written informed consent was obtained from the parents , and assent was obtained from the subjects . the institutional review board at ut southwestern medical center approved this study , which began in august 2006 and ended in may 2008 . participants were randomized to either the mi or sde group based on a sex - stratified schedule . a third education session was planned ( t2 ) if a1c continued to be 9% . three diabetes educators were assigned to the mi arm and trained on motivational interviewing at a 2-day workshop . ( 3 ) , journal articles ( 4 ) , and guidance from the mi trainer and psychologist . the remaining six educators were assigned to the sde arm and did not receive additional training . educators used a comprehensive checklist compiled using core content recommended by the american diabetes association ( ada ) on medication , monitoring , acute complications , and lifestyle ( 5 ) . all audiotapes were coded using the motivational interviewing treatment integrity 3.0 ( miti 3.0 ) coding system ( 6 ) . the coder attended a 2-day workshop on miti 3.0 and was blinded to the treatment groups . a1c ( measured via a dca vantage analyzer ) and psychosocial measures were collected at baseline and at 3 , 6 , and 9 months ( t3 ) . psychosocial measures included the center for epidemiologic studies depression scale ( ces - d ) ( 7 ) , the epidemiology of diabetes interventions and complications quality of life questionnaire ( edic - qol ) ( 8) , and the summary of diabetes self - care activities ( 9 ) . the mixed - model procedures of proc mixed in sas version 9.2 ( sas institute , cary , nc ) were used for the primary analysis . baseline values of a1c and each baseline psychological measure were included as covariates in the respective analyses . the main effect of treatment group and the treatment group  time period interaction effect were examined . cohen 's d was interpreted as the effect size estimator for the between - subject treatment group effect . a1c ( measured via a dca vantage analyzer ) and psychosocial measures were collected at baseline and at 3 , 6 , and 9 months ( t3 ) . psychosocial measures included the center for epidemiologic studies depression scale ( ces - d ) ( 7 ) , the epidemiology of diabetes interventions and complications quality of life questionnaire ( edic - qol ) ( 8) , and the summary of diabetes self - care activities ( 9 ) . the mixed - model procedures of proc mixed in sas version 9.2 ( sas institute , cary , nc ) were used for the primary analysis . baseline values of a1c and each baseline psychological measure were included as covariates in the respective analyses . the main effect of treatment group and the treatment group  time period interaction effect were examined . cohen 's d was interpreted as the effect size estimator for the between - subject treatment group effect . a total of 26 participants were randomized to the mi group and 28 to the sde group . six - month data ( t2 ) were available on 21 and 23 patients in the mi and sde groups , respectively ( table 1 ) . four patients each in the mi and sde groups had a third education session at t2 . baseline characteristics , a1c , psychosocial measures , and miti 3.0 least squares ( ls ) means are adjusted for each respective baseline measure . f statistic was used to test for omnibus mean difference on each measure between the two treatment groups over 6 months of follow - up . * children 's health insurance program ( chip)/children with special health care needs ( chscn ) . primary outcome variable , least squares means for a1c , adjusted for baseline over 6 months of follow - up . overall competence of the clinician in using mi based on a global rating scale of 15 , where 1 is low spirit and 5 is high spirit . the score for beginning proficiency and competency are 3.5 and 4 , respectively . # giving information , education , providing opinion without advising . fidelity to mi would correspond to lower scores on this variable . * * asking permission before giving advice , affirming , emphasizing control , and supporting the participant . number is based on frequency of occurrences . fidelity to mi would correspond to higher scores on this variable . after adjusting for baseline a1c , the pattern of omnibus least squares ( ls ) mean a1c values differed between groups ( f = 4.84 , df = 1 , 42.1 , p = 0.03 ) over the 6 months of follow - up ; the sde group had lower a1c ( least squares mean 10.31 , se 0.32 ) than the mi group ( least squares mean 11.35 , se 0.34 ) ( d = 0.66 , medium effect size ) . no overall time period effect emerged ( f = 0.33 , df = 2 , 34.8 , p = 0.72 ) and no treatment group  time interaction effect was found ( f = 0.20 , df = 2 , 34.8 , p = 0.81 ) ( table 1 ) . after controlling for baseline , there were no differences between the groups on any psychosocial outcome , none of which improved in either group ( table 1 ) . there were 21 subjects in the mi group and 22 in the sde group with interpretable tapes and miti scores . the groups differed on all indicators of fidelity to mi in the expected direction ( p < 0.001 , repeated - measures anova ) ( table 1 ) . after adjusting for baseline a1c , the pattern of omnibus least squares ( ls ) mean a1c values differed between groups ( f = 4.84 , df = 1 , 42.1 , p = 0.03 ) over the 6 months of follow - up ; the sde group had lower a1c ( least squares mean 10.31 , se 0.32 ) than the mi group ( least squares mean 11.35 , se 0.34 ) ( d = 0.66 , medium effect size ) . no overall time period effect emerged ( f = 0.33 , df = 2 , 34.8 , p = 0.72 ) and no treatment group  time interaction effect was found ( f = 0.20 , df = 2 , 34.8 , p = 0.81 ) ( table 1 ) . after controlling for baseline , there were no differences between the groups on any psychosocial outcome , none of which improved in either group ( table 1 ) . there were 21 subjects in the mi group and 22 in the sde group with interpretable tapes and miti scores . the groups differed on all indicators of fidelity to mi in the expected direction ( p < 0.001 , repeated - measures anova ) ( table 1 ) . although we hypothesized that lack of motivation more than poor knowledge impedes good metabolic control , we found that one brief intervention followed by a short education session could decrease mean a1c levels by 1% . subsequent sessions did not further affect the a1c , and the positive effect was maintained at 9 months . we should have assessed knowledge of diabetes pre- and posteducation to show that improved knowledge played a role in our results . however , we did find a higher amount of  given information  in the sde group compared with the mi group by miti scoring . the lack of efficacy of mi in our study is consistent with a recent trial in adult patients with poorly controlled type 1 diabetes ( 10 ) . in contrast , mi improved both metabolic control and psychosocial measures over a 12-month period in teens with diabetes ( 11 ) , but this study had more interventions over a longer period than ours . this was a small study that detected a treatment effect in the direction opposite to that hypothesized . perhaps the educators in the mi group were not proficient in mi compared with other studies ( 1113 ) , but the miti demonstrated good fidelity of our intervention to mi principles . in conclusion , brief motivational interviewing - based counseling with no pre - established level of educational content does not lead to improved metabolic control , whereas ongoing education is important for teens with poorly controlled diabetes . we did show that we could train diabetes educators in mi with adequate proficiency . before translating research to clinical practice future studies should compare structured diabetes education and sde plus motivation in a multicenter setting for a longer follow - up period .
objectiveto compare motivational interviewing  based education ( mi ) and structured diabetes education ( sde ) for improving a1c and psychosocial measures in adolescents with type 1 diabetes.research design and 
 methodsthis study was a 9-month randomized controlled trial comparing mi ( n = 21 ) to sde ( n = 23 ) . 
 interventions were at baseline ( t0 ) and 3 months ( t1 ) , with a1c and psychosocial measures obtained at 6 months ( t2 ) and 9 months ( t3).resultsover the 6 months of follow - up , the sde group had lower adjusted mean a1c value ( least squares mean 10.31 , se 0.32 ) than the mi group ( least squares mean 11.35 , se 0.34 ) ( p = 0.03 , d = 0.66 ) . there were no differences on any of the psychosocial measures.conclusionssde is effective at improving metabolic control in adolescents with type 1 diabetes . 
 diabetes educators were proficient in learning mi .