Sir,

Professor Snoek (1) argues that self-management education may be of limited effect because of its reported failure to persistently improve metabolic control in some recently published clinical trials in patients with type 2 and 1 diabetes (2,3). In our opinion, the problem with these and other trials was not that education per se was ineffective but the way it was conceived and delivered was bound to be so.

To hypothesize that a 6-hour crash course on type 2 diabetes in newly diagnosed patients would, without further reinforcement, turn them into competent self-carers for the rest of their lives was perhaps overoptimistic. That the marginal improvements in BMI and smoking observed at 1 year (4) would disappear after two more years (2) was to be expected.

We were able to observe persistent and reproducible clinical, psychological and cognitive improvements in patients with type 2 diabetes seen 1 hour every 3 months in a structured group education programme fully embedded within clinical practice. It took, however, 2 to 4 years to achieve significant results with these patients (5) and 3 years in patients with type 1 diabetes (6).

What clinicians and educators tend to overlook, especially when they are clinical educators, is that they are dealing with people, young and old, in a difficult time of their lives. Onset of diabetes, or any chronic disease, will profoundly affect an individual, child or elderly, in their perceptions, emotions, and relationships with loved ones (7).

Our almost 20 year long experience with patient education has taught us, if anything, that results arrive mostly from where one does not expect them. It takes time, accepting the complexity of disease and of those who suffer from it, it takes harmonising the work of operators, with all their pre- and misconceptions, which is possibly the most difficult part. It takes training, competence, patience, passion and humility to monitor the results while accompanying patients along a good stretch or perhaps the rest of their life. These ingredients will make working with chronic diseases not only effective but enriching and help prevent discouragement.

Marina Trento, Massimo Porta

References

1. Snoek FJ. Strategies to optimise clinical outcomes for patients with diabetes. Good professional consultation skills and self management education work, but effects don’t endure. BMJ 2012;344:e2673
2. Khunti K, Gray LJ, Skinner T, Carey ME, Realf K, Dalloso H, et al. Effectiveness of a diabetes education and self management programme (DESMOND) for people with newly diagnosed type 2 diabetes mellitus: three year follow-up of a cluster randomised controlled trial in primary care. BMJ 2012;344:e2333
3. Robling M, McNamara R, Bennert K, Butler CC, Channon S, Cohen D, et al. The effect of the Talking Diabetes consulting skills intervention on glycaemic control and quality of life in children with type 1 diabetes: cluster randomised controlled trial (DEPICTED study). BMJ 2012;344:e2359
4. Davies MJ, Heller S, Skinner TC, Campbell MJ, Carey ME, Cradock S, Dallosso HM, Daly H, Doherty Y, Eaton S, Fox C, Oliver L, Rantell K, Rayman G, Khunti K; Diabetes Education and Self Management for Ongoing and Newly Diagnosed Collaborative. Effectiveness of the diabetes education and self management for ongoing and newly diagnosed (DESMOND) programme for people with newly diagnosed type 2 diabetes: cluster randomised controlled trial. BMJ 2008; 336:491-5.
5. Trento M, Gamba S, Gentile L, Grassi G, Miselli V, Morone G, Passera P, Tonutti L, Tomalino M, Bondonio P, Cavallo F, Porta M; for the ROMEO investigators. Rethink Organization To Improve Education And Outcomes (ROMEO). A Multicentre Randomised Trial Of Lifestyle Intervention By Group Care To Manage Type 2 Diabetes. Diabetes Care 2010;33:745-747
6. Trento M, Borgo E, Kucich C, Passera P, Trinetta A, Charrier L, Cavallo F, Porta M. Quality of life, coping ability, and metabolic control in patients with type 1 diabetes managed by group care and a carbohydrate counting program. Diabetes Care 2009;32:e134
7. Biro D. An Anatomy of illness. J Med Human 2012; 33: 41-54

Competing interests: None declared