40(Suppl 1):2421. 

 18. Furman SG. The effect of assertiveness training on locus of control and metabolic control of adolescents with 

diabetes mellitus [dissertation]. Ft. Lauderdale, FL: Nova University School of Psychology; 1983. 

 19. George C. Video in pediatric patient education: the role of formal features in the relationship of intervention, 

knowledge, and anxiety [dissertation]. Austin, TX: University of Texas at Austin; 1991. 

 20. Gordeladze MR, Marinashvili N. Differential diabetes education program for children and adolescents its role 

and results [abstract]. Diabetologia 2002 ;45(Suppl 2):A19-A20. 
D-21

 21. Halvorson M, Kaufman FR, Carpenter S. Evaluation of a comprehensive childhood diabetes program with 

intensive management [abstract]. Diabetes 1996;45(Suppl 2):532. 

 22. Halvorson MJ, Kaufman FR, Engilman R. Comparison of a diabetes Cd-Rom program, diabetes video game 

and diabetes kids class in diabetes management and knowledge acquisiton in children ages 5-10 with type 1 

diabetes [abstract]. Diabetes 1999;48(Suppl 1):A73. 

 23. Harris R. Diabetic teddies help children to learn. ACCNS Journal for Community Nurses 2003;8(2):6. 

 24. Hayes JR. Controlling glucose levels of adolescents with diabetes through the use of a voice processing system 

[dissertation]. Columbus, OH: Ohio State University; 1996. 

 25. Howells L. Telephone support to improve outcomes in young people. Journal of Diabetes Nursing 

2001;5(3):94. 

 26. Huttunen NP, Lankela SL, Knip M, et al. Effect of a once-a-week training-program on physical-fitness and 

metabolic control of diabetes in children with type-1 diabetes [abstract]. Acta Endocrinol (Copenh) 

1987;115(Suppl 282):23. 

 27. International Society for Pediatric and Adolescent Diabetes. 6th ISPAD Workshop: controversial issues in 

childhood and adolescent diabetes mellitus; 1997 April; Garda, Italy. In: Journal of Pediatric Endocrinology and 

Metabolism, Laron Z, Pinelli L. eds.; Tel Aviv, Israel: Freund Publishing House; 1998. 

 28. Kaufman V. The effect of educational and psychological programs on metabolic management and glycemic 

control in diabetes mellitus [dissertation]. San Diego, CA: California School of Professional Psychology—San 

Diego; 1987. 

 29. Levine BS, Anderson B, Butler D, et al. Care Ambassador (CA) intervention reduces costly adverse outcomes 

in youth with type 1 diabetes: a randomized, controlled trial [abstract]. Diabetes 2000;49(Suppl 1):A220-A221. 

 30. Marrero DG. Adjustment to misfortune: an intervention program to improve metabolic stability of insulin 

dependent diabetes mellitus in adolescents [dissertation]. Irvine, CA: University of California, Irvine; 1983. 

 31. Morimoto M, Fukumoto H, Kawabata E. Family education program for the hospitalized diabetic patients 

[abstract]. Diabetologia 1997;40(Suppl 1):2419. 

 32. Murkin SA, Snyder GM, Pichert JW, et al. Anchored instruction enhances diabetes problem solving. Diabetes 

Care 1990;39:8. 

 33. Okoawo IJ. Diabetic education and follow-up program: test of a model [dissertation]. Boston, MA: Boston 

University; 1984. 

 34. Opipari AL, Kichler J, Fredericks E, et al. Self-management intervention improves diabetes-related functioning 

in at-risk adolescents with type 1 diabetes [abstract]. Diabetes 2005;54(Suppl 1):A455. 

 35. Pyorala E. Interaction strategies in dietary counselling of diabetic children [abstract]. Diabetologia 

1997;40(Suppl 1):45. 

 36. Rajab A, Sadegian HA. The effect of home visiting program on blood glucose control in diabetic children in 

Iran [abstract]. Diabetologia 1997;40(Suppl 1):2395. 

 37. Rami B, Schober E, Popow C, et al. Vie-Diab: telemedical support programme for adolescents with type 1 

diabetes mellitus [abstract]. Diabetologia 2004;47(Suppl 1):A348. 

 38. Schiel R, Perenthaler TJ, Kovar F, et al. Metabolic control and interactions with diabetes-related knowledge, 

motivational problems and technical devices in children and adolescents with type 1 diabetes mellitus—

DIDOM, an intervention trial [abstract]. Diabetologia 2005;48:A326-A327. 

 39. Sharma A. Diabetes prevention, education and treatment. International Journal of Diabetes 1994;2(3). 
D-22

 40. Sheldon AW. Computer-assisted diet and exercise training in the behavioral treatment of Type I diabetes 

[dissertation]. Miami, FL: University of Miami; 1996. 

 41. Silverman AH , Opipari ALC, Lang SW, et al. Intensive therapy and self-management training in pediatric 

medicaid patients with IDDM: perceptions of adolescents, parents and physicians [abstract]. Pediatr Res 

2002;51(4):124A. 

 42. Sperlich SB. A diabetic camp: its implications for coping with juvenile diabetes mellitus [dissertation]. 

Washington, DC: The Catholic University of America; 1982. 

 43. Stinchfield PA. Evaluation of an education program for type 1 diabetes [dissertation]. Salt Lake City, Ut: 

University of Utah College of Nursing; 1987. 

 44. Szumowski EK. A family-oriented developmental and behavioral intervention to increase adherence by diabetic 

children to their treatment regimens [dissertation]. Pittsburgh, PA: University of Pittsburgh; 1991. 

 45. Tomasi F, Miselli V. Continuing and reinforcing patient education and metabolic control after a summer camp 

for diabetic children [abstract]. Diabetologia 1989;32(7):A548. 

 46. Wysocki T, Greco P, Harris M, et al. Behavior therapy for families of adolescents with Iddm: maintenance of 

treatment effects [abstract]. Diabetes 1997;46(Suppl 1):351. 
E-1

Appendix E. Secondary Studies 

Table E1. Description of secondary studies 

Primary report: 

Anderson BJ, Brackett J, Ho J, et al. An office-based intervention to maintain parent-adolescent teamwork in diabetes 

management. Impact on parent involvement, family conflict, and subsequent glycemic control. Diabetes Care 

1999;22(5):713-21. 

Associated publications: 

Anderson BJ, Brackett J, Ho J, et al. An intervention to promote family teamwork in diabetes management tasks: 

relationships among parental involvement, adherence to blood glucose monitoring, and glycemic control in young 

adolescents with type 1 diabetes. In: Drotar D ed. Promoting adherence to medical treatment in chronic childhood illness: 

concepts, methods, and interventions. Mahwah, NJ: Lawrence Erlbaum Associates Publishers; 2000. p. 347-65. 

Primary report: 

Anderson BJ, Wolf FM, Burkhart MT, et al. Effect of peer-group intervention on metabolic 

control of adolescents with IDDM. Randomized outpatient study. Diabetes Care 1989;12(3):179-83. 

Associated publications: 

Anderson BJ, Burkhart M, Tomlin P, et al. Behavioral and metabolic effects of a controlled self-efficacy group intervention 

with diabetic adolescents. Diabetes 1986;35(Suppl 1):A78. 

Primary report: 

Brown SJ, Lieberman D, Germeny B, et al. Educational video game for juvenile diabetes: results of a controlled trial. Med 

Inform (Lond) 1997;22(1):77-89. 

Associated publications: 

Lieberman DA. Health education video games for children and adolescents: theory, design, and research findings. Paper 

presented at the 48th Annual Meeting of the International Communication Association; 1998 July 20-24; Jerusalem, Israel. 

Primary report: 

Grey M, Boland E, Davidson, et al. Coping skills training for youth with diabetes mellitus has long-lasting effects on 

metabolic control and quality of life J Pediatr 2000;137:107-03. 

Associated publications: 

Grey M, Yu C, Boland E, et al. Short-term effects of coping skills training as adjunct to intensive therapy in adolescents. 

Diabetes Care 1998;21:902-08.

Primary report: 

Hackett AF, Court S, Matthews JNS, et al. Do education groups help diabetics and their parents. Arch Dis Child 

1989;64(7):977-1003. 

Associated publications: 

Hackett A. Food intake of children with diabetes mellitus before and after a programme of education [dissertation]. United 

Kingdom: University of Newcastle Upon Tyne; 1987. 
E-2

Table E1. Description of secondary studies (continued) 

Primary report: 

Harris M, Harris BS, Mertlich D. Brief report: in-home family therapy for adolescents with poorly controlled diabetes: 

failure to maintain benefits at 6-month follow-up. J Pediatr Psychol 2005;30(8):683-8. 

Associated publications: 

Harris M, Mertlich D. Piloting home-based behavioral family systems therapy for adolescents with poorly controlled 

diabetes. Child Health Care 2003;32(1):65-79. 

Primary report: 

Hoff AL, Mullins LL, Gillaspy SR, et al. An intervention to decrease uncertainly and distress among parents of children 

newly diagnosed with diabetes: a pilot study. Fam Syst Health 2005;23(3):329-42. 

Associated publications: 

Hoff AL. An intervention to decrease illness uncertainty and psychological distress among parents of children newly 

diagnosed with type 1 diabetes: a randomized clinical trial [dissertation]. Oklahoma: Oklahoma State University; 2003. 

Primary report: 

Laffel LMB, Vangsness L, Connell A, et al. Impact of ambulatory family-focused teamwork intervention on glycemic 

control in youth with type 1 diabetes. J Pediatr 2003;142(4):409-16. 

Associated publications: 

Butler D, Volkening LK, Milaszewski K, et al. Family-focused teamwork intervention for youth with type 1 diabetes 

(T1DM) positively impacts A1c and quality of life (QoL): results of a 2-year randomized controlled trial. Diabetes 

2006;55:A421-A421. 

Laffel LMB, Connell AJ, Vangsness LJ, et al. Family-focused ambulatory teamwork (TW) intervention improves a1c 

compared with standard care (SC) in youth with type 1 diabetes (T1DM): results of a randomized trial. Diabetes 

2002;51:A424. 

Primary report: 

Nordfeldt S Johansson C Carlsson E Hammersjo J. Persistent effects of a pedagogical device targeted at prevention of 

severe hypoglycaemia: a randomized, controlled study. Acta Paediatrica 2005;94(10):1395-401. 

Associated publications:

Nordfeldt S, Johansson C, Carlsson E, et al. Prevention of severe hypoglycaemia in type I diabetes: a randomised controlled 

population study. Arch Dis Child 2003;88(3):240-5. 

Primary report: 

Siminerio LM , Charron PD, Banion C, et al. Comparing outpatient and inpatient diabetes education for newly diagnosed 

pediatric patients. Diabetes Educator 1999;25(6):895-906. 

Associated publications: 

Siminerio LM. Comparing outpatient to inpatient diabetes education for newly diagnosed pediatric patients: an exploratory 

study [dissertation]. Pennsylvania: Pennsylvania State University; 1998. 
E-3

Table E1. Description of secondary studies (continued) 

Primary report: 

Wysocki T, Harris M, Greco P, et al. Randomized, controlled trial of behavior therapy for families of adolescents with 

insulin-dependent diabetes mellitus. J Pediatr Psychol 2000;25(1):23-33. 

Associated publications: 

Harris M, Greco P, Wysocki T, et al. Family therapy with adolescents with diabetes: a litmus test for clinically meaningful 

change. Fam Syst Health 2001;19:159-68. 

Wysocki T, Greco P, Harris M, et al. Behavior therapy for families of adolescents with diabetes: maintenance of treatment 

effects. Diabetes Care 2001;24:441-6. 

Wysocki T, Greco P, Harris MA, et al. Behavioral Family Systems Therapy for adolescents with diabetes. In: Drotar D ed. 

Promoting adherence to medical treatment in chronic childhood illness: concepts, methods, and interventions. Mahwah, NJ: 

Lawrence Erlbaum Associates Publishers; 2000. p. 367-81. 

Wysocki T, Miller KM, Greco P, et al. Behavior therapy for families of adolescents with diabetes: effects on directly 

observed family interactions. Behav Ther 1999;30(3):507-25. 

Primary report: 

Wadham C, Hassler Hurst J, Almond J, et al. Integrating group education into paediatric diabetes care: FACTS. J Diabetes 

Nurs 2005;9(6):221-5. 

Associated publications: 

Murphy HR, Wadham C, Rayman G, et al. Integrating pediatric diabetes education into routine clinical care: 

The Families, Adolescents and Children's Teamwork Study (FACTS). Diabetes Care 2006;29(5):1177. 

Primary report: 

Sundelin J, Forsander G, Mattson SE. Family-oriented support at the onset of diabetes mellitus: a comparison of two group 

conditions during 2 years following diagnosis. Acta Paediatrica 1996;85:49-55. 

Associated publications: 

Forsander G, Malmodin B, Eklund C, et al. Relationship between dietary intake in children with diabetes mellitus type I, 

their management at diagnosis, social factors, anthropometry and glycaemic control. Scand J Nutrition/Naringsforskning 

2003;47(2):75-84. 

Forsander G, Persson B, Sundelin J, et al. Metabolic control in children with insulin-dependent diabetes mellitus 5 y after 

diagnosis. Early detection of patients at risk for poor metabolic control. Acta Paediatrica 1998;87(8):857-64. 
 E-4 

Table E1. Description of secondary studies (continued) 

Primary report: 

Wysocki T, Harris MA, Buckloh LM, et al. Randomized trial of behavioral family systems therapy for diabetes: 

maintenance of effects on diabetes outcomes in adolescents. Diabetes Care 2007;30(3):555-60. 

Associated publications:

Wysocki T, Harris MA, Buckloh LM, et al. Effects of behavioral family systems therapy for diabetes on adolescents' family 

relationships, treatment adherence, and metabolic control. J Pediatr Psychol 2006;31(9):928-38. 

Wysocki T, Harris MA, Buckloh LM, et al. Effects of behavioral family systems therapy on adolescents' diabetes outcomes. 

Diabetes 2005;54(Suppl 1):A19. 
F-1

Appendix F. Evidence Tables Table F1. Characteristics of study population and study setting in studies assessing the effectiveness of diabetes education fo

type 1 diabetes and their families 

Author Year Sample Size (n) 

Study Design 

Location 

Age, Mean±SD 

% Male 

Duration of Diabetes, 

Mean±SD 

HbA1c at Baseline, 

Mean±SD 

Other Characteristics 

Anderson5 1999 89 

RCT (parallel) United States 

IG1 12.7 yr. ±1.40 50% IG2 12.7 yr. ±1.40 50% CG 12.5 yr. ±1.4 52% 

IG1 5.3 yr. ±2.56 8.3%±1.10 IG2 6.1 yr. ±2.78 8.7%±1.19 CG 5.2 yr. ±2.17 8.6%±0.97 

Duration of diabetes >1 yr. IG1 – 

respoIG2 – educaCG – Diabe

Anderson6 1989 70 

RCT (parallel) United States 

IG 12.9 yr. 46.7% CG12.5 yr. 46.7% 

IG 4.9 yr. ±3.2 10.47%±2.30 CG 5.1 yr. ±3.3 10.42%±1.9

Duration of diabetes >1 yr. IG – S

skills, CG – Clinic 

Barglow7 1983 42 

CCT United States 

IG 13.4 yr. ±3.3 43% CG12.2 yr. ±2.5 24% 

IG 4.9 yr. ±3.8 12.2%±2.3 CG 3.2 yr. ±3.0 12.1%±3.5

IG – ICG – Diabe

Boardway8 1993 31 

RCT (parallel) United States 

IG 15.44 yr. ±1.19 22.2% CG14.32 yr. ±1.71 60.0% 

IG 6.92 yr. ±5.79 13.99%±2.41 CG 6.34 yr. ±2.61 15.74%±3.57

Noncompliance and/or poor 

metabolic control 

IG – Splus sskills CG – Outpa

CG = control group; IG = intervention group; NR = not reported; TG = total group 
F-2

Table F1. Characteristics of study population and study setting in studies assessing the effectiveness of diabetes education fo

1 diabetes and their families (continued) 

Author Year Sample Size (n) 

Study Design 

Location 

Age, Mean±SD 

% Male 

Duration of Diabetes, 

Mean±SD 

HbA1c at Baseline, 

Mean±SD 

Other Characteristics 

Brown9 1997 59 

RCT (parallel) United States 

IG NR CGNR 

IG NR 8.47%±1.64 CG NR 8.28%±1.89

Duration of diabetes >3 mo. IG – D

CG – Home 

Campaigne10 1985 16 

RCT (parallel) United States 

IG 16.0 yr. ±3 33.3% CG 15.0 yr. ±0.9 60.0% 

IG 6.6 yr. ±3.3 12.0%±3.0 CG6.2 yr. ±2.5 12.0%±2.2 

IG – ECG – NR 

Caravalho11 2000 56 

Uncontrolled beforeand-after study United States 

IG 9.8 yr. 45% 

IG 3 yr. 9.15%±2.32 

IG – Sskills, assesHome

Christensen12 2000 68 

Uncontrolled beforeand-after study United States 

IG NR 47.1% 

IG 5.04 yr. 9.6% 

IG – NCamp 

Cigrang13 1991 37 

RCT (parallel) United States 

IG1 14.6 yr. ±1.6 46.7% IG2 13.5 yr. ±1.7 30.8% CG 13.9 yr. ±1.4 55.6% 

IG1 4.9 yr. ±2.9 9.07%±0.88 IG2 4.5 yr. ±2.9 9.92%±2.2 CG 6.7 yr. ±3.5 8.91%±1.2

Poor metabolic control IG1 – 

strateIG2 – CG – Hosp
F-3

Table F1. Characteristics of study population and study setting in studies assessing the effectiveness of diabetes education fo

1 diabetes and their families (continued) 

Author Year Sample Size (n) 

Study Design 

Location 

Age, Mean±SD 

% Male 

Duration of Diabetes, 

Mean±SD 

HbA1c at Baseline, 

Mean±SD 

Other Characteristics 

Couper14 1999 69 

CCT Australia 

IG 14.2 yr. ±1.7 48.6% CG 14.3 yr. ±1.9 31.3% 

IG 7.08 yr. ±3.6 11.1%±1.3 CG 5.83 yr. ±3.0 10.5%±1.6 

Poor metabolic control IG – G

CG – Hosp

Coupland15 1992 32 

RCT (parallel) Canada 

IG 14.5 yr. ±1.41 53% CG14.7 yr. ±1.75 33% 

IG 4.80 yr. ±2.59 11.6%±1.4 CG 6.64 yr. ±3.02 11.3%±1.22 

Noncompliance and/or poor metabolic control 

IG – GknowadherCG – knowNR 

Delamater16 1991 13 

RCT (parallel) United States 

IG1 NR 33% CG NR 57% TG14.9 yr. 46% 

IG NR CG NR TG 6.5 yr. range: 2.5–15 yr. 10.9%±1.6

Noncompliance and/or poor metabolic control 

IG – Sskills, CG – Hosp

Delamater17 1990 36 

RCT (parallel) United States 

IG1 9.3 yr. ±3.9 58% IG2 8.6 yr. ±4.1 50% CG 9.8 yr. ±2.6 50% 

IG1 < 4 mo. 10.4%±3.1 IG2 < 4mo. 11.1%±2.4 CG < 4 mo 12.3%±2.5 

Newly diagnosed IG1 – 

skills IG2 – adjusCG – Hosp
F-4

Table F1. Characteristics of study population and study setting in studies assessing the effectiveness of diabetes education fo

1 diabetes and their families (continued) 

Author Year Sample Size (n) 

Study Design 

Location 

Age, Mean±SD 

% Male 

Duration of Diabetes, 

Mean±SD 

HbA1c at Baseline, 

Mean±SD 

Other Characteristics 

Dougherty18 1999 63 

RCT (parallel) Canada 

IG 10.7 yr. ±3.9 40.6% CG 9.8 yr. ±3.9 48.4% 

IG 0 yr. 10.0%±2.0 CG 0 yr. 10.7%±1.3 

Newly diagnosed IG – G

knowCG – knowHosp

Golden19 1985 19 

CCT United States 

IG1 2.7 yr. 54.54% IG2NR 62.5% 

IG1 NR IG2 NR 

Newly diagnosed IG1 – 

manasettinIG2 – Diabecare usettin

Greco20 2001 23 

Uncontrolled beforeand-after study United States 

IG 13.1 yr. ±1.98 52.38% IG (Peer)13.6 yr. ±2.25 52.38% 

IG 0.7025 yr. ±0.385 NR IG (Peer) NA 

IG – Gknowproblestress IG (PereceivintervOutpa

Grey21 2000 77 

RCT (parallel) United States 

IG 14.1 yr. ±1.8 48.8% CG 14.6 yr. ±2.2 35.3% 

IG NR 9.1%±1.4 CG NR 9.2%±1.5 

Duration of diabetes >1 yr. IG – C

CG – Hosp
F-5

Table F1. Characteristics of study population and study setting in studies assessing the effectiveness of diabetes education fo

1 diabetes and their families (continued) 

Author Year Sample Size (n) 

Study Design 

Location 

Age, Mean±SD 

% Male 

Duration of Diabetes, 

Mean±SD 

HbA1c at Baseline, 

Mean±SD 

Other Characteristics 

Gross22 1985 14 

RCT (parallel) United States 

IG 11.4 yr. 57.14% CG11.5 yr. 28.57% TG 11.4 yr. 42.85% 

IG NR CGNR TG 4.8 yr. 

≥3 deficit social skill behaviors IG – B

CG – discuNR 

Gross23 1983 11 

RCT (parallel) United States 

IG NR 

IG NR 

IG – SCG – Treat

Hackett24 1989 119 

RCT (parallel) United Kingdom 

IG1 12.7 yr. ±2.9 62.5% IG2 11.4 yr. ±3.3 65.5% IG3 12.4 yr. ±3.6 53.1% CG 11.7 yr. ±3.3 69.2% 

IG1 4.6 yr. ±2.9 11.1%±2.7 IG2 5.9 yr. ±2.8 11.2%±1.7 IG3 5.3 yr. ±3.2 11.0%±2.3 CG 5.0 yr. ±3.1 10.8%±2.1 

IG1 – knowreinfoIG2 – knowIG3 – knowIG1 aCG – Clinic 

Hains25 2000 15 

RCT (parallel) United States 

IG NR 37.5% CGNR 50.0% 

IG NR 10.06%±1.07 CG NR 9.95%±1.42 

Poor metabolic control IG – C

stress CG – Hosp
F-6

Table F1. Characteristics of study population and study setting in studies assessing the effectiveness of diabetes education fo

1 diabetes and their families (continued) 

Author Year Sample Size (n) 

Study Design 

Location 

Age, Mean±SD 

% Male 

Duration of Diabetes, 

Mean±SD 

HbA1c at Baseline, 

Mean±SD 

Other Characteristics 

Hakimi26 1998 35 

RCT (parallel) United States 

IG 11.4 yr. ±2.5 26.7% CG 11.7 yr. ±2.7 55.5% TG 11.5 yr. ±2.5 37.5% 

IG 0 yr. NR CG 0 yr. NR TG 0 yr. NR 

Newly diagnosed IG – G

knowpsychCG – knowNR 

Harkavy27 1983 93 

Uncontrolled beforeand-after study United States 

IG 13.2 yr. 48% 

IG 4.7 yr. NR 

IG – GeducaCamp 

Harris28 2005 18 

Uncontrolled beforeand-after study United States 

IG 67 yr. NR 

IG 14.7 11.3%±1.5 

Noncompliance and/or poor metabolic control 

IG – BsysteHome 

Hill29 2006 134 

Prospective cohort with concurrent control United States 

IG NR CG NR 50% TG NR 50% 

IG NR CG NR TG NR 

IG – Gknowsense CG – Camp 
F-7

Table F1. Characteristics of study population and study setting in studies assessing the effectiveness of diabetes education fo

1 diabetes and their families (continued) 

Author Year Sample Size (n) 

Study Design 

Location 

Age, Mean±SD 

% Male 

Duration of Diabetes, 

Mean±SD 

HbA1c at Baseline, 

Mean±SD 

Other Characteristics 

Hoff30 2005 46 

RCT (parallel) United States 

IG 9.3 yr. ±4.7 47% CG9.4 yr. ±3.4 59% TG 9.4 yr. ±4.1 53% 

IG < 6mo. NR CG < 6 mo. NR TG < 6 mo. NR 

Newly diagnosed IG – C

uncerCG – Hospclinic 

Horan31 1990 20 

RCT (parallel) United States 

IG NR 30.0% CGNR 30.0% 

IG NR 10.0% CG NR 9.6% 

Duration fo diabetes >1 yr. IG – D

coloumoduCG – white Home 

Howe32 2005 89 

RCT (parallel) United States 

IG1 13.6 yr. ±2.0 57.1% IG2 12.1 yr. ±4.0 50.0% CG12.2 yr. ±3.7 57.1% 

IG1 NR 10.1%±1.2 IG2 NR 10.0%±1.4 CG NR 10.2%±1.4 

IG1 – 

knowsessioIG2 – calls CG – Diabe

Kaplan33 1985 21 

RCT (parallel) United States 

IG 14.9 yr. ±1.6 40% CG14.0 yr. ±1.4 36.4% 

IG NR 12.6%±2.4 CG NR 13.5%±1.6 

IG – SCG – knowSumm
F-8

Table F1. Characteristics of study population and study setting in studies assessing the effectiveness of diabetes education fo

1 diabetes and their families (continued) 

Author Year Sample Size (n) 

Study Design 

Location 

Age, Mean±SD 

% Male 

Duration of Diabetes, 

Mean±SD 

HbA1c at Baseline, 

Mean±SD 

Other Characteristics 

Karaguzel34 2005 25 

Uncontrolled beforeand-after study Turkey 

IG 13.2 yr. ±2.6 36% 

IG 5.0 yr. ±4.1 9.28%±2.46 

Moderate–poor metabolic control 

IG – GeducaCamp 

Kemp35 1986 42 

Uncontrolled beforeand-after study United States 

IG 10 yr. NR 

IG NR 8.1%±1.9 

IG – GeducaCamp 

Kennedy-Iwai36 1991 19 

RCT (parallel) United States 

IG 6.0 yr. ±3.2 NR CG7.1 yr. ±4.4 NR 

IG 0.75 yr. ±0.41 9.72%±2.73 CG 0.78 yr. ±0.43 8.69%±2.40 

Newly diagnosed IG – C

progrCG – educaHome 

Koontz37 2001 112 

Uncontrolled beforeand-after study United States 

IG1 NR 30.8% IG2 NR 35.2% IG3 NR 44.4% 

IG1 5.85 yr. ±4.26 8.32%±1.60 IG2 5.56 yr. ±3.45 8.93%±2.06 IG3 4.22 yr. ±2.62 7.99%±1.42 

IG1 – knowIG2 – knowIG3 – knowCamp 
F-9

Table F1. Characteristics of study population and study setting in studies assessing the effectiveness of diabetes education fo

1 diabetes and their families (continued) 

Author Year Sample Size (n) 

Study Design 

Location 

Age, Mean±SD 

% Male 

Duration of Diabetes, 

mean±SD 

HbA1c at Baseline, 

Mean±SD 

Other Characteristics 

Laffel38 2003 105 

RCT (parallel) United States 

IG 11.9 yr. ±2.4 54% CG12.2 yr. ±2.2 52% 

IG 2.7 yr. ±1.6 8.4%±1.3 CG 2.7 yr. ±1.6 8.3%±1.0 

IG – GeducasharinCG – Diabe

Lawson39 2000 28 

Retrospective cohort Canada 

IG1 15.8 yr. ±4.0 NR IG2 15.0 yr. ±1.8 NR 

IG1 7.7 yr. ±1.7 9.5%±1.2 IG2 6.8 yr. ±2.9 8.2%±1.3 

Motivated to improve metabolic control 

IG1 – diabetelephIG2 – diabeDiabe

Likitmaskul40 2002 52 

Prospective cohort with historical control Thailand 

IG 7.07 yr. ±3.87 45.8% CG8.4 yr. ±3.26 35.7% 

IG 0 yr. 17.42% CG 0 yr. 13.56% 

Newly diagnosed IG – S

skills, CG – Hosp

Lipman41 1988 30 

Retrospective cohort United States 

IG 7.4 yr. ±4.3 81.8% IG 7.4 yr. ±3.5 69.2% 

IG 0 yr. NR CG 0 yr. NR 

Newly diagnosed IG – C

specideliveCG – educaHosp
F-10

Table F1. Characteristics of study population and study setting in studies assessing the effectiveness of diabetes education fo

1 diabetes and their families (continued) 

Author Year Sample Size (n) 

Study Design 

Location 

Age, Mean±SD 

% Male 

Duration of Diabetes, 

Mean±SD 

HbA1c at Baseline, 

Mean±SD 

Other Characteristics 

Lucey42 1985 49 

CCT United Kingdom 

IG 11.7 yr. 50% CG12.25 yr NR 

IG NR CG NR 

Poor theoretical and practical diabetes skills 

IG – GknowsolvinCG – NR 

Mann43 1984 39 

RCT (parallel) United Kingdom 

IG1 11.2 yr. ±2.7 65% IG2 12.3 yr. ±2.2 52.6% 

IG1 5.9 yr. ±3.3 12.7%±2.0 IG2 5.6 yr. ±3.2 14.1%±1.3 

Poor metabolic control IG1 – 

instrutelephIG2 – trackiHomeoutpa

Marteau44 1987 97 

Uncontrolled beforeand-after study United Kingdom 

IG 10.7 yr. 27.8% 

IG NR 

IG – Phelp gHotel 

Mason45 1985 93 

CCT United States 

IG NR CGNR 

IG NR CGNR 

IG – DCG – diabeSchoo
F-11

Table F1. Characteristics of study population and study setting in studies assessing the effectiveness of diabetes education fo

1 diabetes and their families (continued) 

Author Year Sample Size (n) 

Study Design 

Location 

Age, Mean±SD 

% Male 

Duration of Diabetes, 

Mean±SD 

HbA1c at Baseline, 

Mean±SD 

Other Characteristics 

Massouh46 1989 33 

RCT (parallel) United States 

IG 12.6 yr. ±0.712 41.1% CG13.1 yr. ±0.987 50% 

IG 3.9 yr. ±3.1 11.3%±3.3 CG 4.7 yr. ±3.5 11.5%±3.6 

IG – GknowlearniCG – knowCamp 

McNabb47 1994 24 

RCT (parallel) United States 

IG 9.7 yr. NR CG10 yr. NR TG 9.9 yr. 54% 

IG NR 10.5%±2.9 CG NR 12.9%±3.8 TG NR 

IG – GmanaparenCG – Diabe

Mendez48 1997 37 

CCT Spain 

IG 13.83 yr. ±2.00 50% CG13.36 yr. ±1.89 47% 

IG 3.73 yr. ±3.93 NR CG 4.46 yr. ±3.52 NR

IG – ACG – Healt

Mitchell49 1996 32 

RCT (parallel) Canada 

IG 10.43 yr. ±2.44 53.3% CG11.0 yr. ±2.35 58.8% 

IG 0 yr. 7.0% CG 0 yr. 8.0% 

Newly diagnosed IG – A

IG – SDiabe

Monaco50 1996 58 

Uncontrolled beforeand-after study United States 

IG 8.5 yr. 50% 

IG NR 

IG – IidentiDiabe
F-12

Table F1. Characteristics of study population and study setting in studies assessing the effectiveness of diabetes education fo

1 diabetes and their families (continued) 

Author Year Sample Size (n) 

Study Design 

Location 

Age, Mean±SD 

% Male 

Duration of Diabetes, 

Mean±SD 

HbA1c at Baseline, 

Mean±SD 

Other Characteristics 

Moran51 1991 22 

CCT United Kingdom 

IG 13.4 yr. ±3.2 37.4% CG14.0 yr. ±4.3 37.4% 

IG 6.2 yr. ±4.3 14.3% CG 5.6 yr. ±2.3 13.7% 

Poor metabolic control IG – P

CG – (hospHosp

Nordfeldt52 2005 332 

RCT (parallel) Sweden 

IG 12.7 yr. ±4.1 45.6% CG1 12.5 yr. ±4.2 44.7% CG2 12.7 yr. ±3.9 45.6% TG 12.2 yr. ±4.1 45.3% 

IG 4.9 yr. ±3.5 7.8%±1.4CG1 5.6 yr. ±4.2 7.8%±1.3 CG2 5.2 yr. ±3.6 8.0%±1.8TG 5.3 yr. ±3.8 7.9%±1.5 

Duration of diabetes >0.5 yr. IG – S

skills, videoCG1 – videoCG2 – Home 

Nordfeldt53 2002 130 

Prospective cohort with historical controls Sweden 

IG 12.2 yr. ±4.3 NR 

IG 4.6 yr. ±3.7 6.6%±1.1 

IG – Sskills, videoHome 

Nordfeldt54 1999 139 

Prospective cohort with historical controls Sweden 

IG 12.9 yr. ±4.4 59% CGNR 

IG 5.0 yr. ±3.9 7.0%±1.1 CG 7.4 yr. ±4.9 7.4%±1.1 

IG – Ibased CG – betwereceivHomeschoo
F-13

Table F1. Characteristics of study population and study setting in studies assessing the effectiveness of diabetes education fo

1 diabetes and their families (continued) 

Author Year Sample Size (n) 

Study Design 

Location 

Age, Mean±SD 

% Male 

Duration of Diabetes, 

Mean±SD 

HbA1c at Baseline, 

Mean±SD 

Other Characteristics 

Nunn55 2006 123 

RCT (parallel) Australia 

IG 11.9 yr. ±3.7 55% CG11.9 yr. ±3.0 57% 

IG 3.73 yr. ±2.41 8.15%±1.14 CG 3.58 yr. ±2.36 8.32%±1.01 

Poor metabolic control IG – G

knowcalls) CG – Home

Olmsted56 2002 85 

RCT (parallel) Canada 

TG 16.0 yr. ±2.0 0% 

TG 7.0 yr. ±3.4 9.1%±1.5 

Eating disorder IG – E

intervCG – Diabe

Panagiotopoulos57

2003 

50 RCT (parallel) Canada 

IG 14.4 yr. ±1.7 44% CG13.8 yr. ±1.5 36% 

IG 7.0 yr. ±3.2 9.7%±1.2 CG 5.5 yr. ±3.1 9.6%±1.3 

Poor metabolic control IG – S

skills CG – Home

Pichert58 1994a 83 

RCT (parallel) United States 

TG NR 

IG 6.1 yr. CG 6.5 yr. range: 6 mo.–15 yr. NR 

TG – instrueducaCamp 

Pichert59 1994b 84 

RCT (parallel) United States 

TG NR 47.6% 

TG 6.9 yr. range: 3 mo.–14 yr. NR 

TG – instrumanaCamp 

Pichert60 1993 70 

RCT (parallel) United States 

TGNR 55.7% 

TG 5 yr. NR 

IG – AprobleCG – discuinstru
F-14

Table F1. Characteristics of study population and study setting in studies assessing the effectiveness of diabetes education fo

1 diabetes and their families (continued) 

Author Year Sample Size (n) 

Study Design 

Location 

Age, Mean±SD 

% Male 

Duration of Diabetes, 

Mean±SD 

HbA1c at Baseline, 

Mean±SD 

Other Characteristics 

Pichert 1993 (continued) 

 Camp 

Povlsen61 2005 37 

Uncontrolled beforeand-after study Denmark 

IG NR 

IG NR 9.2%±1.4 

Ethnic minority IG – R

sessioknowHosp

Remley62 1999 237 

CCT United States 

IG 14.53 yr. 42% CG14.15 yr. 47% 

IG 5.78 yr. 8.98% CG 5.22 yr. 8.76% 

IG – AcommeducaCG – Camp 

Satin63 1989 32 

RCT (parallel) United States 

IG1 15.0 yr. ±2.4 36.4% IG2 14.9 yr. ±2.8 25% CG 13.7 yr. ±2.7 55.6% TG 14.6 yr. ±2.6 37.5% 

IG1 6.3 yr. ±5.1 13.4%±1.3 IG2 5.2 yr. ±3.8 12.6%±0.9 CG 6.3 yr. ±4.3 12.9%±1.4 TG 5.9 yr. ±4.3 NR 

IG1 – teamwIG2 – diabe(pareCG – Hosp

Schlundt64 1996 86 

Uncontrolled beforeand-after study United States 

IG 12.1 yr. ±1.8 47% 

IG 4.5 yr. ±3.1 NR 

IG – ACamp 
F-15

Table F1. Characteristics of study population and study setting in studies assessing the effectiveness of diabetes education fo

1 diabetes and their families (continued) 

Author Year Sample Size (n) 

Study Design 

Location 

Age, Mean±SD 

% Male 

Duration of Diabetes, 

Mean±SD 

HbA1c at Baseline, 

Mean±SD 

Other Characteristics 

Shobhana65 1997 37 

Uncontrolled beforeand-after study India 

IG NR 

IG NR 

Duration of diabetes ≥1 yr. IG – G

knowDiabe

Siminerio66 1999 32 

Prospective cohort with concurrent control group United States 

IG1 10.1 yr. 62.5% IG2 10.2 yr. 56.25% 

IG1 NR IG2 NR 

Newly diagnosed IG1 – 

knowIG2 – knowclinic) Hosp

Smith67 1993 120 

Uncontrolled beforeand-after study United States 

IG 14.9 yr. ±1.4 43% 

IG 4.1 yr. ±3.4 NR

IG – Acommsolvinskills Camp 

Smith68 1991 108 

Uncontrolled beforeand-after study United States 

IG 14.5 yr. ±1.4 44% 

IG 4.5 yr. ±3.5 NR 

IG – SCamp 

Srinivasan69 2004 110 

Prospective cohort with concurrent control group Australia 

IG1 NR IG2 NR 

IG1 NR IG2NR 

Newly diagnosed IG1 – 

diabe(outpaIG2 – know(hospOutpaprogr
F-16

Table F1. Characteristics of study population and study setting in studies assessing the effectiveness of diabetes education fo

1 diabetes and their families (continued) 

Author Year Sample Size (n) 

Study Design 

Location 

Age, Mean±SD 

% Male 

Duration of Diabetes, 

Mean±SD 

HbA1c at Baseline, 

Mean±SD 

Other Characteristics 

Sundelin70 1996 38 

RCT (parallel) Sweden 

IG1 8.7 yr. ±3.2 37% CG 8.8 yr. ±2.7 37% 

IG1 NR 9.6%±0.14 CG NR 9.8%±0.74 

Newly diagnosed IG1 – 

knowapartmCG – knowHosp

Svoren71 2003 301 

RCT (parallel) United States 

IG1 11.8 yr. ±2.4 39% IG2 12.1 yr. ±2.4 42% CG 11.7 yr. ±2.6 49% 

IG1 5.1 yr. ±2.9 8.57%±1.35 IG2 5.3 yr. ±3.0 8.68%±1.03 CG 5.3 yr. ±30. 8.72%±1.17 

Duration of diabetes > 6 mo IG1 – 

to assIG2 – psychCG – Diabe

Szumowski72 1990 27 

RCT (parallel) United States 

IG 78.1 mo. 45% CG 76.4 mo 60% 

IG 3.24 yr. 9.7%±1.2 CG 2.57 yr. 10.0%±1.5 

Duration of diabetes ≥ 1 yr. IG – G

adherCG – knowOutpa

Templeton73 1988 30 

Uncontrolled beforeand-after study United States 

IG 12.7 yr. NR 

IG 4.9 yr. NR 

IG – FSMBG Diabe

Thomas-Dobersen741993 

20 CCT United States 

IG NR 

IG NR 

IG – S(adoleand c(pareCG – NR 
F-17

Table F1. Characteristics of study population and study setting in studies assessing the effectiveness of diabetes education fo

1 diabetes and their families (continued) 

Author Year Sample Size (n) 

Study Design 

Location 

Age, Mean±SD 

% Male 

Duration of Diabetes, 

Mean±SD 

HbA1c at Baseline, 

Mean±SD 

Other Characteristics 

Verrotti75 1993 30 

Uncontrolled beforeand-after Italy 

IG 15.4 yr. ±0.8 40.0% 

IG 1.3 yr. ±0.4 12.0%±2.9 

IG – GknowNR 

Viner76 2003 21 

CCT United Kingdom 

IG 13.0 yr. 28.6% CG 13.3 yr. 60.0% 

IG 6.2 yr. 10.2%±1.4 CG 5.7 yr. 10.0%±1.3 

Poor metabolic control IG – S

therapCG – NR 

von Sengbusch77

2006 

107 Uncontrolled beforeand-after study Germany 

IG 11.1 yr. ±2.5 43.9% 

IG 4.3 yr. ±3.0 7.9%±1.4 

Duration of diabetes > 6 mo. IG – M

Teamknowself-cHosp

Vyas78 1988 63 

Uncontrolled beforeand-after study United Kingdom 

IG 8.4 yr. ±2.0 47% CG 

IG 3.9 yr. ±2.0 NR 

IG – SprobleCamp 

Wadham79 2005 67 

RCT (parallel) United Kingdom 

IG 12.9 yr. ±2.1 56% 

IG 4.9 yr. ±3.25 9.1%±1.25 

IG – GknowcommrespoCG – Clinic 
F-18

Table F1. Characteristics of study population and study setting in studies assessing the effectiveness of diabetes education fo

1 diabetes and their families (continued) 

Author Year Sample Size (n) 

Study Design 

Location 

Age, Mean±SD 

% Male 

Duration of Diabetes, 

Mean±SD 

HbA1c at Baseline, 

Mean±SD 

Other Characteristics 

Webb80 1999 66 

RCT (parallel) United States 

IG1 NR IG2 NR TG 10.2 yr. ±1.4 34.8% 

IG1 NR 8.68%±0.75IG2 NR 9.52%±1.28 TG 5 yr. ±2.6 

Duration of diabetes >1 yr. IG1 – 

settinIG2 – 

guideOutpa

Wolanski81 1996 41 

RCT (parallel) Canada 

IG NR 

IG 4 mo.–12 yr. NR 

Poor self-management skills IG – B

CG – Camp 

Wysocki82 2007 104 

RCT (parallel) United States 

IG1 14.4 yr. ±1.9 56% IG2 13.9 yr. ±1.9 58%CG 14.2 yr. ±1.9 50% 

IG1 5.5 yr. ±3.2 9.7%±1.6IG2 5.1 yr. ±3.0 9.6%±1.6CG 5.9 yr. ±4.0 9.5%±1.5 

Duration of diabetes >2yr. IG1 – 

emphsociaIG 2 – systeCG – Diabe

Wysocki83 2000 119 

RCT (parallel) United States 

IG1 14.5 yr. ±1.2 39% IG2 14.1 yr. ±1.4 38% CG 14.3 yr. ±1.4 49% 

IG1 5.4 yr. ±3.8 NR IG2 4.5 yr. ±3.7 NR CG 5.2 yr. ±3.8 NR 

Poor metabolic control, moderate levels of parentadolescent conflict 

IG1 – systeIG2 – emphsociaCG – Docto
F-19

Table F1. Characteristics of study population and study setting in studies assessing the effectiveness of diabetes education fo

1 diabetes and their families (continued) 

Author Year Sample Size (n) 

Study Design 

Location 

Age, Mean±SD 

% Male 

Duration of Diabetes, 

Mean±SD 

HbA1c at Baseline, 

Mean±SD 

Other Characteristics 

Zorumski84 1997 56 

CCT United States 

IG 10.2 yr. ±1.67 55.6% CG 10.43 yr. ±1.57 36.4% 

IG 2.7 yr. ±2.13 9.93%±2.9 CG 2.79 yr. ±2.37 10.85%±2.14 

IG – GknowCG – Day c
F-20

Table F2. Characteristics and effectiveness of studies of diabetes education for children with type 1 diabetes and their families 

Author Year 

Sample Size (n) 

Study Design 

Setting 

Intervention 

Interventionist 

Duration of Intervention 

Followup Interval 

Aut

Anderson5 1999 89 

RCT (parallel) Diabetes center 

IG1 – 20-30 min. sessions every 3-4 mo. For 12 mo., parent-teen shared responsibility for diabetes tasks and ways to avoid conflict IG2 – 20-30 min. sessions every 3-4 mo. For 12 mo., didactic diabetes education with no focus on parental involvement CG – Standard care 

Research staff (IG1 and IG2); NA (CG) 12 mo. 24 mo. (IG1); 12 mo. (IG2, CG) 

HbA1c – N12 mo. Or 2Pyschosoc– IG reportCG (p<0.07Psychosocrelationship

decrease in at 12 mo.

Anderson6 1989 70 

RCT (parallel) Clinic 

IG – Five 3-hr sessions every 3-4 mo. For 18 mo., SMBG in relation to practical skills, puberty, problem solving, exercise and use with intensive therapies CG – Standard care 

Endocrinologist, diabetes nurse educator, dietician, social work (IG and CG); Nutritionist, psychologist (IG) 18 mo. Immediate 

HbA1c – IG than CG (p Self-monitsignificant d

Barglow7 1983 42 

CCT Diabetes center 

IG – Intensive, multi-component treatment individually designed, delivered over 4 mo., initial visit and assessment, clinic visits every 2 wk., daily telephone calls (providing medical care, teaching, clarification and support), and one group session CG – Standard care 

Multidisciplinary team (IG); NR (CG) 4 mo. 4 mo. 

HbA1c – N

Boardway8 1993 31 

RCT (parallel) Outpatient clinic 

IG – Group sessions over 6 mo., 3 phases: self-monitoring, stress-management, regimen adherence CG – Standard care 

NR 3 mo. 6 mo. (IG); NR (CG) 

HbA1c – Neffects Self-mana

significant tPsychosocdecrease in Coping – Neffects 

BG = blood glucose; carb = carbohydrate; CG = comparison group; d = day; DKA = diabetic ketoacidosis; IG = intervention group; NA = not reported; NS = not significant; SMBG = self-monitoring of blood glucose; Tx = treatment
F-21

Table F2. Characteristics and effectiveness of studies of diabetes education for children with type 1 diabetes and their families 

Author Year Sample Size (n) 

Study Design 

Setting 

Intervention Interventionist 

Duration of Intervention 

Followup Interval 

Aut

Brown9 1997 59 

RCT (parallel) Home 

IG – For 6 mo., children played the video game Packy & Marlon, features characters with diabetes that must engage in self-care CG – For 6 mo., children played a pinball 

video game with no health-related content 

Research staff 6 mo. Immediate 

HbA1c – Neffect (p = Health carfewer urgecompared tn.s.) Knowledgknowledge (p = 0.64, nPsychosocrelationshipcommunicamo. (p = 0.Psychosocreported gacompared tn.s.) Psychosocreported gato CG at 6 

Campaigne10

1985 

16 RCT (parallel) NR 

IG – 3 45-min. exercise sessions for 12 wk., warm-up and stretching, aerobic movements to music and cool-down CG – Subjects continued with their usual exercise routine 

Supervised by principal investigator (IG); NA (CG) 12 wk. Immediate 

HbA1c – Ngroup at 3 Short-term (hypoglyceoccurrence 

Caravalho11 2000 56 

Uncontrolled before-and-after study Home, diabetes center 

IG – Children and parents seen in diabetes team clinic, parents taught insulin adjustment procedures, interventions developed and implemented according to child’s age, telephone calls assessed families and assisted in improving self-management, daily calls for newly diagnosed children 

Nurse, social worker, dietitian 1 yr. Immediate 

HbA1c – Sto post (12 significant Psychosocself-efficacsignificant Quality of scores pre significant 
F-22

Table F2. Characteristics and effectiveness of studies of diabetes education for children with type 1 diabetes and their families 

Author Year Sample Size (n) 

Study Design 

Setting 

Intervention Interventionist 

Duration of Intervention 

Followup Interval 

Aut

Christensen12

2000 

68 Uncontrolled before-and-after study Camp 

IG – 45-min. sessions during 2-wk. camp, 12-18 children per class, grouped by age, carbohydrate counting, label reading, food proportioning and adjusting for activity level, teaching methods tailored to developmental needs 

Camp counsellor, physician, nurse 2 wk. Immediate 

Knowledgstatistically Self-manameal plan iincrease cointervention Self-manadescribe mcomparing values Self-manaportion sizestatistically Self-manameasuring significant 

Cigrang13 1991 37 

RCT (parallel) Hospital 

IG1 – 8 90-min. group sessions focused on identifying issues perceived as difficult or stressful and developing adaptive strategies for coping, youths asked to implement new coping strategies in real-life situations during the week IG2 – 8 90-min. group sessions with a speaker who presented diabetic topics, included a question and answer session and practice time for various skills CG – Standard care 

Diabetes nurse specialist, advanced clinical psychology doctoral student (IG1); diabetes educator, dietitian, endocrinologist, diabetes resource nurse, exercise physiologist (IG2); physician (CG) 8 wk. 3 mo. 

HbA1c – IG but not signCoping – Nbetween grPsychosocsignificant dat 3 mo. (p Psychosocsignificant dgroups at 3 
F-23

Table F2. Characteristics and effectiveness of studies of diabetes education for children with type 1 diabetes and their families 

Author Year Sample Size (n) 

Study Design 

Setting 

Intervention Interventionist 

Duration of Intervention 

Followup Interval 

Aut

Couper14 1999 69 

CCT Hospital, home 

IG – Standard care, plus 6 monthly home visits for 45-60 min. and weekly telephone contact for 5-10 min. to educate and support adolescents in setting goals for insulin adjustment, BGSM, and target blood glucose range, parents not formally involved in home visits, 24-hour phone access for acute problems CG – Standard care, plus 24-hour phone access for acute problems 

Nurse educator (IG); pedatric endocrinologist, diabetes educator, dietitian (IG and CG) 6 mo. 12 mo. 

HbA1c – IG CG at 6 mosignificant dat 12 mo. Knowledghigher than no sig. diff. Knowledghigher than and 12 mo

Coupland15 1992 32 

RCT (parallel) NR 

IG – 3-5 sessions over 2-2.5 mo. Attended by parents, patient, and siblings closest in age to patient, 1 diabetes skills review and update session, 2-4 family adherence counseling sessionsCG – 3-5 sessions over 2-2.5 mo., 1 diabetes skills review (1 parent and patient) and update session, 2-4 stress coping strategy sessions (patient only) 

Ph.D. candidate (IG); diabetes educator (IG and CG) 2.5 mo. 3.5 mo. 

HbA1c – Nbetween grimproved Self-mana

significantly at 6 mo. (pSelf-manafreq. of BG increased c(p<0.001) Self-manapercent of significantly mo. (p<0.0Psychosoc– No signifgroups at 6 
F-24

Table F2. Characteristics and effectiveness of studies of diabetes education for children with type 1 diabetes and their families 

Author Year Sample Size (n) 

Study Design 

Setting 

Intervention Interventionist 

Duration of Intervention 

Followup Interval 

Aut

Delamater16 1991 13 

RCT (parallel) Hospital outpatient clinic 

IG – Six 90-min. group sessions held over 2 

mo. With a booster session 4 wk. after the last session, self-management and psychosocial skills, separate parent and teen discussions CG – Standard care 

Multidisciplinary team (IG); NR (CG) 2 mo., plus 1 booster session 4wk. later (IG); NA (CG) 4 mo. 

HbA1c – Nbetween grSelf-mana

rated themthan CG at Psychosocpatient-repbetween grPsychosocparent-repobetween grPsychosoc– No signifgroups at 4 Psychosoc– No signifgroups at 4 Psychosocsupportive self-report) between grPsychosocsupportive self-report) between grPsychosocsupportive self-report) between grPsychosocsupportive self-report) between gr

Delamater17 1990 36 

RCT (parallel) Hospital, home 

IG1 – 7 sessions held in the 4 mo. After discharge, additional sessions at 6 and 12 mo., SMBG, self-management skills aimed at developing and reinforcing problem solving strategies IG2 – 7 sessions held in the 4 mo. After 

Social worker with diabetes expertise (IG1); social worker (IG2); physician, dietitian (CG) 12 mo. 

HbA1c – Ssignificantly (p<0.05) 
F-25

Table F2. Characteristics and effectiveness of studies of diabetes education for children with type 1 diabetes and their families 

Author Year Sample Size (n) 

Study Design 

Setting 

Intervention Interventionist 

Duration of Intervention 

Followup Interval 

Aut

Delamater 1990 (continued) 

discharge, additional sessions at 6 and 12 mo. Focused on psychosocial adjustment issues, patients encouraged to keep accurate BMBG records CG – Standard care

12 mo. 

Dougherty18 1999 63 

RCT (parallel) Hospital, home 

IG – Home visits 1-2 times a day for the first 2-3 days, instruction and supervision of treatment, problem solving encouraged during followup, diabetologist and dietitian teaching offered 2 wk. after diagnosis, patient hospitalized if necessary CG – Patient hospitalized for metabolic stabilization, initial insulin therapy, and teaching sessions provided 

Multidisciplinary team 2 wk. 36 mo. 

HbA1c – Hsignificantly hospital groShort-term 

events) – Nbetween grShort-term hyperglycedifferences Short-term No significagroups Short-term (hyperglycesignificant dShort-term hypoglycemdifferences Knowledgdifferences Self-mana
F-26

Table F2. Characteristics and effectiveness of studies of diabetes education for children with type 1 diabetes and their families 

Author Year Sample Size (n) 

Study Design 

Setting 

Intervention Interventionist 

Duration of Intervention 

Followup Interval 

Aut

Dougherty 1999 (continued) 

 significant 

Psychosocgroup signiCompared (p<0.05) Coping – Nbetween grSchool Pedays of abs29.7±28.7 d

Golden19 1985 19 

CCT Diabetes center, parent care unit, a motel-like setting 

IG – Teaching occurred in a motel-like setting where entire family stayed and was responsible for care, learned diabetes management skills and dietary guidelines, initial crisis intervention offered to families, psychosocial support occurred at 3-mo. Intervals preceded by a 1-hr session with 5-6 other families CG – Delayed treatment, intervention began an average of 14.9 mo. After initial treatment group 

Psychiatric social worker (IG and CG) NR 6-24 mo. (at least partially concurrent with treatment) 

HbA1c – OIG mean Hequivalent Health carhospitalizateducation, before inteShort-term 

(hypoglycein CG childgroups (p<

Greco20 2001 23 

Uncontrolled before-and-after study Outpatient clinic 

IG – Four 2-hr sessions, composed of 3-6 pairs (diabetes patient and peer), reviewed homework, focused on etiology, physiology and treatment of diabetes, reflective listening skills, problem solving related to diabetes, stress management, game or exercise to practice concepts and homework assignment 

Psychologist 4 wk. Immediate 

Knowledgadolescentsignificant their peers baseline Self-mana

significant Psychosoc– Peers prosupport relfollowing inPsychosoc

relationsignificconflict (p<0.05
F-27

Table F2. Characteristics and effectiveness of studies of diabetes education for children with type 1 diabetes and their families 

Author Year Sample Size (n) 

Study Design 

Setting 

Intervention Interventionist 

Duration of Intervention 

Followup Interval 

Aut

Greco2001 (continued) 

Psychosocrecord) – Pimproveme(p<0.01), asignificant cPyschosocand attitudiDM) – TrenadjustmentPsychosocbehavior, asignificant 

Grey21 2000 77 

RCT (parallel) Hospital, home 

IG – Standard care, plus 6 weekly coping skills training sessions, retrained inappropriate or nonconstructive coping styles, modeled appropriate behaviors, emphasis on social problem solving, skills training, cognitive behavior modification and conflict resolution CG – Standard care, monthly outpatient visits, plus interim telephone contact 

Multidisciplinary team (IG and CG) 4 to 8 wk. 12 mo. 

HbA1c – IG lower HbA112 mo. Short-term hypoglycem27 in IG, 21 Short-term hypoglycem18 in IG, 22 Short-term episode (mPyschosocsignificantly 0.002) aftestatistically Pyschosocsignificantly efficacy (p groups statQuality of 

negativ
F-28

Table F2. Characteristics and effectiveness of studies of diabetes education for children with type 1 diabetes and their families 

Author Year Sample size (n) 

Study Design 

Setting 

Intervention Interventionist 

Duration of Intervention 

Followup Interval 

Aut

Grey21 2000 

(continued) 

Coping – with diabetCoping – Idiabetes

Gross22 1985 14 

RCT (parallel) NR 

IG – 8 weekly 90-min. sessions, separate parent and child groups, children read and completed 1-2 lessons a week from a text on behavior modification, parents discussed similar topics and were required to conduct a behavior modification project on selfidentified, problematic components of their child’s diabetes CG – 8 weekly 90-min. sessions, separate parent and child groups, children participated in open ended discussion, parents discussed problems with having a diabetic child

Psychologist (IG and CG) 8 wk. 6 mo. 

HbA1c – SHbA1c (botsignificant d(p>0.05) Knowledghigher com

Self-manademonstratcompliance Psychosocrelationshipconflicts/wemo., CG reconflicts/weperiod 

Gross23 1983 11 

RCT (parallel) Treatment room 

IG – Two 45-min. social training sessions per week for 5 wk., modeling behaviors, providing feedback and praise, trained on one behavior until reliably performed CG – No intervention 

NR 5 wk. 6 wk. 

HbA1c – N(p>0.05) (bPyschosocpercentage from 53-95Psychosocpercentage verbalizatio(IG) Psychosocduration incPsychosocratings incr

Hackett24 1989 119 

RCT (parallel) 

IG1 – 4 90-min. education sessions over 8 mo., background and management information, insulin, diet and practical problems, 4 90-min. reinforcement 

Research staff (IG) NA (CG) 16 mo. (IG1); 8 mo. (IG2 and 

HbA1c – Nmarginal im>11 yr.Knowledg
F-29

Table F2. Characteristics and effectiveness of studies of diabetes education for children with type 1 diabetes and their families 

Author Year Sample Size (n) 

Study Design 

Setting 

Intervention Interventionist 

Duration of Intervention 

Followup Interval 

Aut

Hackett24 1989 

(continued) 

Clinic session over 8 mo. (following the first 

session) IG2 – 4 90-min. education sessions over 8 mo. IG3 – 4 90-min. education sessions over 8 

 mo. Starting 10 mo. After IG1 and IG2 

CG – No intervention

IG3) Immediate (all IG); 16 mo. (CG) 

knowledge cohorts) Knowledgfor mothers evidence oKnowledg– No signif(all ages)

Hains25 2000 15 

RCT (parallel) Hospital 

IG – 3-phase cognitive behavioral stress inoculation training program, 6 1-hr. sessions: conceptualization phase (1 session), skill acquisition and rehearsal phase (sessions 2-4) and application phase (sessions 5 and 6) CG – No intervention 

Pyschologist, doctoral student in counseling psychology (IG) 6 wk. 1 mo. 

HbA1c – Ngroups Psychosocdifference bPsychosocbetween grCoping (nebetween grCoping (pobetween grCoping (bebetween gr

Hakimi26 1998 35 

RCT (parallel) NR 

IG – Same as CG, plus additional 2-hr. program, common emotional/behavioral problems, parental reaction to diabetes diagnosis, common sibling problems, mistakes or misconceptions of outsiders, treatment of diabetic child and family interaction to promote positive adaptation CG – Standard care, 3-4 d. education program 

Psychologist (IG); physician, nurse, dietitian (CG) 3-4 d. 6 wk. 

Psychosocdifferences post-interve

Harkavy27 1983 93 

Uncontrolled before-and-after study Camp 

IG – 2-wk. camp, informal and formal teaching sessions, diabetes etiology/pathology, self-management skills, effects of diabetes on stress and social issues 

Physician, nurse, camp counsellor 2 wk. Immediate 

Knowledgfor 12-13 afor each). N10-11-yr. operiod Self-mana
F-30

Table F2. Characteristics and effectiveness of studies of diabetes education for children with type 1 diabetes and their families 

Author Year Sample Size (n) 

Study Design 

Setting 

Intervention Interventionist 

Duration of Intervention 

Followup Interval 

Aut

Harkavy 1983 (continued)

 testing) – G

accurately sexes imprimprovemeolds (p<0.0difference i

Self-manainjection) – accurately improved thcamp (p<0KnowledgSignificant 14-15-yr. osignificant dover the 2-

Harris28 2005 18 

Uncontrolled before-and-after study Home 

IG – 10 90-min. behavioral family systems therapy sessions, 6-8 weeks covering 4 topics: problem solving, communications skills, cognitive restructuring and functional/structural family therapy 

Social worker, psychologist 5-8 wk. 6 mo. 

HbA1c – Nmetabolic cAdherence significant dbaseline anCoping – Ndifferences mean 6 moSelf-manastatistically between baValues Pyschosocrelationshipsignificant dbaseline anPyschosocstatistically between baValues 
F-31

Table F2. Characteristics and effectiveness of studies of diabetes education for children with type 1 diabetes and their families 

Author Year Sample Size (n) 

Study Design 

Setting 

Intervention Interventionist 

Duration of Intervention 

Followup Interval 

Aut

Harris 2005 (continued) 

Psychosoc– No statistbetween baValues

Hill29 2006 134 

Prospective cohort with concurrent controls Camp 

IG – Foundation for Children and Youth with Diabetes 6-day teen camp, knowledge of diabetes management, encouragement to self-monitor and regulate, participated in leisure activities, fostered choice, a sense of self-control and a sense of belonging, on last day campers gathered in small cabin groups to discuss knowledge, questions and comments about camp CG – Camp Hodia, regular camp session 

Physician, nurse, dietitian, counselor, assistant (IG); camp counselor (CG) 6 d. 3 mo. 

Psychosoccompetencdifferences Psychosocautonomy) autonomy iPsychosocrelationshiphigher than intervention 

Hoff30 2005 46 

RCT (parallel) Hospital, endocrinology clinic 

IG – Standard care, plus 2 weekend sessions, 2.5 hr. long, construct of illness (session 1) and uncertainty management techniques (session 2) CG – Standard care 

Advanced clinical psychology graduate students (IG); NR (CG) Two 2.5 hr. sessions 6 mo. 

Psychosocreport of ch– IG had siinternalizin6-mo. Comand 0.02, rPsychosocreport of ch– CG had sinternalizincompared tPsychosocchild externsignificantly behavior at baseline (p Psychosocexternalizinsignificant when comp
F-32

Table F2. Characteristics and effectiveness of studies of diabetes education for children with type 1 diabetes and their families 

Author Year Sample Size (n) 

Study Design 

Setting 

Intervention Interventionist 

Duration of Intervention 

Followup Interval 

Aut

Horan31 1990 20 

RCT (parallel) Home 

IG – 7 weeks of diabetes education modules (phase 2), dynamic and colorful, subjects determined when and what modules to read, recorded insulin and blood glucose data daily on computer and mailed data to investigators every 3 wk., 8 wk. of goal setting and problem solving modules (phase 3), subjects focused on self-control and applying information from education sessions CG – 7 wk. diabetes education, modules were static and black-and-white, subjects determined when and what modules to read, recorded insulin and blood glucose data and mailed to investigators every 2 wk., 8 wk. of goal setting and problem solving, no additional modules 

Commodore computer (IG); printed materials (CG) 15 wk. Immediate 

HbA1c – Nbetween grKnowledgsignificant dat posttest KnowledgIG subjects compared tSelf-mana

reported mfunction of 

Howe32 2005 75 

RCT (parallel) Diabetes center (all); home (IG2) 

IG1 – Standard care, plus 1 education session with families, basic diabetes management skills, families given customized written guidelines, parents expected to identify problems and know when to call for assistance IG2 – Standard care, plus IG1, plus telephone calls from study coordinator, standardized protocol, diabetes management techniques, parental and behavioral management skills discussed with parent CG – Standard care 

Master’s-prepared nurse (IG1, IG2 and CG), pediatric endocrinologist (IG1 and IG2); study coordinator (IG2) 6 mo. Immediate 

HbA1c – Nbetween grKnowledgsignificant baseline–6 Psychosocappropriate significant 0.002), EDcompared tPsychosocbehaviors) x time intergroup signiCG (p = 0.0
F-33

Table F2. Characteristics and effectiveness of studies of diabetes education for children with type 1 diabetes and their families 

Author Year Sample Size (n) 

Study Design 

Setting 

Intervention Interventionist 

Duration of Intervention 

Followup Interval 

Aut

Kaplan33 1985 21 

RCT (parallel) Summer school 

IG – 5 social skills training sessions, 3 hr. a day over 1 wk., identified social situations where peer influence might cause variation in diabetes regimen and suggested appropriate responses CG – 5 diabetes knowledge lectures and small group discussion, 3 hr. a day over 1 wk., an interactive computer system, educational videos and an assignment identifying important facts for diabetic teens 

Pedatric endocrinologist, expert in diabetes care (IG and CG); psychology graduate student (IG) 3 wk. 4 mo. 

HbA1c – IG levels at 4 

Karaguzel34 2005 25 

Uncontrolled before-and-after study Camp 

IG – 1-wk. camp, education in the morning, during meals and spontaneously, selfmanagement skills, recognition of hypoglycemia, DKA, adjustment related to nutrition and activity level, complications, importance of control and new therapies 

Multidisciplinary team 1 wk. 12 mo. 

HbA1c – P12 mo. Sig(p<0.05) Short-term (hypoglycedifference a12 mo. Val3 and 6 moKnowledgpost-camp camp and 3 (p<0.01 vs

Kemp35 1986 42 

Uncontrolled before-and-after study Camp 

IG – 2-wk. camp, 8 hr. of formal diabetes education either as lectures or computer assisted instruction; eye, skin and foot care, treatment of hypo- and hyperglycemia, nutrition, insulin adjustment and exercise 

NR 2 wk. 1 yr. 

HbA1c – NchangeKnowledgknowledge post interve(p<0.0001) 
F-34

Table F2. Characteristics and effectiveness of studies of diabetes education for children with type 1 diabetes and their families 

Author Year Sample Size (n) 

Study Design 

Setting 

Intervention Interventionist 

Duration of Intervention 

Followup Interval 

Aut

Kennedy-Iwai361991 

19 RCT (parallel) Home (IG); hospital (CG) 

IG – Standard care, plus 6-8 sessions of a couple communication program using the text Couple Communication 1: Talking Together, 

explored feelings and intentions, active listening, observing and information checking, communication styles and providing support, program delivered at home CG – Standard care, plus education on selfmanagement skills, could also receive information on stress management, childrearing and handling emotions surrounding diagnosis 

Research staff, counseling psychologist (IG); NR (CG) 8-10 hr. (IG), NR (CG) 3 mo. (IG), NR (CG) 

HbA1c – Lposttest in Psychosoccohesion) – values at 3 Psychosocconflict) – Iscores than no differenTreatment 

Koontz37 2001 112 

Uncontrolled before-and-after study Camp 

IG1 (grades 9-10) – 1-wk. camp, selfmanagement skills, insulin administration, the relationship between diet, exercise and insulin, meal and snack planning, selecting and measuring food portions, SMBG, identifying and treating insulin reactions, aimed to enhance camper’s emotional adjustment and improve self-esteem IG2 (grades 6-8) – same as IG1 IG3 (grades 2-5) – same as IG1 

Camp counsellor 1 wk. 3 mo. 

HbA1c – Nto followup Health carhospitalizatmedical folHealth carvisited physcheck-upSelf-manasignificant dpost camp than youngyounger cotime PsychosocDifferences athletic comCoping – Ccoping stra
F-35

Table F2. Characteristics and effectiveness of studies of diabetes education for children with type 1 diabetes and their families 

Author Year Sample Size (n) 

Study Design 

Setting 

Intervention Interventionist 

Duration of Intervention 

Followup Interval 

Aut

Laffel38 2003 105 

RCT (parallel) Diabetes center (both); home (CG) 

IG – Written material and family discussion on 4 module topics: communication, meaning of HbA1c and need for teamwork during adolescent period, response to blood sugar tests and sharing the burden of diabetes tasks, at the end of each session a responsibility-sharing plan was negotiated CG – Standard care, plus written material from IG at the end of the study 

Research staff 1 yr. Immediate 

HbA1c – IG lower levels PsychosocIG had signthan CG (p Psychosocconflict, pasignificant dat 12 mo. Psychosocconflict, pasignificant dat 12 mo. Quality of differences 

Lawson39 2000 28 

Retrospective cohort Diabetes center (both); home (IG) 

IG – 6-8 hr of education (comparable to the DCCT), over 3-4 sessions on an outpatient basis, weekly phone contact reviewed insulin dose adjustments and provided ongoing support, diabetes clinic visits CG – Two 2-hr. group education sessions attended by patient and their parents, one 1-2 hr individualized session, meal plans and insulin dose adjustment, small group problem solving sessions, weekly physician contact encouraged 

Nurse, dietitian (IG and CG); research fellow (IG); diabetologist (CG) 3 mo. 12 mo. 

HbA1c – Bdecrease in following 12 both groupremained sbaseline leHbA1c did baseline Short-term 

(hypoglycegroup had reactions a
F-36

Table F2. Characteristics and effectiveness of studies of diabetes education for children with type 1 diabetes and their families 

Author Year Sample Size (n) 

Study Design 

Setting 

Intervention Interventionist 

Duration of Intervention 

Followup Interval 

Aut

Likitmaskul40

2002 

52 Cohort with historical comparison Hospital (IG); NR (CG) 

IG – Hospital admission, 10-12 d., or until family felt comfortable, patient and at least 1 family member attended program, selfmanagement skills, how to manage abnormal blood and urine sugar levels and how to detect and correct hypoglycemia, followup visits to education clinic once a month for 3 mo., then every 3 mo. Thereafter CG – Standard care (historical control) 

Multidisciplinary team (IG); NA (CG) 10–12 days (IG); NR (CG) Average follow up: 43.5 ±13.1 mo. (IG); 39.9 ±26.8mo. (CG) 

HbA1c – IG than CGHealth carlength of firmuch shortHealth carReadmissiomore than 

Lipman41 1988 30 

Retrospective cohort Hospital 

IG – Group instruction coordinated and education provided by a clinical nurse specialist with help from staff nurses, daily education plan delineated responsibilities, diabetes care plan revised and expanded to include child/family assessment tool, reading material and discharge criteria same as CG CG – Staff nurses provided instruction according to diabetes education flowsheet and standardized diabetes care plan, education booklet provided, tasks depended upon age, discharged when child and/or parent could perform diabetes tasks and answer questions 

Nurse (both); clinical nurse specialist (IG) NR None 

Health carsignificantly hospitalizat

Lucey42 1985 49 

CCT NR 

IG – Two 6-hr. small group sessions using demonstration, drama and a video camera, video facilitated discussion, problem solving alternatives discussed, a canteen-style lunch provided and video taken of food choices used for nutrition discussion, second session provided evening tea and observation of insulin injection CG – No intervention 

Layperson, adult leader (IG); N/A (CG) Two 6-hr. sessions 4–22 wk. 

Knowledgbetter on gquestions tPyschosocDifference problem sostatistically 
F-37

Table F2. Characteristics and effectiveness of studies of diabetes education for children with type 1 diabetes and their families 

Author Year Sample Size (n) 

Study Design 

Setting 

Intervention Interventionist 

Duration of Intervention 

Followup Interval 

Aut

Mann43 1984 39 

RCT (parallel) Home, outpatient clinic 

IG1 – Teaching during home visits, injection 

sites inspected, videos on procedures available in waiting area of clinic, group discussion or practical dietary demonstrations, telephone contact encouraged to discuss problems in diabetes management, glucose measurements recorded IG2 – Same as IG1, plus glucose measurements recorded graphically, patients given dose-regulation algorithms, attempted to achieve specified glucose levels 

Physician, diabetes educator, dietitian NR 18 mo. 

HbA1c – Afluctuation, and end of in both groHealth cargroup showhospitalizatcontrol and 

Marteau44 1987 97 

Uncontrolled before-and-after study Hotel 

IG – Weekend program, parents divided into groups, sessions on problem solving, forming self-help groups, health care for diabetics, ways to achieve best care 

Multidisciplinary team 1.5 d. 3 mo. 

Coping – Plooking afteunchanged Coping – Psignificantly after their cmo. 

Mason45 1985 93 

CCT School, diabetes center 

IG – 2-4 player board game designed to support the role of the health care team, alert individuals to possible complications of diabetes, provide opportunities for discussion and decision making and the ability to control diabetes, players collected tools (cards) for management to ensure continued control, player with the most tools wins 

Diabetes educator NR NR 

Knowledgsignificantly scores from significant dgroups 
F-38

Table F2. Characteristics and effectiveness of studies of diabetes education for children with type 1 diabetes and their families 

Author Year Sample Size (n) 

Study Design 

Setting 

Intervention Interventionist 

Duration of Intervention 

Followup Interval 

Aut

Massouh46 1989 33 

RCT (parallel) Camp 

IG – 1-hr. program presented on selfmanagement and the physiology of diabetes, 40-min. social learning intervention session, role modeling used to enact behaviors used to deal with peer pressure CG – 1-hr. program presented on selfmanagement and the physiology of diabetes, 40-min. session developing questions for a game show 

Diabetes expert (IG and CG); psychologist (IG) 8 d. 3 1⁄2 mo. 

HbA1c – Nbetween IG test states HbA1c afte

McNabb47 1994 24 

RCT (parallel) Diabetes center 

IG – 6 1-hr sessions, children learned and practiced relevant self-care behaviors, parents learned parenting skills, at the end of the session children set self-care goals and practiced the behaviour with their parents, modified goal to a less demanding one if necessary CG – Standard care 

NR (IG); Physician, nurse, dietitian (CG) 6 wk. (IG); 0 wk. (CG) 6 wk. (IG); 12 wk. (CG) 

HbA1c – Msignificantly (p<0.04) bucompared tSelf-mana

Difference not statisticPyschosoc– Children responsibilsignificantly 

Mendez48 1997 37 

CCT Health center (IC); NR (CG) 

IG – 12 sessions, review, new content (audiovisual and printed material), skill practice and homework assignment, parents attended 2 sessions, emphasizing reinforcement of adherence behaviors rather than punishing noncompliance CG – NR 

The authors of the paper, psychologist (IG); NR (CG) January-April 1993 13 mo. 

Knowledg

than CG not sig

Knowledg

nutritioactivitythan CG but lose

Self-mana

significantly (p = 0.002) PyschosocNo significagroups for support at 
F-39

Table F2. Characteristics and effectiveness of studies of diabetes education for children with type 1 diabetes and their families 

Author Year Sample Size (n) 

Study Design 

Setting 

Intervention Interventionist 

Duration of Intervention 

Followup Interval 

Aut

Mendez 1997 (continued) 

Coping (sphassles) – CG at postmo. (p = 0.Coping (deof response significantly (p = 0.040) 

Mitchell49 1996 32 

RCT (parallel) Diabetes center 

IG – Standard care, plus booklet Improving Compliance with Treatment for Diabetes, identifies problems with adherence and offers basic self-management skills, contents reviewed with patient CG – Standard care 

Multidisciplinary team (IG and CG) NR 12 mo. 

HbA1c – IG compared tmo. Pyschosocsignificant dgroups. IG mo. (p<0.0Psychosocrelationshipdifferences significant c(p<0.05)Coping (pediabetes msignificant dCoping (soadjustmentdifferences 

Monaco50 1996 58 

Uncontrolled before-and-after study Diabetes center 

IG – 1 session, children instructed in the use of injection site charts (before) and injection site bears (after) 

Research staff Single event Immediate 

Knowledgbear there injection sitcompared t0.0005) Knowledgbear there injection sitcompared t0.0001) 
F-40

Table F2. Characteristics and effectiveness of studies of diabetes education for children with type 1 diabetes and their families 

Author Year Sample Size (n) 

Study Design 

Setting 

Intervention Interventionist 

Duration of Intervention 

Followup Interval 

Aut

Moran51 1991 22 

CCT Hospital, home 

IG – 45-minute psychotherapy sessions, probable cause of child’s psychological disturbance determined during initial meeting, 

interviews unstructured and focused on child’s interest and emotional concerns CG – Standard care, possible therapy for 

emotional problems

Psychologist, nurse 45-minute sessions 3–5 meetings/week for 5–28 weeks (IG); 1–12 weeks (CG) 12 mo. 

HbA1c – IG improvemepercent), Cpercent) Health carNo significahospitalizatfewer diabethan CG 

Nordfeldt52 2005 332 

RCT (parallel) Home 

IG1 – 2 video programs (17 and 18 min.) received at baseline, reviewed practical selfmanagement skills aimed at preventing hypoglycemia, FAQ brochure (32 pp., 5,200 words), received 1 mo. Later, information on symptoms and prevention of hypog;ycemia and maintenance of normoglycemia IG2 – Standard care, plus video (13-min.) and brochure (16 pp., 800 words) with general diabetes information CG – Standard care 

Videotape, brochure (IG and IG2), NA (CG) NA (expected to use tools as needed) 24 mo. 

Short-term 

(hypoglycereduction a0.0241), no other two g

Nordfeldt53 2002 130 

Prospective cohort with historical controls Home 

IG – 2 self-study brochures, prevention of severe hypoglycemia (16 pp., 1,800 words) and self-management skills (12 pp., 1,500 words), 2 video programs (17 and 18 min.) with content related to brochures mailed later, outpatient clinic visits 

Videotape, brochure NA 3 yr. 

HbA1c – S1996-7 (p = = 0.006) Short-term 

hypoglycemevents/pt. ydecreased, significant Short-term percent patunconscioudecrease, bsignificant 
F-41

Table F2. Characteristics and effectiveness of studies of diabetes education for children with type 1 diabetes and their families 

Author Year Sample Size (n) 

Study Design 

Setting 

Intervention Interventionist 

Duration of Intervention 

Followup Interval 

Aut

Nordfeldt54 1999 139 

Prospective cohort with historical controls Home, community, school, diabetes center 

IG – Scheduled visits to individual families, intense problem-based training, supplemented by training at camps and evening lectures, continuous individual psychosocial support provided 

Multidisciplinary team Median: 4 visits/yr. (range 3-8) 248 patient yr. 

HbA1c – Mdifferent froHealth carfrom 3 incidto 0 incidencalculated) Short-term 

(hypoglyceevents/pati0.17 events1995 Short-term No change events/pt. y

Nunn55 2006 123 

RCT (parallel) Home (IG) diabetes center (both) 

IG – 15-30-min. phone calls, 3 main topics: insulin, carbohydrate intake, and blood glucose values, events which may impact diabetes management, and education program, spoke to parent if child unable to make independent decisions CG – Standard care 

Diabetes educator (IG), pediatric endocrinologist (IG and CG) 5-8 mo. Immediate 

HbA1c – Nbetween grHealth carsignificant dKnowledgdifferences Psychosocsignificant dPsychosocsignificant dPyschosocNo significagroups PsychosocNo significagroups Psychosocsignificant d
F-42

Table F2. Characteristics and effectiveness of studies of diabetes education for children with type 1 diabetes and their families 

Author Year Sample Size (n) 

Study Design 

Setting 

Intervention Interventionist 

Duration of Intervention 

Followup Interval 

Aut

Olmsted56 2002 85 

RCT (parallel) Diabetes center 

IG – 6 weekly 90-min. sessions adapted from a standardized intervention for eating disorders, parents and daughters in separate rooms, written and oral presentations on the nature of eating problems, strategies for change, patients asked to read chapters from a manual before each session CG – Standard care 

Individuals with expertise in eating disorders, and adolescent diabetes (IG); NR (CG) 6 wk. 6 mo. 

HbA1c – Nbetween grPsychosoc28 days) – between grsuggest moPyschosoc28 days) – between grPsychosicSignificant (p<0.00005Psychosocsignificant dPsychosocSignificant (p<0.00005

Panagiotopoulos57

2003 

50 RCT (parallel) Home, diabetes center 

IG – 1-2 times per week educator telephoned patients for 15-20 min., recorded blood glucose values and adjusted insulin, encouraged more frequent SMBG and record keeping, reinforced target blood glucose values, educated on insulin adjustment, addressed teen issues and encouraged individualized goal-setting CG – Standard care 

NR 6 mo. 12 mo. (continuous) 

HbA1c – Smo. In both (p = 0.01), differences 

Pichert58 1994a 83 

RCT (parallel) Camp 

IG – 3 45-min. groups sessions devoted to nutrition-related skills and knowledge, written material, video, made food choices for a 3-day high energy adventure CG – 3 45-min. session using flash cards to learn food group/exchange equivalents and meal planning 

Diabetes educator (IG); dietitian (IG and CG)  3 45-min. sessions Tested at 2-4 d. and 5-6 d. 

Knowledgplans) – Sigboth group(p<0.01) Knowledgequivalentsdifference bSelf-mana

measures) between grimprovemeSelf-mana
F-43

meals, ove

Table F2. Characteristics and effectiveness of studies of diabetes education for children with type 1 diabetes and their families 

Author Year Sample Size (n) 

Study Design 

Setting 

Intervention Interventionist 

Duration of Intervention 

Followup Interval 

Aut

Pichert 1994a (continued) 

difference bboth showe

Pichert59 1994b 84 

RCT (parallel) Camp 

IG – 2 45-min. sessions, video and discussion, 9 guidelines for sick-day management CG – 2 45-min. sessions, viewed video, and completed paper and pencil activity (session 1), reviewed knowledge, played games that prompted rehearsal and application of sickday guidelines, discussion (session 2) 

Diabetes educator (IG and CG)  2 45-min. sessions 8 mo. 

Knowledgoutperformsignificant dgroups Knowledgcampers ou(p<0.01) bubetween stKnowledgOlder camp(p<0.01) bubetween stKnowledgcampers ou(p<0.01) bubetween stSchool pedifference b

Pichert60 1993 70 

RCT (parallel) Camp 

IG – 4 45-min. sessions during a 2-wk. camp, topics included guidelines for testing glucose and ketons, calculating snacks needed to cover for exercise, preventing dehydration, wearing identification and carrying sugar, all classes were presented according to IDEAL method CG – 4 45-min. sessions during a 2-wk. camp, topics included guidelines for exercise and diabetes, open discussion on social issues and diabetes, IG instructor videotaped sessions for CG, which was then show by a proctor to CG 

Nurse, physician, camp counsellor (IG and CG) 4 45-min. sessions Immediate 

Knowledgguidelines) outperformoverall posthan pretesbetween grsignificant Knowledgknowledgeoutperformoverall posthan pretesinteraction testing was 
F-44

Table F2. Characteristics and effectiveness of studies of diabetes education for children with type 1 diabetes and their families 

Author Year Sample Size (n) 

Study Design 

Setting 

Intervention Interventionist 

Duration of Intervention 

Followup Interval 

Aut

Povlsen61 2005 37 

Uncontrolled before-and-after study Hospital 

IG – 7 re-education sessions, parents and children focused on increasing knowledge, self-care and providing psychosocial support 

Nurse Aug 2002–June 2003 6 mo. 

HbA1c – Sintervention increased tat 3 and 6 Short-term 

(hypogycemof events insignificantly Short-term One event intervention Knowledgknowledge differences 

Remley621999 237 

CCT Camp 

IG1 – Week long camp, 1-hr. didactic lecture on assertive communication, 1-hour peer group discussion, 1-hr. play, 1-hr. nutritional education CG – Attended camp, no specialized education 

Physician, nurse, camp counselor, nutritionist (IG); NA (CG) 1 wk. 3 mo. 

HbA1c – Nboth groupKnowledgsignificant camp Knowledgsignificant camp Self-manaplanning seslightly, CG to post caminteraction general lineAdherence from pre to Pyschosoc– No signifpost camp Psychosocdiabetes) – from pre to Psychosic
F-45

Table F2. Characteristics and effectiveness of studies of diabetes education for children with type 1 diabetes and their families 

Author Year Sample Size (n) 

Study Design 

Setting 

Intervention Interventionist 

Duration of Intervention 

Followup Interval 

Aut

Remley 1999 (continued) 

 quality) – N

from pre to Psychosocsignificant camp. IG uthen decreslightly presignificant)

Satin63 1989 32 

RCT (parallel) Hospital 

IG1 – 2 90-min. sessions established group 

process, stressed that diabetes is a family disease and requires teamwork, discussion of feelings around diabetes, 4 90-min. sessions on diabetes management and adherence IG2 – Same as IG1 plus, parents simulated diabetes self-management for 1 week, adolescents taught parents how to manage their diabetes CG – No intervention 

Social worker, nurse practitioner (IG1 and IG2); NA (CG) 6 wk. 6 mo. 

HbA1c – IGcompared timprovemesignificant Psychosocrelationship

Schlundt64 1996 86 

Uncontrolled before-and-after study Camp 

IG – 2 sessions, 1-3 days apart, used a 17-min. video on obstacles faced by adolescents with diabetes, campers identified, analyzed and proposed solutions, then apply them to their own lives 

Dietitian 2 wk. Immediate 

Psychosocbehavioral) increase in (p<0.01) Psychosoccare abilitiein score aft

Shobhana65 1997 37 

Uncontrolled before-and-after study Diabetes center, hospital 

IG – 1 day consisted of 1-hour didactic lecture on diabetes with a question and answer period, injection and monitoring skills, pamphlets and other reading material, individualized diet-counseling 

Multidisciplinary team NR (approximately 1 d.) 6 mo. 

Knowledgcomparing IDDM, insuhypoglycemSignificant testing and areas exce
F-46

Table F2. Characteristics and effectiveness of studies of diabetes education for children with type 1 diabetes and their families 

Author Year Sample Size (n) 

Study Design 

Setting 

Intervention Interventionist 

Duration of Intervention 

Followup Interval 

Aut

Siminerio66 1999 32 

Prospective cohort with concurrent control group Hospital (IG1); home (both); outpatient clinic (IG2) 

IG1 – 10-12 hr. of inpatient education sessions over 3 d., individualized, basic knowledge about diabetes, hypo- and hyperglycemia, self-management skills, nutrition and exercise, follow-up telephone calls made IG2 – Same as IG1, except on an outpatient basis 

Diabetes educator, dietitian 3-5 d. 1 mo. 

Health carepisodes in 

month post Knowledgdifferences KnowledgOutpatients than inpatie(p<0.004) aSelf-manaregulation) significantly group (p<0Self-mana(emergencgroup signiinpatient (pPsychosoc– Increase the outpatieCoping – Nbetween gr

Smith67 1993 120 

Uncontrolled before-and-after study Camp 

IG – Daily 1-hr. sessions during a 5-d. camp, provided information, facilitated sharing, opportunities to practice assertive communication, problem solving and negotiation skills, general and diabetesspecific situations discussed, sessions included 7-9 campers 

Medical education staff 5 d. 3 mo. 

PyschosocSignificant comparing day of camPsychosocrelationshipin degree ocommunicasignificant dcommunicaand similar (p<0.06) po
F-47

Table F2. Characteristics and effectiveness of studies of diabetes education for children with type 1 diabetes and their families 

Author Year Sample Size (n) 

Study Design 

Setting 

Intervention Interventionist 

Duration of Intervention 

Followup Interval 

Aut

Smith68 1991 108 

Uncontrolled before-and-after study Camp 

IG – Daily 1-hr. sessions on stress and diabetes, management techniques described, modeled and practiced using relaxation, imagery, exercise, problem solving and challenging negative thoughts and cognitive distortions 

Medical education staff NR NR 

Coping – Npre to postc

Srinivasan69 2004 110 

Prospective cohort with concurrent control group Outpatient day care program (IG); hospital (CG) 

IG – Diabetes day care program attended by family for 2-3 successive d. for “survival skills” diabetes education, printed guide and instructions on when to contact on-call team for assistance, additional 3-4 formal education sessions, families attended an outpatient clinic CG – Hospitalized for 4-7 d. for detailed education program, families returned to newpatient clinic within 3-6 wk. 

Multidisciplinary team 4-6 wk. (IG); 4-7 d. (CG) 12 mo. 

HbA1c – Nbetween grKnowledgdifferences Psychosocand conflicdifferences PsychosocNo significagroups Coping – Nbetween gr

Sundelin70 1996 38 

RCT (parallel) Apartment on hospital grounds (IG); hospital (CG) 

IG – Families lived in training apartment, all members encouraged to move in for 2 wk., family-orientated crisis therapy, interactions occurred through a variety of day-to-day situations using problems and questions formulated by family, customized management strategies, individualized dietary recommendations, followup according to Swedish standards CG – Child hospitalized with one parent, encouraged to attend informative meetings with medical staff, individualized dietary 

recommendations, 

Multidisciplinary team (IG); Diabetes educator, dietitian (CG) 2 wk. (IG); 3 wk. (CG) 2 yr. 

HbA1c – Sdifference oto 3 extremPsychosocstatistically between grPsychosocrelationshipchild social disturbancesignificant d
F-48

Table F2. Characteristics and effectiveness of studies of diabetes education for children with type 1 diabetes and their families 

Author Year Sample Size (n) 

Study Design 

Setting 

Intervention Interventionist 

Duration of Intervention 

Followup Interval 

Aut

Sundelin 1996 (continued) 

followup according to Swedish standards Pyschosoc

climate) – Ndifference bPyschosocisolation, cstatistically between gr

Svoren71 2003 301 

RCT (parallel) Diabetes center 

IG1 – Care ambassador assigned to assist families in scheduling and monitoring appointments, help with billing and insurance issues and provide outreach after missed or canceled appointments IG2 – Same as IG1, plus eight 15-30 min. psychoeducational modules delivered at quarterly clinic visits, family discussion encouraged, 2-3 pp. of written material given after each visit CG – No intervention 

Research staff (IG1 and IG2); NA (CG) 24 mo. 24 mo. 

Health carSignificantlgroup comgroups (p = Health car(hospitalizareduced racompared t0.04) over Short-term (hypoglcemreduced racompared t0.02) over 

Szumowski72

1990 

27 RCT (parallel) Outpatient clinic 

IG – Six 60-90-min. meetings over 8 wk., children and parents seen separately, at meetings homework reviewed, lesson presented, children completed activities to facilitate learning, parents engaged in discussion, contact maintained with families via monthly mailings and telephone calls, specific diabetes behaviors targeted, goals set in first meeting CG – Same as IG, without diabetes behavior education or goal-setting 

Multidisciplinary team 2 mo. 3 mo. 

HbA1c – Ncomparing Short-term (hypoglycedifference cmo. Knowledgapplied to cx time intergroups com KnowledgIncrease in mo., but stareported Knowledg
F-49

Table F2. Characteristics and effectiveness of studies of diabetes education for children with type 1 diabetes and their families 

Author Year Sample Size (n) 

Study Design 

Setting 

Intervention Interventionist 

Duration of Intervention 

Followup Interval 

Aut

Szumowski 1990 (continued) 

 Increase in 

mo., but stareported PyschosocSignificant comparing Pyschosocrelationshipdifference cmo. Self-mana(physical adifference cmo. Self-mana(nutritional significant dbaseline to 

Templeton73 1988 30 

Uncontrolled before-and-after study Diabetes center 

IG – Adolescents met in groups (5-7 people) for 1 90-min. session, arrived at the clinic fasting, took blood sugar then administered insulin while nurse observed, with dietitian, group converted each person’s breakfast into exchanges, blood glucose measured at 30-min. intervals and plotted on a graph, discussion about SMBG 

Multidisciplinary team 1 90-min. session Immediate 

Knowledgnutritional crange from median = 8statistical sKnowledgnutritional ctopics) – P96%-100% 96%), no csignificance 

ThomasDobersen74 1993 20 

CCT NR 

IG – 14 90-min. sessions over 3 mo., adolescents learned self-management skills, importance of diet and exercise and knowledge around hypoglycemia, manuals for both adolescents and adults, parents offered 13 sessions covering strategies to support weight-loss, methods to alter family diet and 

Psychologist, dietitian, child health associate (IG); NA (CG) 3 mo. 1 yr. 

Knowledgincrease in CG at 3 or PyschosocCG subject 15 mo., com(significanc
F-50

Table F2. Characteristics and effectiveness of studies of diabetes education for children with type 1 diabetes and their families 

Author Year Sample Size (n) 

Study Design 

Setting 

Intervention Interventionist 

Duration of Intervention 

Followup Interval 

Aut

ThomasDobersen 1993 (continued) 

 activity patterns and improve parenting 

 and communication skills 

CG – Standard care

Verrotti75 1993 30 

Uncontrolled before-and-after study NR 

IG – 9 2-hr. education sessions over 15 d., delivered one-to-one using simple language, new sessions evaluated discussion from previous one, self-management skills, hyperand hypoglycemia, nutrition, diet and exercise, diabetes complications and one session dedicated to mixing insulin, parents attended session on diet 

Physician, nurse 15 d. 12 mo. 

HbA1c – Alevels ahd 0.019) Short-term 

(hypogycemlower numbKnowledgscores at 1baseline 

Viner76 2003 21 

CCT NR 

IG – 6 weekly sessions, groups broken down by age, motivational and solution-focused therapy techniques, systematic questions, a narrative approach and cognitive behavioural therapy used, parent group run to facilitated 

parental support for change CG – No intervention 

NR 6 wk. 1 yr. 

HbA1c – Adecreased at 7–12 moto CG but nPyschosocsignificant PsychosocSignificant cases rece0.014) 

von Sengbusch77

2006 

107 Uncontrolled before-and-after study Hospital 

IG – 5 d. of inpatient education by Mobile Diabetic Teaching Team, children grouped (4-6 people) by age, included knowledge, self-confidence, age appropriate independence and self-management, parents trained in groups, or one-on-one, 1-2 times on insulin, sick days and everyday challenges 

Physician, nurse 5 d. 6 mo. 

HbA1c – Nchanges afShort-term (hypoglycesignificant Health carsignificant comparing Knowledgimproveme(p<0.01) ancompared t
F-51

Table F2. Characteristics and effectiveness of studies of diabetes education for children with type 1 diabetes and their families 

Author Year Sample Size (n) 

Study Design 

Setting 

Intervention Interventionist 

Duration of Intervention 

Followup Interval 

Aut

von Sengbusch 2006 (continued) 

Quality of improvemeand 12 mobaseline

Vyas78 1988 63 

Uncontrolled before-and-after study Camp 

IG – Camp, 10 d. for children 5–7 yr. and 14 days for children 9–14 yr., similar activities during each camp, children learned selfmanagement and problem solving skills 

Camp medical staff, camp leaders 10–14 d. 3 mo. 

Self-manablood/urineincrease of comparing Self-mana(independeStatistically ability (p = holiday to 3 

Wadham79 2005 67 

RCT (parallel) Clinic 

IG – 4 sessions: food enjoyment with carbohydrate counting, insulin dose adjustment, blood sugar testing and HbA1c, teamwork and communication to support blood glucose and independence, sharing responsibility and letting go CG – No intervention 

Nurse, physician, dietitian (IG); NA (CG) 12 mo. Ongoing with intervention 

HbA1c – resignificant d

Webb80 1999 66 

RCT (parallel) Outpatient clinic 

IG – Presentation on the importance of goal setting, 5 guidelines for goal setting given to parent and child, therapist encouraged childparent dyads to select 1 goal in 4 self-care behavioral areas, parents worked closely with children, trained to use goal setting worksheets to assist recording and monitoring goal process CG – Child-parent dyads worked with therapist to set goals using goal setting worksheet 

Research staff (IG and CG) 12 wk. 3 mo. (IG); 2 mo. (CG) 

HbA1c – Nbetween grphases (all Self-mana

for insulin aincrease (pcompared tSelf-manafor SMBG) between grSelf-manafor physicaincrease (p compared t
F-52

Table F2. Characteristics and effectiveness of studies of diabetes education for children with type 1 diabetes and their families 

Author Year Sample Size (n) 

Study Design 

Setting 

Intervention Interventionist 

Duration of Intervention 

Followup Interval 

Aut

Webb 1999 (continued) 

Self-manafor food inta(p = 0.001) to GSO assp>0.05) Self-manainteraction assessmen

Wolanski81 1996 41 

RCT (parallel) Camp 

IG – Camp, 1-2 individualized 15-30 min. sessions, self-testing under supervision, received corrections, discussed importance of correct testing, small group discussion (based on age) concerning self-testing CG – Attended camp, no specialized education 

Trained observer, supervisor (IG); NR (CG) 1-2, 15-30 min. sessions Immediate 

Self-manasyst. error difference bcomparing intervention Self-manaerrors) – Nbetween grbaseline to Psychosocnegative cosignificantly other groupPsychosoccommunicaimproved c6 and12 moPsychosocreciprocity) improvemegroups at 6 Psychosocresolution) improvemegroups at 6 
F-53

Table F2. Characteristics and effectiveness of studies of diabetes education for children with type 1 diabetes and their families 

Author Year Sample Size (n) 

Study Design 

Setting 

Intervention Interventionist 

Duration of Intervention 

Followup Interval 

Aut

Wysocki82 2007 104 

RCT (parallel) Diabetes center 

IG1 – Standard care, plus 12 90-min. meetings within 6 mo., groups included 3-5 families, meetings emulated a common mental health service for families of chronically ill teens, content followed chapters of an ADA curriculum for teens, family communication and conflict resolution skills were excluded IG2 – Standard care, plus 12 behavioral family systems therapy sessions, 4 components—problem-solving training, communication skills, cognitive restructuring, functional and structural family therapy CG – Standard care 

Nurse (IG1); psychologist (IG2 and CG); diabetes educator, pediatric endocrinologist (CG) 6 mo. 12 mo. 

HbA1c – Bthan CG (p18 mo.; BFthan ES (pSelf-manaBFST-D sigthan SC at significant dand ES or time, signifgroups (p<interaction Psychosocrelationshiplower than significant (p<0.03), beffect not s

Wysocki83 2000 119 

RCT (parallel) Doctor’s office 

IG1 – Standard care, plus 10 sessions of BFST, 4 components—problem-solving training, communication skills, cognitive restructuring, functional and structural family therapy, families received individualized plans, session activities included problem solving discussions, feedback, modeling, rehearsal, homework IG2 – Standard care, plus 10 group meetings, emphasized education and social support, 2–5 families per group, family communication and conflict resolutions skills excluded CG – Standard care 

Psychologist (IG1); social worker, health educator (IG2); physician (CG) 3 mo. 12 mo. 

HbA1c – Nbetween grSelf-manaSome imprchildren at dissipated Psychosocbeliefs) – Bscores commo. FU (p 
F-54

Table F2. Characteristics and effectiveness of studies of diabetes education for children with type 1 diabetes and their families 

Author Year Sample Size (n) 

Study Design 

Setting 

Intervention Interventionist 

Duration of Intervention 

Followup Interval 

Aut

Zorumski84 1997 56 

CCT Day camp (IG); doctor’s office (CG) 

IG – 1-wk. camp, covered all aspects of diabetic self-management, used active participation and educational presentations, observed and demonstrated behaviors CG – Standard care 

Diabetes educator, health care professional (IG); physician (CG) 1 wk. (IG); NR (CG) 4 mo. 

HbA1c – Ndifference bPsychosocstatistically (p<0.05) at Psychosoc

No statisticbetween gr
F-55

Table F3. Methodological quality of uncontrolled before-and-after and cohort studies assessing the effectiveness of diabetes e

type 1 diabetes and their families 

Selection bias Allocation bias Confounding Blinding Data collection methods W

Author Year 

Representative of target 

population? 

% agreed to participate 

Rating 

Study design 

Rating 

Between group differences 

prior to intervention? 

Relevant confounders 

specified 

Confounders adequately 

managed in analysis? 

Rating 

Assessor(s) blinded to 

intervention status? 

Rating 

Data collection tools valid? 

Data collection tools 

reliable? 

Rating 

Caravalho11

2000 

Somewhat 

likely 

<60 W Uncontrolled 

beforeand-after study 

W NA Age, sex, 

duration, SES 

NA M No W Yes Yes S 6

Christensen12

2000 

Not likely ≥80 W Uncontrolled 

beforeand-after study 

W NA Sex, 

duration 

NA W No W No No W ≥

Greco20 2001 Somewhat 

likely 

60-

79 

M Uncontrolled 

beforeand-after study 

W NA Age, sex, 

duration, SES 

NA M NR W Yes Yes S ≥

Harkavy27

1983 

Somewhat 

likely 

NR M Uncontrolled 

beforeand-after study 

W NA Age, sex, 

duration, SES 

NA M NA W No No W ≥

Harris28 2005 Not likely <60 W Uncontrolled 

beforeand-after study 

W NA Age, sex, 

SES 

NA W NR W Yes Yes S ≥

Hill29 2006 Somewhat 

likely 

NR W Prospective 

cohort with concurrent control 

M Can't 

Tell 

Age, sex NA W No W Yes Yes S <

M = moderate; NA = not applicable; NR = not reported; SES = socioeconomic status; W = weak 
F-56

Table F3. Methodological quality of uncontrolled before-and-after and cohort studies assessing the effectiveness of diabetes e

type 1 diabetes and their families (continued) 

Selection bias Allocation bias Confounding Blinding Data collection methods W

Author Year 

Representative of target 

population? 

% agreed to participate 

Rating 

Study design 

Rating 

Between group differences 

prior to intervention? 

Relevant confounders 

specified 

Confounders adequately 

managed in analysis? 

Rating 

Assessor(s) blinded to 

intervention status? 

Rating 

Data collection tools valid? 

Data collection tools 

reliable? 

Rating 

Karaguzel34

2005 

Not likely NR W Uncontrolled 

before-andafter study 

W NA Age, sex, 

duration 

NA W No W No No W ≥

Kemp35 1986 Somewhat 

likely 

NR W Uncontrolled 

before-andafter study 

W NA Age NA W No W Yes Yes S N

Koontz37 2002 Somewhat 

likely 

60-

79 

M Uncontrolled 

before-andafter study 

W NA Age, sex, 

duration, SES 

NA S No W Yes Yes S <

Lawson39

2000 

Somewhat 

likely 

NR W Retrospective 

cohort 

W No Age, 

duration 

NA W NR W Yes Yes S ≥

Likitmaskul40

2002 

Very likely NR M Prospective 

cohort with historical control 

W No Age, sex, 

duration 

NA W No W Yes Yes S ≥

Lipman41

1988 

Somewhat 

likely 

≥80 M Retrospective 

cohort 

W No Age, sex, 

duration 

NA W No W Yes Yes S ≥

Marteau44

1987 

Not likely NR W Uncontrolled 

before-andafter study 

W NA None NA W No W No No W ≥

Monaco50

1996 

Very likely NR M Uncontrolled 

before-andafter study 

W No Age, sex NA W No W Yes Yes S ≥
F-57

Table F3. Methodological quality of uncontrolled before-and-after and cohort studies assessing the effectiveness of diabetes e

type 1 diabetes and their families (continued) 

Selection bias Allocation bias Confounding Blinding Data collection methods W

Author Year 

Representative of target 

population? 

% agreed to participate 

Rating 

Study design 

Rating 

Between group differences 

prior to intervention? 

Relevant confounders 

specified 

Confounders adequately 

managed in analysis? 

Rating 

Assessor(s) blinded to 

intervention status? 

Rating 

Data collection tools valid? 

Data collection tools 

reliable? 

Rating 

Nordfeldt54

1999 

Very likely ≥80 S Prospective 

cohort with historical controls 

W NA Age, sex, 

duration 

NA W No W No No W ≥

Nordfeldt53

2002 

Very likely NR M Uncontrolled 

before-andafter study 

W NA Age, duration 

(average) 

NA W No W Yes Yes S N

Povlsen61

2005 

Somewhat 

likely 

NR W Uncontrolled 

before-andafter study 

W NA Age, 

duration 

NA W NR W Yes No W 6

Schlundt64

1996 

Somewhat 

likely 

NR W Uncontrolled 

before-andafter study 

W NA Age, sex, 

duration 

NA W No W Yes Yes S <

Shobhana65

1997 

Somewhat 

likely 

NR M Uncontrolled 

before-andafter study 

W NA None NA W NR W No No W <

Siminerio66

1999 

Somewhat 

likely 

NR M Prospective 

cohort with concurrent control group 

W No Sex, age, 

SES, duration 

NA M NR W Yes Yes S ≥

Smith68 1991 Somewhat 

likely 

60-

79 

M Uncontrolled 

before-andafter study 

W NA Age, sex, 

duration 

NA W NA W No Yes W ≥
F-58

Table F3. Methodological quality of uncontrolled before-and-after and cohort studies assessing the effectiveness of diabetes e

type 1 diabetes and their families (continued) 

Selection bias Allocation bias Confounding Blinding Data collection methods W

Author Year 

Representative of target 

population? 

% agreed to participate 

Rating 

Study design 

Rating 

Between group differences 

prior to intervention? 

Relevant confounders 

specified 

Confounders adequately 

managed in analysis? 

Rating 

Assessor(s) blinded to 

intervention status? 

Rating 

Data collection tools valid? 

Data collection tools 

reliable? 

Rating 

Smith67 1993 Somewhat 

likely 

≥80 M Uncontrolled 

before-andafter study 

W NA Age, sex, 

duration, SES 

NA M No W Yes Yes S <

Srinivasan69

2004 

Very likely NR M Prospective 

cohort with concurrent control group 

W No Age, A1c, 

SES 

NA W No W Yes Yes S ≥

Templeton73

1988 

Somewhat 

likely 

NR W Uncontrolled 

before-andafter study 

W NA Age, 

duration 

NA W No W No No W ≥

Verrotti75 1993 Somewhat 

likely 

NR W Uncontrolled 

before-andafter study 

W No Age, sex, 

duration, SES 

NA M NR W Yes Yes S ≥

von 

Sengbusch77 2006 

Somewhat 

likely 

≥80 M Uncontrolled 

before-andafter study 

W Yes Age, sex, 

duration, family structure 

NA M NR W Yes Yes S ≥

Vyas78 1988 Very likely NR M Uncontrolled 

before-andafter study 

W NA Age, sex, 

duration 

NA W No W Yes Yes S 6