Diabetes Self-management Education Program Research Articles

Digital Health Tools and Behavioral Strategies to Increase Engagement With Diabetes Self-Management Education and Support: Design and Feasibility of DM-BOOST.

The purpose of the study was to describe the development and feasibility of implementing the DM-BOOST program in support of an established diabetes self-management education and support (DSMES) program. A patient panel of 4 adults with type 2 diabetes (T2DM) codesigned DM-BOOST. DM-BOOST is a patient-focused program that includes peer-written text messages about diabetes self-management behaviors and digital health training to improve patient portal use and initiate goal setting prior to a scheduled DSMES appointment. Adults with T2DM and A1C ≥8.0% participated in a 6-month feasibility pilot. Participants were randomly assigned (1:1) to receive either DM-BOOST or usual care. Outcomes included DSMES engagement (scheduled and attended DSMES appointments) and changes in diabetes self-efficacy and treatment satisfaction. Pilot participants (n = 60) were 60.0% female with mean age 45.5 years (SD 8.3) and A1C 10.1% (SD 1.8%). All DM-BOOST participants (30/30, 100%) had DSMES appointments scheduled compared to 86.7% of usual care (26/30). DM-BOOST participants had fewer DSMES appointment no-shows/cancellations (3/30, 10%) compared to usual care (10/26, 35%). There was greater improvement in diabetes self-efficacy in the DM-BOOST group compared to usual care and no difference in treatment satisfaction. DM-BOOST, leveraging peer-written text messaging and digital health training, increased DSMES engagement. Implementation of DM-BOOST was determined to be feasible, with several system-level barriers identified, including obtaining provider referrals and scheduling appointments. An effectiveness trial of DM-BOOST is needed to evaluate the impact on clinical outcomes.

Profiles of knowledge, self-efficacy, psychological and physical health in type 2 diabetes and its association with outcomes

BackgroundSelf-management is impacted by knowledge, self-efficacy, psychological health (general mental health and diabetes-related distress) and physical health (KSPP), and variations in KSPP contribute to heterogeneity in diabetes self-management education (DSME) program outcomes. This study aimed to identify unique KSPP profiles, and their associations with self-management behaviors. MethodsA cross-sectional survey was conducted in 518 participants with type 2 diabetes. Diabetes knowledge, self-efficacy, diabetes-related distress, mental and physical health, self-care, medication adherence and social support were assessed. A mixed-model latent profile analysis was conducted on eight KSPP variables, and sociodemographic, self-care (diet, physical activity, and medication adherence), and glycemic levels were compared across profiles. ResultsFour unique KSPP profiles were identified: profile 1 (untroubled), profile 2 (distressed: diabetes-specific), profile 3 (distressed: global) and profile 4 (activated). Profile 3 was associated with the lowest self-care, highest glycemic and lowest social support levels. Profile 4 was associated with the highest self-care, lowest glycemic and highest social support levels. ConclusionsOur study identified novel KSPP profiles, which were associated with differential self-management behaviors and metabolic profiles. Practice ImplicationsIdentifying KSPP profiles might improve self-management support through identifying clustering of care needs, and support more targeted DSME development.

Family model diabetes self-management education and support in faith-based organizations in the Republic of the Marshall Islands: A study protocol

IntroductionThe Republic of the Marshall Islands (RMI) is an independent nation and a member of the United States (US) Affiliated Pacific Islands through a Compact of Free Association. Health disparities in the RMI are striking, with high rates of type 2 diabetes mellitus (T2DM). The International Diabetes Federation has documented age-adjusted prevalence of T2DM at 23.0 %, compared to the US (13.2 %) and globally (9.8 %). T2DM has a devastating impact on patients and their families. MethodsThe purpose of this article is to present the study protocol for the fully powered two-arm cluster randomized controlled trial using a wait-list control to evaluate the effectiveness of a Family Diabetes Self-Management Education and Support (Family DSMES) program when delivered in a group setting by community health workers (CHWs) in faith-based organizations (FBOs) in the RMI. The study used a community engaged approach, and the study protocol includes adaptations based on the results of our one-arm pilot study. SummaryThis study will provide new and innovative information on the effectiveness of Family DSMES delivered in a group setting by CHWs in FBOs in the RMI. The knowledge gained from this research will inform DSMES interventions conducted with Marshallese and other Pacific Islander communities, as well as DSMES interventions conducted in other low-resource countries.

Footcare Intervention Delivered by Community Health Workers: A Modified Delphi Study.

Studies have shown that community health workers (CHWs) can effectively deliver footcare interventions (FCIs) as part of diabetes self-management education programmes in high-resource countries. However, more evidence is needed on implementing FCI in low-resource countries and more detailed information about the core components of FCI provided by CHWs. This study aims to refine the core components of the footcare intervention to be delivered by CHWs (FIne-CHWs) for T2DM patients and to analyse Delphi panel members' opinions and perceptions regarding the core components of FIne-CHWs. Triangulation data from previous steps of data collection (scoping and mapping review combined with interview data) identified 42 statements representing the core components of FIne-CHWs. After two rounds of a Delphi exercise involving 22 panel members, experts in diabetes from all over Indonesia, a consensus agreement was reached on 41 out of 42 statements of the core components of FIne-CHWs. Free-text responses to the Delphi survey were analysed using thematic analysis. One overarching theme emerged: CHWs "are only volunteers." This then was discussed in three themes, namely CHWs deliver footcare education for all people with diabetes, remuneration and incentives, and flexibility of community FCI. This study determined the core components of FIne-CHWs and also identified that the position of CHWs within the Indonesian healthcare system could impact the implementation of the FIne-CHWs programme.

Rural-Urban Differences in Self-Reported Participation in Diabetes Self-Management Education.

Rural America faces a dual challenge with a higher prevalence of diabetes mellitus (hereafter, diabetes) and diabetes-related mortality. Diabetes self-management education (DSME) can improve glucose control and reduce adverse effects of diabetes, but certified DSME programs remain disproportionately limited in rural counties than in urban counties. The goal of this study is to examine the proportion of urban and rural adults who report having received DSME using a nationwide, 29-state survey while considering the potential consequences of lower service availability. This cross-sectional study used data from the 2019 Behavioral Risk Factor Surveillance System (BRFSS). Residence was defined as urban (metropolitan county) vs rural (non-metropolitan county). Logistic regression, incorporated survey weights, was used to determine the odds of having received DSME by residence. BRFSS is a nationally representative survey, and this study included participants from 29 states that were distributed throughout all regions of the United States. The study sample consisted of 28,179 adults who reported having diabetes, lived in one of the states that administered the diabetes module in 2019, and answered all relevant questions. The main outcome measure was whether a participant had ever received DSME. Participants were considered to have received DSME if they self-reported having ever taken a class on how to manage diabetes themselves. Overall, 54.5% of participants reported having received DSME; proportionately fewer rural residents (50.4%, ±1.1%) than urban residents (55.5%, ±1.0%) reported DSME. Rural disparities persisted after adjusting for demographic, enabling, and need factors (Adjusted Odds Ratio=0.79; CI, 0.71-0.89). By sociodemographic factors, Hispanic persons vs non-Hispanic White persons and single vs married/coupled individuals were less likely to report DSME receipt (both 0.76 [0.62-0.94]). Ongoing national efforts addressing rural disparities in diabetes-related complications should target individuals most at risk for missing current diabetes educational programming and design appropriate interventions.

Effect of structured individual and combined education on blood glucose regulation in type 2 diabetes mellitus

Abstract Although various approaches have been used in diabetes self-management education (DSME) programs, the effect of DSME programs on glycemic control is controversial. This study aimed to compare the effects of structured individual education and combined education on glycemic regulation in type 2 diabetes mellitus (T2DM). This study included T2DM patients who applied to the Ust Kaynarca Diabetes Center between 1 January 2018 and 11 March 2020. All data were retrospectively evaluated from hospital information systems. Patients who received only individual education were defined as the individual education group (IEG), and patients who received both individual and group education were defined as the combined education group (CEG). A total of 496 T2DM patients, with 248 (50.0%) in the IEG and 248 (50.0%) in the CEG, were included in the study. The change in HbA1c (ΔHbA1c) value for the IEG was 1.0% (2.5%), while the ΔHbA1c value for the CEG was 1.9% (2.8%) (P < 0.001). When factors affecting the glycemic control were evaluated, it was determined that the type of education [odds ratio (OR) = 2.295, P < 0.001], gender (OR = 1.799, P = 0.007), presence of hyperlipidemia (OR = 0.559, P = 0.032) and presence of medications added to treatment (OR = 1.558, P = 0.041) were effective on glycemic control. Combined education, in which individual and group education are conducted together, is more effective than individual education in glucose regulation.

Educational Programs for Patients with Diabetes: Challenges and Effectiveness

Diabetes self-management education (DSME) is integral to managing diabetes, a chronic condition affecting millions globally. DSME programs aim to equip patients with essential knowledge and skills to manage their diabetes effectively and enhance their quality of life. This review assesses the challenges and effectiveness of current DSME programs. Key challenges include a lack of individualization, cultural and socioeconomic barriers, inadequate health literacy, and difficulties in achieving sustained behavioral change. Despite these challenges, DSME programs have shown potential in improving clinical outcomes, enhancing quality of life, and being cost-effective. Effective strategies to improve DSME include personalizing education to meet individual needs, integrating behavioral support techniques, addressing cultural and socioeconomic factors, and utilizing digital technologies. Addressing these challenges through tailored, evidence-based approaches and ongoing support can enhance the impact of DSME programs. Future research should focus on refining these strategies and exploring innovative methods to optimize diabetes education. Keywords: Diabetes self-management education (DSME), Diabetes management, Patient education, Behavioral change

The Case for Strategic Integration of Diabetes Education in Southern Nigeria, Informed by Insights from a Pilot Study

The surge in diabetes cases affecting 3.6 million individuals in Nigeria demands a proactive response. Despite the high prevalence, the current Nigerian model is reactive leading to delayed treatment, heightened complications, elevated healthcare expenses, and diminished quality of life. This document proposes the solution of integrating culturally adapted Diabetes Self-Management Education and Support (DSMES) programs into Nigerian health policy as standard practice. Additionally, it recommends establishing diabetes educator training programs and a nationwide accreditation process. The development of such a program, in collaboration with the University of Port Harcourt Teaching Hospital, is outlined, highlighting both successes and failures during its initial implementation. These insights emphasize the importance of enhanced collaboration, sustainable funding, and a comprehensive monitoring and evaluation framework. These observations are currently driving ongoing program development.

Effect of the Implementation of a Multiple-Behavior Self-Monitoring Intervention on Dietary Intake in Type 2 Diabetes: Secondary Data Analysis.

An electronic diary embedded in a mobile device to monitor lifestyle can be as effective as traditional methods. However, the efficacy of self-monitoring multiple behaviors for dietary intake has not been well studied in people with diabetes. This study aimed to compare the effect of using technology-assisted self-monitoring versus paper diaries on changes in dietary intake. This is a secondary analysis of data collected from 39 people with type 2 diabetes as part of a 3-month pilot clinical trial. Changes in energy intake and the contribution of total fat intake and total carbohydrate intake to total calories (%) from baseline to after intervention (3 months) were evaluated. In total, 26 (67%) of the 39 participants preferred mobile diaries over paper diaries. Participants in the mobile diary group showed slightly higher self-monitoring adherence. Linear mixed modeling results indicated a significant overall decrease in total energy intake (P=.005), dietary fat intake (P=.01), and carbohydrate intake (P=.08) from baseline to 3 months. No significant group differences were detected (P>.05). The implementation of a 3-month, multiple-behavior, self-monitoring intervention in Diabetes Self-Management Education programs has resulted in successful reduction in dietary intake (energy, fat, and carbohydrate), whichever self-monitoring method is chosen by participants according to their preferences. Long-term studies are needed to confirm our findings on dietary intake and examine other behavioral and disease outcomes that require monitoring.

Accessibility of diabetes education in the United States: barriers, policy implications, and the road ahead.

Diabetes Self-Management Education and Support (DSMES) programs are an effective, yet underutilized, resource to improve health outcomes and behaviors for people with diabetes. We examined the attendance and referral rates for people with diabetes to DSMES classes at an academic medical center, noting a 10% referral rate and 37% completion rate for those referred. We identified barriers to DSMES care at patient, provider, and health system levels. Current technology platforms and training fail to prioritize referrals to diabetes education; providers and people with diabetes are often unfamiliar with program content and benefits. Scheduling mechanisms often delay or lose interested patients in receiving vital education. Existing Medicare reimbursement strategies limit expansion of DSMES programs, generating significant wait times and limit capabilities for Diabetes Care and Education Specialists. We identify potential policy solutions and recommend alterations to existing referral and scheduling systems to expand existing technology platforms for DSMES programs and shift reimbursement policies to individualize and better support care for persons with diabetes.

Service Users' Experiences of a Nationwide Digital Type 2 Diabetes Self-Management Intervention (Healthy Living): Qualitative Interview Study.

Diabetes Self-Management Education and Support programs for people living with type 2 diabetes mellitus (T2DM) can increase glycemic control and reduce the risk of developing T2DM-related complications. However, the recorded uptake of these programs is low. Digital self-management interventions have the potential to overcome barriers associated with attendance at face-to-face sessions. Healthy Living is an evidence-based digital self-management intervention for people living with T2DM, based on the Healthy Living for People with Type 2 Diabetes (HeLP-Diabetes) intervention, which demonstrated effectiveness in a randomized controlled trial. NHS England has commissioned Healthy Living for national rollout into routine care. Healthy Living consists of web-based structured education and Tools components to help service users self-manage their condition, including setting goals. However, key changes were implemented during the national rollout that contrasted with the trial, including a lack of facilitated access from a health care professional and the omission of a moderated online support forum. This qualitative study aims to explore service users' experiences of using Healthy Living early in the national rollout. A total of 19 participants were interviewed via telephone or a videoconferencing platform. Topics included users' experiences and views of website components, their understanding of the intervention content, and the overall acceptability of Healthy Living. Transcripts were analyzed thematically using a framework approach. Participants valued having trustworthy information that was easily accessible. The emotional management content resonated with the participants, prompting some to book an appointment with their general practitioners to discuss low mood. After completing the structured education, participants might have been encouraged to continue using the website if there was more interactivity (1) between the website and other resources and devices they were using for self-management, (2) with health professionals and services, and (3) with other people living with T2DM. There was consensus that the website was particularly useful for people who had been newly diagnosed with T2DM. Digital Diabetes Self-Management Education and Support programs offering emotional aspects of self-management are addressing an unmet need. Primary care practices could consider offering Healthy Living to people as soon as they are diagnosed with T2DM. Participants suggested ways in which Healthy Living could increase interaction with the website to promote continued long-term use.

Understanding the preferences of young adults with type 2 diabetes mellitus with regard to diabetes self-management education: a qualitative study

AimYoung-onset type 2 diabetes (YOD) is associated with poorer clinical outcomes. To support the development of more effective diabetes self-management education (DSME) programmes, this study aimed to understand the preferences...

A community health worker led diabetes self-management education program: Reducing patient and system burden

AimsConduct a secondary analysis of the TIME (Telehealth-supported, Integrated Community Health Workers (CHWs), Medication access, diabetes Education) made simple trial (SIMPLE) to evaluate healthcare utilization and explore variables that may have influenced HbA1c. MethodsParticipants (N = 134 [67/group]) were low-income, uninsured Hispanics with or at risk for type 2 diabetes mellitus. We included in-person and telehealth clinician visits, other visits, missed visits, orders placed, and guideline-adherence (e.g., vaccinations, quarterly HbA1c for uncontrolled diabetes). Using multivariable models, we explored for associations between HbA1c changes and these measures. ResultsThe control arm had higher missed visits rates (intervention: 45 %; control: 56 %; p = 0.007) and missed telehealth appointments (intervention: 10 %; control: 27.4 %; p = 0.04). The intervention group received more COVID vaccinations than the control (p = 0.005). Other health measures were non-significant between groups. Intervention individuals' HbA1c improved with more missed visits (−0.60 %; p < 0.01) and worsened with improved guideline-adherent HbA1c measurements (HbA1c: 1.2 %; p = 0.057). The control group had non-significant HbA1c associations. ConclusionsFindings suggest that the SIMPLE trial's improved HbA1c levels stemmed from a CHW-driven intervention and not additional healthcare contact. Exploratory outcomes resulted in seemingly counterintuitive HbA1c associations with missed visits and guideline-adherent measurements; these may suggest that an intervention that enhances communication provides support to reduce the amount of follow-up needed by participants without sacrificing clinical improvements.

Healthcare and health situation of adults with type 2 diabetes in Germany: The study GEDA 2021/2022-Diabetes.

The nationwide study German Health Update (GEDA) 2021/2022-Diabetes was conducted to assess the current healthcare and health situation of adults with diabetes in Germany. GEDA 2021/2022-Diabetes comprises a sample of adults with diagnosed diabetes from the general population. The analysis focuses on adults aged 45 years and over with type 2 diabetes (N = 1,448) and provides selected indicators on diabetes care as well as mental, social and general health. 87.5 % of participants aged 45 years and over with type 2 diabetes are treated with blood glucose-lowering medication. 36.5 % receive insulin alone or in combination with other antidiabetics; 0.7 % use an insulin pump. Almost 96 % had an HbA1c measurement in the last year and about two thirds each report annual foot and eye examinations, participation in a diabetes self-management education programme and self-monitoring of their feet and of blood glucose (12.0 % with continuous glucose monitoring). On average, the quality of diabetes care is perceived as moderate. 23.8 % rate their mental health as excellent/very good. More than a tenth each have anxiety or depressive symptoms and feelings of loneliness. Half rate their general health as very good/good. There is a potential for improvement in the quality of diabetes care and the mental and physical health of adults with type 2 diabetes.

Self-Management of Type 2 Diabetes

Topic to be searched: Self-Management Education Program’s Impact on Glycaemic Control in type 2 diabetes mellitus Rationale for topic: According to the Royal College of Nursing(2022), more than 3.8 million individuals across the UK have been diagnosed with diabetes mellitus. Also, approximately one million of the population have the condition, but are not aware. Thus, I wanted to explore the impact of diabetes self-management education program in enhancing patient’s self-care behaviours like controlling glycaemic.

Improvement of knowledge following diabetes self-management education with respect to socioeconomic status: A retrospective cohort study among type 2 diabetes in Eastern India.

We assessed the baseline knowledge and the improvement and retention of knowledge after attending diabetes self-management education (DSME) programs with respect to different socioeconomic status (SES). We also looked into the change in body mass index (BMI), blood pressure, and glycemic parameters after attending the DSME sessions. This was a retrospective, cohort study carried out via chart review based on data collected from manual or electronic medical records (EMR) and questionnaire responses of 160 adult patients with type 2 diabetes (T2D) who attended two DSME sessions with a gap of at least six months. Baseline knowledge on diabetes was uniform (P = 0.06), irrespective of differences in SES, and DSME sessions significantly improved the knowledge in all socioeconomic classes (P value < 0.05 in each SES group). However, SES did have a significant influence on the finally acquired knowledge of diabetes as was evident from the final score after attending two DSME sessions. A significant number of patients (48.1%) from our cohort either improved or retained their knowledge of diabetes over a mean follow-up of 15.5 months. The BMI of our cohort was significantly reduced from baseline to final follow-up (P = 0.016). DSME sessions were effective in improving knowledge and awareness among T2D patients, irrespective of socioeconomic classes in Eastern India. The acquired knowledge from DSME sessions was retained over a long time.

Role of social support in culturally sensitive diabetes self-management education among an ethnic minority population in Denmark.

CUSTOM is a culturally sensitive diabetes self-management education and support programme tailored to Urdu, Turkish and Arabic-speaking people in Denmark. The aim of this study was twofold: first, to examine the functional social support perceived by CUSTOM participants before and after the intervention; and, second, to explore how participants' structural social support affected the physical and mental health benefits of the intervention. The participants were people with type 2 diabetes whose primary language was Urdu, Arabic or Turkish (n = 73). Outcomes included A1C, body fat percentage, diabetes distress, well-being and functional social support. Changes were observed between baseline and six months after participation in a single-group pre-test/post-test design. The Cochran-Armitage trend test was used to assess pre-post differences in functional social support. The role of structural social support was assessed using moderation regression analysis. Participants reported higher availability of functional social support after the programme (p < 0.05), although the change in loneliness was not significant. In addition, cohabitating with adult children increased the average body fat percentage reduction achieved following the programme, while living with a partner lowered the average body fat percentage reduction achieved. The intervention was particularly successful in improving diabetes distress among those with weak structural social support. Culturally sensitive diabetes self-management education and support can improve social support among people with an ethnic minority background. The structure of social relations may influence the benefit of culturally sensitive diabetes self-management education and support. Future programmes should include family members and other social relations more actively, drawing attention to both positive and negative aspects of social relations.

Tailoring African American Faith Community-Based Diabetes Self-Management Education.

African Americans (AA) experience a disparate effect of type II diabetes (T2D). For this nurse-led pilot study, a pre-validated 6-week diabetes self-management education (DSME) program was implemented in a faith community setting and tailored to the participants' faith and culture by using short scriptural lessons, prayers, and individual sharing. Participants demonstrated improvements in fasting blood glucose (p = .042), diabetes knowledge (p = .002), and psychosocial self-efficacy (p = .001). Although generalizability of findings is limited, the structure and methods used in tailoring this DSME program could be transferable to other faith-based settings.

Long-Term Results of a Digital Diabetes Self-Management and Education Support Program Among Adults With Type 2 Diabetes: A Retrospective Cohort Study.

The purpose of this study is to examine the long-term impact of a digital diabetes self-management education and support (DSMES) program on A1C among adults with type 2 diabetes (T2DM). Data analyzed were from a retrospective cohort of commercially insured members with T2DM enrolled in the Omada for Diabetes program between January 1, 2019, and January 31, 2022 (n = 1,322). Linear mixed models measured changes in A1C and weight across 12 months (collected at baseline and every 3 months over 1 year) overall and stratified by A1C at baseline (≥8% vs <8%). On average, members were 53.5 years old, 56.9% female, and 71.5% White, with a mean baseline body mass index (BMI) of 36.9 and A1C of 7.6%. Members with baseline A1C ≥8% demonstrated clinically and statistically significant adjusted mean reductions in A1C during follow-up, from 9.48% at baseline to 7.33%, 7.57%, 7.59%, and 7.47% at 3, 6, 9, and 12 months, respectively. Those with A1C <8% maintained glycemic stability (6.73%, 6.50%, 6.54%, 6.62%, and 6.51%, respectively). Collectively, members experienced a -1.17 kg/m2 mean reduction in BMI over 12 months. This study provides real-world evidence that members with elevated baseline A1C (≥8%) enrolled in a digital DSMES program experienced clinically meaningful and statistically significant reductions in A1C. Those with baseline A1C within goal treatment range (<8%) maintained glycemic stability over 1 year. The findings support existing evidence that scalable digital DSMES solutions can help individuals with T2DM manage their condition.

Diabetes self-management education programs: Results from a nationwide population-based study on characteristics of participants, rating of programs and reasons for non-participation.

Population-based studies of reasons for not participating in diabetes self-management education (DSME) are scarce. Therefore, we investigated what sociodemographic and disease-related factors are associated with participation in DSME, the reasons for not participating in DSME and how participants evaluate DSME. We used data from the nationwide survey "Disease knowledge and information needs-Diabetes mellitus 2017", which included a total of 1396 participants diagnosed with diabetes mellitus (diabetes; n = 394 DSME-participants, n = 1002 DSME-never-participants). Analyses used weighted logistic or multinominal regression analyses with bivariate and multivariable approaches. Participants were more likely to attend DSME if they had a medium (OR 1.82 [95%CI 1.21-2.73]),or high (OR 2.04 [95%CI 1.30-3.21]) level of education, had type 1 diabetes (OR 2.46 [1.24-4.90]) and insulin treatment (OR 1.96 [95%CI 1.33-2.90]). Participants were less likely to attend DSME if they lived in East Germany (OR 0.57 [95%CI 0.39-0.83]), had diabetes for >2 to 5 years (OR 0.52 [95%CI 0.31-0.88] compared to >5 years), did not agree that diabetes is a lifelong disease (OR 0.30 [95%CI 0.15-0.62], had never been encouraged by their physician to attend DSME (OR 0.19 [95%CI 0.13-0.27]) and were not familiar with disease management programs (OR 0.67 [95%CI 0.47-0.96]). The main reasons for non-participation were participant's personal perception that DSME was not necessary (26.6%), followed by lack of recommendation from treating physician (25.7%) and lack of information on DSME (20.7%). DSME-participants found DSME more helpful if they had a medium educational level (OR 2.06 [95%CI 1.10-3.89] ref: low level of education) and less helpful if they were never encouraged by their treatment team (OR 0.46 [95%CI 0.26-0.82]). Professionals treating persons with diabetes should encourage their patients to attend DSME and underline that diabetes is a lifelong disease. Overall, the majority of DSME participants rated DSME as helpful.