Patient Education and Counseling xxx (2018) xxx–xxx 

The effect of diabetes self-management education on psychological status and blood 

glucose in newly diagnosed patients with diabetes type 2 
Sanbao Chaia, Baoting Yaob, Lin Xub, Danyang Wangb, Jianbin Suna, Ning Yuana, Xiaomei Zhanga,*, 
Linong Jia,c 
aDepartment of Endocrinology and Metabolism, Peking University International Hospital, Beijing, 102206, China b Department 
of Endocrinology and Metabolism, First Hospital of Dandong, Dandong, 118000, China cDepartment of Endocrinology and 
Metabolism, Peking University People's Hospital, Beijing, 100044, China 
A R T I C L E I N F O 
Article history: Received 6 October 2017 Received in revised form 13 March 2018 Accepted 24 March 2018 
Keywords: Type 2 diabetes mellitus Self-management education Anxiety Depression Blood glucose 
A B S T R A C T 
Objective: The purpose of this study was to evaluate the efficacy of self-management education on psychological outcomes and 
glycemic control in type 2 diabetes mellitus. Methods: Patients were randomly assigned to education group and control group. 
Education group received professional education and control group received routine outpatient education. Results: A total of 118 
patients were randomly assigned to two groups (education group, n = 63; control group, n = 55). Compared with control group, 
the anxiety score (36.00 vs. 42.50, P < 0.05) and depression score (35.50 vs. 44.00, P < 0.05) significantly decreased at the sixth 
month in education group, respectively. Compared with control group, fasting blood glucose (6.78 mmol/L vs. 7.70 mmol/L, P < 
0.00), postprandial blood glucose (7.90 mmol/L vs. 10.58 mmol/L, P < 0.00) and glycosylated haemoglobin A1 
C 
level [6.20 (5.80, 6.60)% vs. 6.70 (6.40, 7.30)%, P < 0.01] significantly decreased after the sixth month in 
education group. Conclusion: The psychological status and blood glucose of patients with diabetes receiving self- management 
education were significantly improved. Practice Implications: Type 2 diabetes mellitus has been usually linked to increased 
prevalence and risk of depression and anxiety, which can affect blood glucose levels. Through education, the mood of newly 
diagnosed patients with diabetes improved, resulting in better blood glucose control. 
© 2018 Published by Elsevier B.V. 
1. Introduction 
Type  2 diabetes mellitus (T2DM) is a worldwide epidemic, and its prevalence is growing, creating a global healthcare burden. 
It  is  linked  to  increased  risk  of  severe  cardiovascular  complications,  morbidity  and  mortality  which  can  be  reduced  by  optimal 
glycemic  control  [1].  According  to  the  International  Diabetes  Federation,  in  2015  it  was  estimated  that  there  were  415  million 
people  with  diabetes  aged  20–79  years,  and  this  figure  was  predicted  to  rise  to  642  million  by  2040 [2]. To effectively manage 
individuals  with  diabetes,  appropriate  education,  lifestyle  modification,  medication  treatment  and  blood  glucose  monitoring are 
all required. Educa- tion is the foundation of care for all diabetes patients who want to 
achieve  successful  health  related  outcomes  [3].  Diabetes  self-  management  training,  the  process  of  teaching  individuals  to 
manage  their  diabetes,  has  been  considered  as  an  important  part  of  clinical  management  since  the  1930s.  50–80%  individuals 
with diabetes lack of knowledge about diabetes education, and ideal glycosylated haemoglobin A1 
C 
(HbA1 
C 
)  7.0%  target  is  achieved  in  less  than  half  of  type  2  diabetes  [4,5,6].  Extensive 
self-management  related  to  diet,  exercise  and  medication  are  regarded  as  critical  treatment  for  all  patients with diabetes [7]. As 
such,  diabetes  self-  management  education  (DSME)  is  widely  recommended  and  carried out. However, despite the great variety 
of  DSME  programs  that  are  currently  available  internationally,  there  is  a  lack  of  knowledge  about  the  importance  of  diabetes 
education  in  the  treatment  of  diabetes  and  in  prevention  of  diabetes  complications  in  developing  countries  [8,9].  Also  patients 
with diabetes have an 
* Corresponding author at: Life Park Road No.1, Zhongguancun Life Science Park, Changping District, Beijing, China. 
102206. 
E-mail address: z.x.mei@163.com (X. Zhang). 
increased  risk  of  developing  mental  disorders  and  psychological  disturbances.  Previous  studies  suggested  that  compared  to  the 
general population, individuals with diabetes have a higher 
https://doi.org/10.1016/j.pec.2018.03.020 0738-3991/© 2018 Published by Elsevier B.V. 
G Model PEC 5922 No. of Pages 6 
Contents lists available at ScienceDirect 

Patient Education and Counseling 

journal homepage: www.else vie r.com/locate /pateducou 
Please cite this article in press as: S. Chai, et al., The effect of diabetes self-management education on psychological status and 
blood glucose in newly diagnosed patients with diabetes type 2, Patient Educ Couns (2018), 
https://doi.org/10.1016/j.pec.2018.03.020 
 
prevalence  of  depression  and  anxiety  [10,11].  Therefore,  the  primary  objective  of  the  present study was to evaluate the efficacy 
of self-management education on psychological outcomes and glycemic control in newly diagnosed T2DM. 
2. Methods 
2.1. Study design 
The  study  was  approved  by  the  Ethics  Committee  in  the  First  Hospital  of  Dandong.  The  patientsinvolvedin 
thestudywererecruited  from  both  outpatients  and  inpatients  of  the  First  Hospital  of  Dandong.  Thephysician  in  chargeof  this 
researchfirst  introducedtheprogram  to  patients  eligible.  With  patients’  consent,  the  Informed  Consent  Forms  were  signed 
hereafter.  Based  on  the  statistical  analysis,  there  was about 5%patienteligiblebut failing toparticipatein thisstudy.Patients had the 
right  to  refuse  to  participate  in  or  withdraw  from  the  study  at  anytime.FromMay12016toJuly12016,atotalof118newlydiagnosed 
T2DM  were  recruited  into  our  study.  The  inclusion  criteriawere  newly  diagnosed  type  2  diabetes  (!18  years)  treated  with  oral 
hypoglycemic  agents  combined  with  or  without  insulin.  Nursing  mothers,  pregnant  woman,  hepatorenal  disease,  or  psychotic 
disorders  were  excluded.  Eligible  participants  were  divided  into  two  groups  according  to  completely  randomized  design: 
education  group  and  control  group.  The  program  duration  was  six  months.  The  education  of  the  patients  was  accomplished  by 
professional  education  nurses.  All  nurses  were  well-trained.Theeducationcoursesinthisstudyweredeliveredunder  the  guidance  of 
Problem  Based  Learning  (PBL).  Lecturing  approach,  audio-visual  approach, discussion approach and demonstration approaches 
were  adopted.  Lecturing  approach  was  targeted  at  all  patients  and  helped  them  to  receive  knowledge  systematically.  Audio- 
visual  approach  was  implemented  with  the  assistance  of  PowerPoint  and  video  projector  etc.  Discussion  approach  was  used  to 
encourage  patients  to  proactively  ask  questions  and  express  their  own  feelings.  Through  discussion,  patients  were  able  to learn 
from  each  other  and  communicate  on  knowledge  and  experience  of  diabetes.  In  demon-  stration  approach,  further  explanation 
was  given  to  patients  with  the  help  of  specific  models  and  teaching  aids. As for the content of education courses, we designed a 
detailed  curriculum  in  advance.  We  offered  a  two-hour  course  each  week,  comprising  of  two  sessions  of  lectures  (40  minutes 
each),  two  breaks  (10  min  each)  and  interactive  session  (20  min).  In  the  interactive  session,  patients  could  communi-  catewith 
each  otherin  groups  or  raiseany  questions  tothe  lecturers.  In  control  group,  doctors  make  more  health  education  with  patients. 
Patients  in  the  education  group  were  given  daily  record  sheets  to  track  the  diet,  physical  activities,  medications  and  blood 
glucose.  Patients  shouldfill  in  the  sheetsbasedon  theirown  conditions  andreturn  them  by  week.  Based  on  the  real-time 
information,  we  would  assess  the  patient  conditions  and  offer  corresponding  suggestions  for  better  self-  management.  The 
Self-rating  Anxiety  Scale  (SAS)  and  Self-rating  Depression  Scale  (SDS)  are  the  scales  for  assessing  anxiety  and  depression, 
which includes 20 problems respectively, using a 4-point scalerangingfrom 1 (none,oralittleof thetime)to4 (most,orall of the time) 
[12,13]. The statistical score of all questions were calculated after completion of the answers. 
2.2. Education group 
Patients  in  the  education  group  were  delivered  2-h  diabetes  education  course by professional educational nurses every week. 
Patients  in  education  group  were  divided  into  different  groups  by  their  most  remarkable  feature:  overweight  group  (BMI  !  24 
kg/m2,  30  patients);  smoking  group  (!10  cigarettes  per  day,  10  patients);  sedentary  group  (!7  hours  per  day,  12  patients);  low 
education  group  (high  school  degree  and  less,  5  patients);  drinking  group  (!50  g  per  day,  6  patients).  The  content  of  education 
included 
2 S. Chai et al. / Patient Education and Counseling xxx (2018) xxx–xxx 
G Model PEC 5922 No. of Pages 6 
healthydiet,exercise,  self-monitoringofbloodglucose,complication  prevention  and  understanding  the  risk  factors  of  diabetes. 
Mean-  while,  the  patients  were  provided  with  medical  history  assessment,  physical  examination  and  laboratory evaluation. The 
anxiety and depression scale was used to assess the psychological status of the patients at the beginning and end of the study. 
2.3. Control group 
Patients  in  the control group did not receive diabetes education provided by professional education nurses. Diabetes education 
was  usually  provided  upon  routine  outpatient  visits.  The  length  of  education  varied  from  5  to  10 min. The content of education 
included  healthy  diet,  exercise,  self-monitoring  of  blood  glucose,  complication  prevention  and  understanding  the risk factors of 
diabetes.  In  addition,  they  were  provided  with  medical  history  assessment,  physical  examination and laboratory evaluation. The 
anxiety and depression scale was used to assess the psychological status of the patients at the beginning and end of the study. 
2.4. Statistical analysis 
SPSS  16  was used for statistical analysis. Data were expressed as mean Æ standard deviation or median (p25, p75). Statistical 
analysis included independent t-test, paired t-test and Mann- Whitney U test. P < 0.05 was considered statistically significant. 
3. Results 
3.1. Baseline data 
A  total  of  118  patients  were  assigned  to  the  education  group  (n  =  63)  and  control  group (n = 55). No significant differences 
between groups were detected with respect to baseline clinical data and laboratory findings between the two groups. (Table 1) 
3.2. Six months outcomes 
In  education  group,  anxiety  score  decreased  from  40.00  (38.00,  47.00)  at  baseline  to  36.00 (30.75, 40.50) at the sixth month 
(P  <  0.05),  and  depression  score  decreased  from  41.00  (38.00,  47.75)  at baseline to 35.50 (30.75, 42.25) at the sixth month (P < 
0.05),  respectively.  In  control  group,  anxiety score [42.00 (40.00, 44.50) vs. 42.50 (36.50, 47.50), P = 0.73] and depression score 
[42.00  (40.00,  42.00)  vs.  44.00  (41.00,  47.50),  P  =  0.10]  were  not  significantly  lower  at  the  sixth  month,  respectively.  As 
compared  with  baseline,  education group showed reduced fasting blood glucose (FBG) (8.00 mmol/L vs. 6.78 mmol/L, P < 0.00) 
and  showed  reduced  postprandial  blood  glucose  (PBG)  (13.29  mmol/L  vs.  7.90  mmol/L,  P  <  0.00)  at  the  sixth  month.  In 
education group, HbA1 
C 
significant-  ly  decreased  at  the  sixth  month  compared  with  baseline 
[7.20%  (6.40%, 9.10%) at baseline and 6.20% (5.80%, 6.60%) at the sixth month, P < 0.00]. FBG (8.00 mmol/L vs 7.70 mmol/L, 
P  <  0.00)  and  PBG  (12.67  mmol/L  vs  10.58 mmol/L, P < 0.00) were significantly lower at the sixth month in control group than 
baseline. HbA1 
C  decreased  from  7.90%  (6.80%,  10.30%)  at  baseline  to 
6.70% (6.40%, 7.30%) (P < 0.00) at the sixth month in control group. (Table 2) 
3.3. Group comparisons 
The  education  group  showed  significantly reduced anxiety score [36.00 (30.75, 40.50) vs. 42.50 (38.00, 47.00), P < 0.05] and 
depression  score  [35.50  (30.75,  42.25)  vs.  44.00  (41.00,  47.50),  P  < 0.05] at the sixth month, compared with control group (Fig. 
1A). Compared with control group, FBG [6.78 (6.43, 7.18) mmol/L vs. 7.70 (7.22, 8.23)mmol/L, P < 0.00] and PBG [7.90 (6.93, 
Please cite this article in press as: S. Chai, et al., The effect of diabetes self-management education on psychological status and 
blood glucose in newly diagnosed patients with diabetes type 2, Patient Educ Couns (2018), 
https://doi.org/10.1016/j.pec.2018.03.020 
 
Poorly 10.00)mmol/L vs. 10.58 (8.70, 13.10)mmol/L, P < 0.00] significantly 
controlled blood glucose leads to serious 
complications, decreased at the sixth month in education group, respectively 
which will impose a large economic burden on the 
individual and (Fig. 1B). HbA1 
C 
significantly decreased in education group 
healthcare system. Hence, caring of patients with 
diabetes is of compared to control group at the sixth month [6.20 (5.80, 
growing importance to public health. For proper 
control of 6.60)% vs. 6.70 (6.40, 7.30)%, P < 0.01] (Fig. 1C). There was no 
diabetes mellitus, it is essential for patients to actively 
participate difference in blood pressure (SBP), diastolic blood pressure (DBP), 
in their own management such as appropriate diet, 
physical body mass index (BMI), waist hip ratio (WHR), the ratio of urinary 
activity, blood glucose monitoring and adherence to 
medication. albumin to creatinine (UAER), blood lipids and depression scores 
The basic targets in the treatment of T2DM are the 
normalization of between education group and control group. 
blood glucose, blood pressure control and lipid management. Studies have shown that good glycemic control is associated with 4. 
Discussion and conclusion 
significant reduction in the risk of many complications. Control of diabetes is affected by both lifestyle factors and by 
pharmacologi- 4.1. Discussion 
cal treatments, and the management of diabetes is largely the responsibility of those affected. Several clinical practice guidelines 
Diabetes mellitus is a chronic and progressive disease and 
recommend a stepwise treatment pathway for T2DM. 
Diet control characterized by insulin resistance and relative insulin deficiency. 
and lifestyle intervention are considered as the cornerstones for 
Table 2 Comparison of pre- and post-intervention parameters each group 
parameter control group education group p-value 
Pre Post p-value Pre Post 
BMI(kg/m2)* 25.06 Æ 3.38 25.28 Æ 3.47 0.15 25.70 Æ 3.38 25.16 Æ 3.38 0.85 WHR* 0.89 Æ 0.06 0.88 Æ 0.06 0.07 0.88 Æ 
0.06 0.87 Æ 0.05 0.23 SBP(mmHg)# 120.00(120.00, 140.00) 130.00(125.00, 140.00) 0.60 130.00(120.00, 140.00) 
130.00(120.00, 140.00) 0.94 DBP(mmHg)# 80.00(80.00, 90.00) 85.00(80.00, 95.00) 0.01 80.00(80.00, 90.00) 80.00(80.00, 
90.00) 0.45 FBG(mmol/L)# 8.00(7.00, 13.00) 7.70(7.22, 8.23) <0.00 8.00(7.00, 10.00) 6.78(6.43, 7.18) <0.00 PBG(mmol/L)# 
12.67(10.05, 17.10) 10.58(8.70, 13.10) <0.00 13.29(9.70, 16.08) 7.90(6.93, 10.00) <0.00 HbAlc(%)# 7.90(6.80, 10.30) 6.70(6.40, 
7.30) <0.00 7.20(6.40, 9.10) 6.20(5.80, 6.60) <0.00 UAER(mg/g)* 21.41 Æ 14.75 23.00 Æ 12.30 0.22 20.22 Æ 11.61 20.48 Æ 
14.43 0.20 ALT(U/L)# 23.00(18.00, 29.00) 25.00(19.00, 31.00) 0.18 21.00(16.00, 33.00) 23.00(18.00, 30.00) 0.67 AST(U/L)# 
21.00(17.00, 25.00) 21.00(18.00, 27.00) 0.41 19.00(17.00, 25.00) 19.00(16.00, 23.00) 0.11 CHO(mmol/L)* 5.30 Æ 1.17 5.25 Æ 
0.93 0.65 5.35 Æ 1.06 5.14 Æ0.95 0.04 TG(mmol/L)# 1.80(1.30, 2.40) 1.95(1.42, 2.75) 0.09 1.60(1.00, 2.40) 1.49(1.16, 2.35) 
0.47 HDL-C(mmol/L)# 1.26(1.07, 1.42) 1.24(1.10, 1.44) 0.85 1.37(1.08, 1.70) 1.36(1.11, 1.60) 0.50 LDL-C(mmol/L)* 3.29 Æ 
0.93 3.28 Æ 0.80 0.90 3.18 Æ 0.75 3.12 Æ 0.77 0.47 anxiety score# 42.00(40.00, 44.50) 42.50(36.50,47.50) 0.73 40.00(38.00, 
47.00) 36.00(30.75, 40.50) <0.05 depression score# 42.00(40.00, 42.00) 44.00(41.00, 47.50) 0.10 41.00(38.00, 47.75) 
35.50(30.75, 42.25) <0.05 
Abbreviations: BMI, body mass index; WHR, waist hip ratio; SBP, systolic blood pressure; DBP, diastolic blood pressure; FBG, 
fasting blood glucose; PBG, postprandial blood glucose; HbA1c, glycated haemoglobin A1 
C 
; UAER, urinary albumin to creatinine ratio; ALT, alanine aminotransferase; AST, aspartate 
aminotransferase; HDL-C, high-density lipoprotein cholesterol; LDL-C, low-density lipoprotein cholesterol. *data expressed as 
mean Æ standard deviation and tested by independent t-test. # data expressed as median (p25, p75) and tested by Mann-Whitney 
U test. 
S. Chai et al. / Patient Education and Counseling xxx (2018) xxx–xxx 3 
Table 1 Baseline characteristics of patients in the education group and control group 
parameter control group education group p value 
N(F/M)  55.00  (26.00/29.00)  63.00  (33.00/30.00)  0.58  Age*  53.00  Æ  9.00  55.00  Æ  7  0.00 0.10 Duration# 0.20(0.10, 0.50) 0.30 
Æ  0.30  0.30  BMI(kg/m2)* 25.06 Æ 3.38 25.70 Æ 3.35 0.30 WHR* 0.89 Æ 0.06 0.88 Æ 0.06 0.59 SBP(mmHg)# 120.00(120.00, 
140.00)  130.00(120.00,  140.00)  0.94  DBP(mmHg)#  80.00(80.00,  90.00)  80.00(80.00,  90.00)  0.91  FBG(mmol/L)#  8.00(7.00, 
13.00)  8.00(7.00,  10.00)  0.22  PBG(mmol/L)#  12.67(10.05,  17.10)  13.29(9.70,  16.08)  0.89  HbAlc(%)#  7.90(6.80,  10.30) 
7.20(6.40,  9.10)  0.07  UAER(mg/g)*  21.41  Æ  14.75  20.92  Æ  14.38  0.93  ALT(U/L)#  23.00(18.00,  29.00)  21.00(16.00,  33.00) 
0.88  AST(U/L)#  21.00(17.00,  25.00)  19.00(17.00,  25.00)  0.67  Cholesterol(mmol/L)*  5.30  Æ  1.17  5.35  Æ  1.06  0.78 
Triglyceride(mmol/L)#  1.80(1.30,  2.40)  1.60(1.00,  2.40)  0.37  HDL-C(mmol/L)#  1.26(1.07,  1.42)  1.37(1.08,  1.70)  0.12 
LDL-C(mmol/L)*  3.29  Æ  0.93  3.18  Æ  0.75  0.47  anxiety  score#  42.00(34.00, 42.50) 41.00(38.00,52.00) 0.25 depression score# 
40.00(34.00, 45.50) 42.50(36.00, 51.00) 0.37 
Abbreviations;: BMI, body mass index; WHR, waist hip ratio; SBP, systolic blood pressure; DBP, diastolic blood pressure; FBG, 
fasting blood glucose; PBG, postprandial blood glucose; HbA1c, glycated haemoglobin A1 
C 
; UAER, urinary albumin to creatinine ratio; ALT, alanine aminotransferase; AST, aspartate 
aminotransferase; HDL-C, high-density lipoprotein cholesterol; LDL-C, low-density lipoprotein cholesterol. *data expressed as 
mean Æ standard deviation and tested by independent t-test. # data expressed as median (p25, p75) and tested by Mann-Whitney 
U test. 
G Model PEC 5922 No. of Pages 6 
Please cite this article in press as: S. Chai, et al., The effect of diabetes self-management education on psychological status and 
blood glucose in newly diagnosed patients with diabetes type 2, Patient Educ Couns (2018), 
https://doi.org/10.1016/j.pec.2018.03.020 
 
treatment  of  T2DM  according  to  these  guidelines.  Comprehensive  lifestyle  interventions  effectively  decrease  the  incidence  of 
diabetes  in  high-risk  patients,  but  its  effect  in  patients  who  already  have  T2DM are variable among trials [14,15]. So the role of 
education  is  to  improve  patients’  understanding  of  diabetes  mellitus  and  enhance self-management practices. Meanwhile, active 
collaboration with care givers can improve clinical outcomes and quality of life. 
Similarly,  mental  health  of  patients with diabetes can not be ignored. Some studies have shown that both depressive disorders 
and  anxiety  disorders  have  a  close  relationship  with  type  2  diabetes  [16,17].  Studies  of  adults suggest that psychological states, 
particularly  depressive  symptoms,  may  independently  predict  increased  risk  for  type  2  diabetes  [18,19].  Depressive  symptoms 
have  both  been  associated  with  increases  in  fasting  insulin,  insulin  resistance,  the  onset  of  type  2  diabetes,  and  future  risk  for 
poorer  glycemic  control  in  T2DM  [20,21].  Baumeister  et  al.  [22]  conducted  a systematic review to evaluate the effectiveness of 
psychological  and  pharmacological  interventions  for  depression  in  patients  with  both  diabetes  and  depression.  The  results 
indicated  that  short-  term glycemic control improved in pharmacological trials with depression remission. Xie et al. [23] reported 
that  the  psychosocial  intervention  was  effective  for  depression  symptoms  and  anxiety  symptoms.  Meanwhile,  the  additional 
effects indicated a better improvement of FBG, PBG, and HbA1c. These results demonstrated 
between Fig. 1. Changes in anxiety scores, depression scores, 
FBG, PBG and HbA1 
C the education group and control group at the sixth month. 
Abbreviations;: A: anxiety and depression scores; B: FBG and PBG; C: HbA1 
C 
;  CG:  control  group;  EG:  education  group;  FBG:  fasting  blood 
glucose; PBG: postprandial blood glucose; HbA1c: glycated haemoglobin A1 
C 
. *p < 0.05, #p < 0.01 vs. CG (6m). 
4 S. Chai et al. / Patient Education and Counseling xxx (2018) xxx–xxx 
G Model PEC 5922 No. of Pages 6 
Please cite this article in press as: S. Chai, et al., The effect of diabetes self-management education on psychological status and 
blood glucose in newly diagnosed patients with diabetes type 2, Patient Educ Couns (2018), 
https://doi.org/10.1016/j.pec.2018.03.020 
that  the  psychosocial  intervention  was  very effective in treatment of T2DM patients with depression and anxiety. In addition, the 
improvement  of  anxiety  and  depression  can  also  indirectly  affect  blood  glucose.  A  recent  study  [24] focusing on psychological 
intervention  for  T2DM  indicated  that  the  patients  turned  to  be  more  proactive  in  self-management,  such  as  diet,  along with the 
improvement  of  anxiety  and  depression.  Therefore,  the  blood  glucose  was  strictly  controlled.  In  our  study,  the  patients’ 
depression  and  anxiety  scores  have  significantly  decreased  after  6  months’  self-management  education,  as  compared  with 
baseline  data.  Meanwhile,  the  blood  glucose  of  patients  have  also  been  better  controlled.  Combining  with  the  results  of  above 
listed  studies,  we  believe that the improvement of depression and anxiety does play an active role in the control of blood glucose. 
As  it’s  known,  there  are  many  factors  influencing  the level of blood glucose. There is no denying that the improvement of blood 
glucose  has  been  impacted  by  the  professional  education.  Through  systematic  learning  of  diet,  physical  activities,  diabetic 
medica-  tions  and  complications,  patients  have  gained  a better under- standing of diabetes before enrollment. They have become 
capable  of  tackling  with  diabetes  and  also  confident  for proper self- management of diabetes. Therefore, the improvement of the 
psychological  status  of  patients  with  diabetes  promoted  the  outcome  of  education  in  turn.  There  are  several  possible 
pathophysiological  mechanisms  that  may  explain  the  possible  relationship  between  depression and blood glucose level. Depres- 
sion  is  associated  with  disruption  to  the  hypothalamic-pituitary-  adrenal  axis,  causing an increase in cortisol and catecholamine, 
hormones  responsible  for  antagonizing  the  hypoglycemic  effects  of  insulin  and  resulting  in  IR  [25].  People  with  diagnostic 
depression  have  increased  levels  of  inflammation  [26],  and  psychological  stresses  have  been  shown  to  activate  the  innate 
inflammatory  response  leading  to  IR  in  the  early stage of T2DM [27]. Depression can also have influence on lifestyle associated 
with diabetes risk factors such as dietary intake, sleep disturbance and exercise [28,29]. 
Our study indicated both anxiety scores and depression scores were decreased at the sixth month as compared with baseline level 
 in education group. Moreover, anxiety scores and depression scores of patients in the education group showed significant 
improvement as compared to the control group at the sixth month. The incidence of depression in patients with diabetes seems to 
be associated with family status, obesity, smoking habits, physical activity and sedentary lifestyle [30]. Therefore, in the 
education group, the content of education was mainly focused on these aspects. Patients were divided into different groups based 
on their actual situation. For example, there were an overweight group, a smoking group and a sedentary group. According to the 
assess- ment results of the patients, professional educators would define one pacesetter in each group every month. This approach 
was intended to stimulate the patients' motivation. With weight loss, quitting smoking and other lifestyle changes, the patients’ 
mental state and self-confidence had been significantly improved. The role of education professionals is to enable patients to 
acquire knowledge, while making active choices about their diseases. Subjective initiative cannot be given or taught, it is a 
spontaneous process that people must engage in for themselves. With the improvement of mental health, the control of blood 
glucose, quality of life and treatment adherence will be in a good direction. The present study found that there were significant 
improve- ments in blood glucose control at the sixth month in control group, compared with the baseline level. In control group, 
FBG, PBG and HbA1c reduced in different degrees by usual care compared with the baseline levels. In education group, FBG, 
PBG, HbA1 
C 
and  psychological  scores  improved  significantly  at  the  sixth 
month compared with the baseline levels. These results indicated that 
 
both  usual  care  and  intensive  education  can  improve  glycemic  control in some degree. But comparisons were made between the 
two groups. In the education group, FBG, PBG, and HbA1 
C 
have  improved  significantly.  Content  of  education  in  both  the 
education  and  control  groups  involved  diet,  exercise,  self-monitoring  of  blood  glucose  and  prevention  of  complications.  But in 
the  education  group,  the  content  of  education was more specific and detailed. On the basis of the patients’ ideal body weight and 
daily  activity,  the  daily  needs  of  calories  were  calculated.  Individualized  plan  of  daily  or  weekly  exercises  was  formulated. 
Pictures  and  teaching  aids  were  used  to  explain  the  complications  of  diabetes.  Patients  in  the  education  group were delivered a 
2-h  diabetes  education  course  by  professional  education  nurses  every  week.  While  diabetes  educa-  tion  was  usually  provided 
upon  routine  outpatient  visits  in  control  group.  The  length  of  course  was  usually  from  5  to  10  min.  The  patients  were  merely 
provided  with  a  brief  principle  of  diet  and  exercise  by  doctors.  The  distinction  of  education  can  lead  to  difference  in  disease 
awareness.  With  the  patients’ understanding of diabetes and the improvement of disease self-management, the mental state of the 
patients  in  the  education  group  was  improved.  They  became  more  active  in  self-management  of  blood  glucose.  The  present 
findings  were  consistent  with  those  of  similar  studies  investigating  the  efficacy  of  structured  group  education  compared  with 
usual  care  [31,32].  Yang  et  al.  [31]  reported  that  there  was  significant  improvement in glycemic outcomes from baseline to 3, 6 
and  12  months  in  the  structured  education  group,  as  compared  with  the  usual  care  group.  Research  evidence  [33]  shown  that 
intensified  monthly  self-monitoring  of  blood  glucose  combined  with  education  was  effective  in improving postprandial glucose 
and HbA1 
C 
in  diabetes.  The  intervention  group  also  showed  higher  improvements  in  knowledge,  attitude  and  behavior  than the 
control  group.  A  recent  study  [34]  reported  that  group  education  intervention  may  improve  clinical  outcomes,  such  as  fasting 
glucose,  systolic  blood  pressure  (SBP)  and  diastolic  blood  pressure  (DBP).  However,  our  study indicated that education did not 
have  any  effect  on  other  risk  factors,  including  BMI,  SBP,  DBP,  UAER,  low-  density  lipoprotein  cholesterol  (LDL-C),  and 
high-density  lipopro- tein cholesterol (HDL-C), compared with control group. Studies of focused educational intervention did not 
yield  consistent  results.  Some  effects  were  shown  on  measures  of  glycemic  control  in  studies  that  focused  on  diet  or  exercise 
alone.  Recently,  Huang  and  his  colleagues  [35]  reported  that  diet  modifications  showed  a  significant  improvement  in  all major 
cardiovascular risk factors associated with diabetes, such as the HbA1 
C 
,  SBP,  DBP,  and  HDL-C,  except  for  LDL-C  and  BMI.  The  physical  activity 
intervention showed a significant improvement on HbA1 
C 
and DBP, but not on the other risk factors (BMI, SBP, LDL-C, and HDL-C). The 
patient  education  program,  however,  did  not  show  any  difference  in  all  the  risk  factors  assessed  in  the  study.  There  are  many 
factors  involved  in  the  complexity  of  the  education,  including  the  variety  of  education  programs  and  group  size  as  well  as  the 
difference in education background. These factors need to be taken into account in interpretation of the results. 
The  study  was  conducted  in  China.  As  it’s  known,  there  are  lots  of  differences  between  the  Western  and  Eastern  food. 
Carbohy-  drate  is  the  main  type  of  diet  in  China,  while  the  Western  diet  is  dominated  by  meat,  eggs and milk. Food difference 
plays  an  important  role  in  the  content  of  education.  Carbohydrate  should  be  appropriately  controlled  in  Asia  and  high-fat  food 
should  be  appropriately  reduced  in  Europe  and  America.  As  mentioned  earlier,  a  diagnosis  of  T2DM  increases  the  risk  of 
incidence  of  depression  and  may  result  in  severe  depression.  Diabetes  self-  management  is  directly  related  to  the  prognosis  of 
patients  with  diabetes.  Therefore,  in  any case, self-management of blood glucose is suitable for all patients with diabetes in Asia, 
Europe and America. 
G Model PEC 5922 No. of Pages 6 
S. Chai et al. / Patient Education and Counseling xxx (2018) xxx–xxx 5 
There  is  also  limitation  to the present study. One shortcoming is that self-management education simply gives the patients the 
principle  of  diet  and  exercise,  so  the  intensity  of  the  exercise  and  variety  of  dietary  regimen  might  also  affect  the  clinical 
outcomes.  Secondly,  mental  health  is  also  affected  by  economic  conditions,  but  we  did  not  evaluate  the  patients’  incomes. 
Thirdly,  we  did  not  have  a  subgroup  analysis  of  whether  blood  glucose  levels  were  related  to  the  severity  of  anxiety  or 
depression. 
4.2. Conclusion 
In  summary,  this  paper  indicated  that  self-management  education  was  effective  in  improving  psychological  status  and 
glycemic  control.  Intensive  education  did  not lead to significant improvements in BMI, SBP, DBP, UAER, LDL-C, and HDL-C, 
compared to control group. 
4.3. Practice implications 
Diabetes  education  plays  a  very  important  role  in  newly  diagnosed  patients  with  diabetes.  Patients  with  newly  diagnosed 
diabetes  have  mood  swings,  such  as  anxiety  or  depression,  which  can  affect blood glucose levels. Through education, the mood 
of newly diagnosed patients with diabetes has been improved. Meanwhile, the blood glucose is better controlled. 
I  confirm all patient/personal identifiers have been removed or disguised so the patient/person(s) described are not identifiable 
and cannot be identified through the details of the story. 
Funding: This research did not receive any specific grant from funding agencies in the public, commercial, or not-for-profit 
sectors. 
Conflicts of interest 
None. 
Appendix A. Supplementary data 
Supplementary data associated with this article can be found, in the online version, at 
https://doi.org/10.1016/j.pec.2018.03.020. 
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blood glucose in newly diagnosed patients with diabetes type 2, Patient Educ Couns (2018), 
https://doi.org/10.1016/j.pec.2018.03.020