Group-based Self-management Program Research Articles

Telehealth Self-Management Support in Early Stroke Rehabilitation: A Feasibility Randomized Controlled Trial.

Skills to manage the chronic effect of stroke are often not sufficiently addressed in early stroke rehabilitation. The study evaluated the feasibility of conducting a trial testing the efficacy of telehealth self-management support early in stroke recovery. Process, resources, and scientific feasibility was assessed for a randomized controlled trial comparing the effect of motivational interviewing and a group-based self-management program to treatment-as-usual with first-time stroke patients. Data were analyzed using descriptive statistics, effect sizes, and thematic analysis. Fifteen stroke patients were enrolled, and 10 completed the study (intervention n = 6). 100% attendance was achieved with technical support, reminders, and schedule flexibility. Participants were satisfied with the intervention and reported emotional benefits and gain of new insights. Perceived recovery showed moderate effect (r = 0.54). The findings support the feasibility of an efficacy trial as well as the potential benefit of integrating telehealth self-management support early in stroke rehabilitation.

Rethinking Activity: Development And Implementation Of A Virtual Self-management Program For People Living With Long COVID-19

PURPOSE: A subset of people who contract COVID-19 will continue to experience symptoms for months after the infection, a phenomenon known as long COVID. Long COVID is an episodic health condition with symptoms (such as dyspnea, fatigue, and post-exertional symptom exacerbation) that last for at least two months that cannot be explained by an alternative diagnosis. The likely volume of current and future long COVID patients in Canada is so high that primary care may not be able to cope given current resources. Many patients are struggling, and more support for self-management of symptoms and activities is required. METHODS: Individuals living with long COVID were recruited using clinical and patient-oriented networks. The BREATHE program is a free, virtual, multidisciplinary, patient-centred, group-based self-management program for long COVID that provides education on Breathing, Rest/recovery, Education, Activity management, Thinking/cognition, Healthy voice strategies, and Eating/nutrition. Group sessions include breakout room discussions on activity pacing and reframing exercise. Content is based on clinical experience, evidence from other conditions and the recommendations for safe rehabilitation in people living with long COVID. Three cohorts of adults living with long COVID took part in March, May and August 2021. Data on recruitment and attendance were collected, and anonymous patient feedback was collected for the purpose of quality improvement. RESULTS: Across the three cohorts, group sizes were n = 8 (an initial pilot), n = 16, and n = 16, and overall attendance was 90%, 91%, and 86%, respectively. There were 3 withdrawals, and feedback was received from 28 individuals. The program was significantly modified in response to patient priorities and preferences, and therapeutic relationships and peer support were emphasized. BREATHE is now an eight-week program involving two sessions per week. Feedback has been increasingly positive, and 100% of respondents from the most recent cohort found BREATHE helpful and would recommend it to other people with long COVID. CONCLUSIONS: The BREATHE self-management program is a feasible, potentially beneficial and cost-effective supportive care strategy for people living with long COVID that could be adopted within the healthcare system.

A pragmatic randomized controlled trial of a group self-management support program versus treatment-as-usual for anxiety disorders: study protocol

BackgroundThe integration of a personal recovery-oriented practice in mental health services is an emerging principle in policy planning. Self-management support (SMS) is an intervention promoting recovery that aims at educating patients on the nature of their mental disorder, improving their strategies to manage their day-to-day symptoms, fostering self-efficacy and empowerment, preventing relapse, and promoting well-being. While SMS is well established for chronic physical conditions, there is a lack of evidence to support the implementation of structured SMS programs for common mental disorders, and particularly for anxiety disorders. This study aims to examine the effectiveness of a group-based self-management support program for anxiety disorders as an add-on to treatment-as-usual in community-based care settings.Methods/designWe will conduct a multicentre pragmatic randomized controlled trial with a pre-treatment, post-treatment (4-month post-randomization), and follow-ups at 8, 12 and 24-months.Treatment and control groupsa) group self-management support (10 weekly 2.5-h group web-based sessions with 10–15 patients with two trained facilitators); b) treatment-as-usual. Participants will include adults meeting DSM-5 criteria for Panic Disorder, Agoraphobia, Social Anxiety Disorder, and/or Generalized Anxiety Disorder. The primary outcome measure will be the Beck Anxiety Inventory; secondary outcome measures will comprise self-reported instruments for anxiety and depressive symptoms, recovery, self-management, quality of life, and service utilisation.Statistical analysisData will be analysed based on intention-to-treat with a mixed effects regression model accounting for between and within-subject variations in the effects of the intervention.DiscussionThis study will contribute to the limited knowledge base regarding the effectiveness of structured group self-management support for anxiety disorders. It is expected that changes in patients’ self-management behaviour will lead to better anxiety management and, consequently, to improved patient outcomes.Trial registrationClinicalTrials.gov: NCT05124639. Prospectively registered 18 November 2021.

Effectiveness of a self-management support program for type 2 diabetes patients in the first years of illness: Results from a randomized controlled trial.

AimsTo evaluate the immediate and six-month effectiveness of a group-based self-management support program for people diagnosed with type 2 diabetes (1–3 years post diagnosis) on diabetes self-care, distress and cognitions.MethodsPeople with type 2 diabetes were randomized into the intervention (four group-based interactive sessions) or the control group (a single educational lecture) with their partners. Outcomes were measured at baseline, immediately after the third course session and six months later using validated questionnaires on diabetes self-care, distress, illness perceptions, diabetes-related attitudes, empowerment and partner support. Multilevel analyses were conducted according to the intention-to-treat principle using the data from 82 intervention and 86 control group participants, to test for differences in changes over time between the two groups.ResultsThe intervention group showed a significantly higher increase in physical activity and fruit and vegetable intake immediately after the program, whereas the low baseline levels of diabetes distress remained unaffected. Furthermore, the intervention group believed their illness to be more likely to be caused by chance/bad luck, but also felt more empowered to handle their condition and its treatment immediately after the program compared with the control group. Six months later, only the differences in empowerment had persisted.ConclusionsGroup-based self-management support results in favorable short-term behavioral changes and more persistent alterations in (perceived) empowerment in people living in the first years of type 2 diabetes. In order to achieve more sustainable behavioral changes, more prolonged support is necessary. This could be achieved by integrating attention to patients’ illness perceptions and continuous self-management support in regular diabetes care.Trial registrationNetherlands Trial Registry NL3158.

Views of healthcare professionals on training for and delivery of a fatigue self-management program for persons with multiple sclerosis

Purpose: To explore the experiences and perspectives of the healthcare professionals who were trained to and delivered “Minimise Fatigue, Maximise Life” (MFML), a patient-centered group-based fatigue self-management program for persons with multiple sclerosis.Methods: A qualitative descriptive study with semi-structured individual interviews at two time points. Data were analyzed for themes. Six healthcare professional facilitators who were trained to and delivered “Minimise Fatigue, Maximise Life” participated in a first interview, and five in a second. Participants were all female, aged between 23 and 66 years old and either occupational therapists or physiotherapists.Results: Two themes were evident in the data. The first, “Reciprocity,” showed how the healthcare professionals were trained to deliver MFML, then reciprocated in the program delivery as active participants, which then provided feelings of personal reward and expansion of their usual practice. The second, “Enhancements,” encompassed suggested directions for future training and deliveries of the program.Conclusion: This study suggests that multidimensional patient centered interventions also benefit the healthcare professionals who provide them because it expands their practice. Healthcare professionals who recognize the benefits of innovative and patient-centered interventions, supports both the patients with whom they work, and adds value to the health services they provide.Implications for rehabilitationHealthcare professionals who undergo training to facilitate delivery of self-management programs, which are based in an empowerment model, report an enhancement or expansion of their traditional practice.An empowerment-based program delivered in a group situation encourages and facilitates people to draw on their own and peers’ knowledge and expertise to problem solve for self-management.Healthcare professional education should facilitate the healthcare professional’s learning, and ability and willingness to acknowledge the richness in knowledge and expertise held by their patients.

Stepping On: Cancer Edition: A fall-prevention intervention adapted for older adults with cancer.

e22020Background: 20-50% of older patients (pts) with cancer have fallen in the past 6 months. Stepping On, a 7-week group-based self-management fall-prevention program addressing exercise, medicat...

Evaluation of uptake and effect on patient-reported outcomes of a clinician and patient co-led chronic musculoskeletal pain self-management programme provided by the UK National Health Service.

In the United Kingdom, chronic pain affects approximately 28 million adults, creating significant healthcare and socio-economic costs. The aim was to establish whether a programme designed to use best evidence of content and delivery will be used by patients with significant musculoskeletal pain problems. Of 528 patients recruited, 376 participated in a 7-week-long group-based self-management programme (SMP) co-delivered by clinical and lay tutors. Of these, 308 patients (mean age, 53 years; 69% females, 94% White) completed at least five SMP sessions. Six months after pre-course assessment, participants reported significantly improved patient activation and health status, lower depression and anxiety scores, decreased pain severity and interference, and improved self-management skills. There were no improvements in health state and pain self-efficacy. Uptake rate was 71% and completion 82%. The results should be of value to commissioners of pathways of care for the large numbers of patients attending the English NHS for chronic musculoskeletal pain.

A Self-Management Programme of Activity Coping and Education - SPACE for COPD(C) - in primary care: The protocol for a pragmatic trial

IntroductionNational guidance for chronic obstructive pulmonary disease (COPD) suggests that self-management support be provided for patients. Our institution has developed a standardised, manual-based, supported self-management programme: Self-Management Programme of Activity...

The effect of a lay-led, group-based self-management program for patients with chronic pain: a randomized controlled trial of the Danish version of the Chronic Pain Self-Management Programme.

The Stanford Chronic Pain Self-Management Programme (CPSMP) consists of 6 2½-hour weekly workshops focusing on how to manage pain in daily life. The workshops are facilitated by 2 workshop leaders of whom at least 1 must suffer from a long-term pain condition. The program is highly structured and manualized. Only few controlled trials testing the effect of CPSMP exist. Enrolled in the study were 424 adults from 19 Danish municipalities, (72% women; age: 25-93 years) with pain of any etiology and great variation in pain history (0-50 yrs). Of these, 216 were randomized to a lay-led version of the CPSMP. The primary outcome was pain-related disability. Secondary outcomes were pain, pain catastrophizing, self-efficacy, emotional distress, physical symptoms, and illness worry. Outcomes were measured before randomization, immediately after the CPSMP (response rate: 94%), and at 3-month follow-up (response rate: 92%). National register data on health expenditure were obtained to examine effects on health care use. ClinicalTrials.gov Identifier: NCT01306747. The CPSMP had no effect on the primary outcome pain-related disability or on health expenditure during intervention and follow-up period. Small positive effects on emotional distress and illness worry 3 months after CPSMP were observed. Lay-led CPSMP is not recommended as treatment for chronic pain-related disability. This heterogeneous group of patients with pain did not benefit from the CPSMP except for a small, but clinically insignificant improvement in psychological well-being.

Effectiveness of a group-based self-management program for people with chronic fatigue syndrome: a randomized controlled trial

Objective: To evaluate the effectiveness of a group-based self-management program for people with chronic fatigue syndrome. Design: A randomized controlled trial. Setting: Four mid-sized towns in southern Norway and two suburbs of Oslo. Subjects: A total of 137 adults with chronic fatigue syndrome. Intervention: A self-management program including eight biweekly meetings of 2.5 hours duration. The control group received usual care. Main measures: Primary outcome measure: Medical Outcomes Study-Short Form-36 physical functioning subscale. Secondary outcome measures: Fatigue severity scale, self-efficacy scale, physical and mental component summary of the Short Form-36, and the illness cognition questionnaire (acceptance subscale). Assessments were performed at baseline, and at six-month and one-year follow-ups. Results: At the six-month follow-up, a significant difference between the two groups was found concerning fatigue severity (p = 0.039) in favor of the control group, and concerning self-efficacy in favor of the intervention group (p = 0.039). These significant differences were not sustained at the one-year follow-up. No significant differences were found between the groups concerning physical functioning, acceptance, and health status at any of the measure points. The drop-out rate was 13.9% and the median number of sessions attended was seven (out of eight). Conclusions: The evaluated self-management program did not have any sustained effect, as compared with receiving usual care.

Feasibility of a Group-Based Self-Management Program for Ethnically Diverse People With HIV/AIDS in Hawaii

HIV/AIDS has transformed from a terminal to a chronic health condition affecting individuals for decades rather than years. Yet the development of care models that enhance client-focused HIV disease management skills is still in progress, especially in HIV resource-poor locales. This pilot study tested the feasibility of implementing the group-based Positive Self-Management Program (PSMP) to participants recruited from Oahu, Hawaii. The PSMP is a self-management program developed at Stanford University. A paucity of data exists on the efficacy of implementing the specialized PSMP that addresses unique needs of persons living with HIV. With a focus on enhancing self-efficacy beliefs, examples of topics addressed during seven weekly 2-hr group sessions include managing the physiological and psychological aspects of HIV, adherence to treatment regimes, symptom management, and fostering healthy lifestyle behaviors. Using a randomized waitlist control design, participants were recruited via convenience sampling and active outreach. The manualized PSMP was delivered by trained seropositive lay leaders. The completion rate for those who attended any sessions was 93.5%. The average attendance rate was 85%. The majority of participants reported being comfortable in the PSMP group setting and very satisfied with program activities. Almost all participants reported that the PSMP was a useful and easy method to learn new ways of managing their illness. The majority (93.8%) were most satisfied with skill development in goal setting and action planning. Implementation of the program for persons living with HIV in Hawaii was feasible. Lessons learned for future research and application to practice are discussed.

Development of a group-based self-management programme for individuals with chronic fatigue syndrome: a pilot study

Objective: The aim of the study was to develop a group-based self-management programme for individuals with chronic fatigue syndrome (CFS) by using the participants’ experiences with the initial version of the programme, which intends to promote coping with the illness in a primary healthcare setting. Methods: An initial programme was developed, based on self-efficacy theory and the concepts of client-centred practice and empowerment. Subsequently, the programme was tested and further developed by drawing on the participants’ experiences with the programme. Focus-group interviews were applied. The interviews were analysed using thematic analysis. Results: The initial programme was found to be feasible, although several modifications regarding the content and practical organization of the programme were proposed. Conclusion: In line with the participants’ experiences, the final self-management programme was developed, which includes short presentations of eight topics, exchange of experiences among participants, goal-setting, construction of action plans, and relaxation exercises, in addition to a meeting for relatives. The programme will be provided in eight biweekly sessions and be led by juxtaposed peer counsellors and occupational therapists. The effects of the final programme will be evaluated in a randomized controlled trial.

An evaluation of a self-management program for patients with long-term conditions

ObjectiveTo evaluate a group-based self-management program (SMP) delivered as part of a quality improvement program, Co-Creating Health, for patients living with one of four long-term conditions (LTCs): chronic obstructive pulmonary disease, depression, diabetes, and musculoskeletal pain. MethodsThe 7 week SMP was co-delivered by lay and health professional tutors. Patients completed self-reported outcome measures at pre-course and 6 months follow-up. Results486 patients completed (attended ≥5 sessions) the SMP and returned pre-course and 6 months follow up data. Patients reported significant improvements in patient activation (ES 0.65, p<0.001), with 53.9% of all patients reporting a meaningful ≥4 point improvement. Health-related quality of life (ES 0.06, p=0.04), and health status (ES 0.33, p<0.001) were also significantly improved. Patients’ anxiety (ES 0.37, p<0.001) and depression (ES 0.31, p<0.001) significantly improved. Patients also reported significant improvements in their self-management skills (p values from p<0.001 to p=0.028). ConclusionAttending the SMP led to improvements in a range of outcomes. Improvement in patient activation is important, as activated patients are more likely to perform self-care activities. Practice implicationsCo-delivered SMPs provide meaningful improvements in activation for >50% of those who complete and are a useful addition to self-management support provision.

Living with diabetes: a group-based self-management support programme for T2DM patients in the early phases of illness and their partners, study protocol of a randomised controlled trial

BackgroundThe present article presents the protocol for a randomised controlled trial to test the effectiveness of a group-based self-management support programme for recently diagnosed type 2 diabetes mellitus (T2DM) patients (one to three years post-diagnosis) and their partners. The course aims to support T2DM patients and their partners in successfully integrating diabetes care into their daily lives and hereby enhance self-management and diabetes-specific health-related quality of life. The content of the course is based on the Common-Sense Model of Self-Regulation (CSM). Furthermore, principles from the Social Cognitive Theory (SCT) and social support theories are integrated.Methods/DesignWe aim to recruit 160 recently diagnosed T2DM patients and their partners from general practices in six different regions in the Netherlands. Patients need to be diagnosed with T2DM for one to three years and have to experience some degree of diabetes-related difficulties, as measured with a three-item screener. Participating patients and their partners are randomly allocated to the intervention or control condition. Participants in the intervention condition receive three monthly group sessions and a booster session three months later. Participants in the control condition receive a single information meeting. Data will be collected at baseline (T0), directly after the programme (T1) and six months post-programme (T2), including: self-management, diabetes-specific health-related quality of life, illness perceptions, attitudes, social support and empowerment. A three-level multilevel model will be used to compare change-scores between the conditions (intervention/control) on each outcome.DiscussionOur study will be the first to determine whether a group-based support programme based on the CSM is effective in enhancing self-management and diabetes-specific health-related quality of life in recently diagnosed T2DM patients. The important role of patients’ partners in effective diabetes care is also acknowledged in the study.Trial registrationNetherlands National Trial Register (NTR) NTR3302.

Development and Pilot Study of Group-Based Dietary Self-Management Program for Community Dwellers with Hypertension

Background: In most countries worldwide, hypertension is considered as an important problem. Moreover, an increasing trend in the prevalence and incidence has been reported in most countries. This increasing trend requires an innovative approach to improve the lifestyle modification of hypertensive sufferers including their dietary behaviors. Objective: This developmental research aims to develop a program for improving the dietary behaviors of community dwellers with hypertension. Method: The process of this program development includes a literature review related to the self-management programs for hypertension, and dietary behavior outcomes, expert validation, and pilot testing. Result: The setting, strategies, duration, and outcome measurement from the literature review were taken into consideration to develop the new program. The newly developed group-based self-management program consists of: 1) the sharing and reflecting of individual current dietary behavior, 2) group educational session, 3) individual comparison of behavior and reflection of obstacles, 4) individual goal setting, and 5) follow up. In the educational session, the DASH eating plan is used as the reference as it is commonly used in studies about diet for hypertension.

Remote participants' experiences with a group-based stroke self-management program using videoconference technology

Telehealth is an all-inclusive term for the provision of health services using information and communication technology. Videoconference delivery is one form of telehealth whereby a synchronous, two-way audio and visual connection is made between two or more sites. Videoconference is used in remote areas to improve access to healthcare, perform individual clinical assessments and deliver group education. Moving On after Stroke (MOST®) is a group-based, self-management program for stroke survivors and their caregivers, which consists of information sharing, facilitated discussion, goal-setting, and exercise. This program was delivered simultaneously to local participants onsite in Thunder Bay, Canada, and distant participants in smaller, remote communities in Northwestern Ontario using videoconferencing (MOST-Telehealth Remote). The objective of this study was to explore the experiences of remote participants, their perceptions regarding factors that enable or limit videoconference participation, and to obtain suggestions for enhanced delivery of videoconferenced group programs. This qualitative study used an interpretive methodology. Semi-structured interviews were conducted in person with remote MOST-Telehealth Remote (MOST-TR) participants within one year post-program. Participants were recruited using purposive sampling and included both male and female stroke survivors and caregivers, those who participated alone and those who participated with others at the remote site. Twenty-seven people were approached, eight declined, and 19 agreed to participate. The average age of participants was 66.2 years (range 48-84). The interviews were transcribed and coded using NVivo v2.0 (www.gsrinternational.com). Data were analyzed for common categories using qualitative descriptive methods. All participants valued access to the program without having to travel long distances. They felt safe in discussions and when exercising with the group across videoconference. Many reported 'feeling as if they were in the same room' but also acknowledged that there were limitations to participating via videoconference. Participants recognized a loss of subtleties in communication and the group facilitators found it difficult to discern whether participants were finding the exercises too difficult or too easy. The videoconference medium also limited participants' ability to privately or informally address concerns. Factors facilitating engagement and participation were similar to factors in face-to-face groups. Additionally, the importance of collaboration with onsite coordinators, volunteers, and other local participants was highlighted. Facilitators have the added responsibility of including all participants more explicitly, especially those offsite. Suggestions to improve group cohesion and participation included a preliminary face-to-face meeting with all participants, implementing technical strategies, and ongoing onsite support. For MOST-TR participants, videoconference participation was valuable. Addressing the limitations of videoconference connection and enhanced local support may improve the experience for remote participants in small-group, videoconferenced, self-management programs. Using videoconference technology to participate in existing programs greatly increases accessibility for people living in remote areas.

Impact of a Low-Vision Self-Management Program on Informal Caregivers

To evaluate caregivers' experiences and outcomes following attendance at a patient-centered group-based self-management program called "Living with Low Vision." Participants were caregivers of adults with low vision. A pre-post study design evaluated the impact of the program on single-item indicators that assessed levels of understanding of low vision, awareness of devices, aids and practical strategies, and questionnaires to assess confidence to deal with low vision, self-efficacy, and emotional well being. Participants formed three groups: (1) those who attended the program [intervention group 1 (IG1)] and received a take-home pack; (2) those who received a take-home pack only [intervention group 2 (IG2)]; and (3) those who received no intervention [comparison group (CG)]. Sixty participants (IG1 = 16, IG2 = 33, CG = 11) with mean (SD) age 67.2 years (SD = 14.8) were recruited. Half (n = 31; 51.7%) were the spouse of the adults with low vision. With the exception of two single-item indicators that assessed awareness of low-vision aids and practical strategies; no significant group differences on follow-up scores between the three study groups were found on any measure. Compared with CG participants, IG1 and IG2 participants demonstrated significantly greater awareness of low-vision aids and practical strategies (p < 0.05, for all). In addition, IG1 participants demonstrated significantly improved awareness of practical strategies than IG2 participants (p = 0.024). Most IG1 participants (n = 10; 62.5%) agreed that the program was relevant and helpful, and most would recommend it to other caregivers. Involving caregivers in a patient-centered group-based self-management program and providing them with an informative take-home self-help pack improved their awareness of low-vision aids, devices, and practical strategies. Our findings should be followed up with larger studies to clearly identify optimal ways of providing caregivers with information and problem-solving skills to effectively manage the demands of low vision.

Feasibility of a group-based self-management program among congestive heart failure patients

This study assessed the feasibility of the Chronic Disease Self-Management Program (CDSMP) among patients with congestive heart failure (CHF). The program emphasizes patients' central role and responsibility in managing their illness. Patients were randomly assigned to the program, which was led by a cardiac nurse specialist and a CHF patient. Data on performance according to protocol, adherence, and opinion about the program were collected among 186 patients and 18 leaders. Eighty percent of the group sessions were carried out largely according to protocol. Three fourths of the patients attended at least 4 of the 6 sessions. Female sex and lower New York Heart Association classification predicted good attendance. Directly after the program and at 12-month follow-up, approximately three fourths of the patients stated that they had benefited from the program. Recommendations mainly concerned spending more time on several program topics and specifying patient-selection criteria in more detail. The program was considered feasible.

Effectiveness and feasibility of a structured group-based self-management programme among congestive heart failure patients in The Netherlands

Effectiveness and feasibility of a structured group-based self-management programme among congestive heart failure patients in The Netherlands

Structured patient education: the Diabetes X‐PERT Programme makes a difference

To develop a patient-centred, group-based self-management programme (X-PERT), based on theories of empowerment and discovery learning, and to assess the effectiveness of the programme on clinical, lifestyle and psychosocial outcomes. Adults with Type 2 diabetes (n = 314), living in Burnley, Pendle or Rossendale, Lancashire, UK were randomized to either individual appointments (control group) (n = 157) or the X-PERT Programme (n = 157). X-PERT patients were invited to attend six 2-h group sessions of self-management education. Outcomes were assessed at baseline, 4 and 14 months. One hundred and forty-nine participants (95%) attended the X-PERT Programme, with 128 (82%) attending four or more sessions. By 14 months the X-PERT group compared with the control group showed significant improvements in the mean HbA1c (- 0.6% vs. + 0.1%, repeated measures anova, P < 0.001). The number needed to treat (NNT) for preventing diabetes medication increase was 4 [95% confidence interval (CI) 3, 7] and NNT for reducing diabetes medication was 7 (95% CI 5, 11). Statistically significant improvements were also shown in the X-PERT patients compared with the control patients for body weight, body mass index (BMI), waist circumference, total cholesterol, self-empowerment, diabetes knowledge, physical activity levels, foot care, fruit and vegetable intake, enjoyment of food and treatment satisfaction. Participation in the X-PERT Programme by adults with Type 2 diabetes was shown at 14 months to have led to improved glycaemic control, reduced total cholesterol level, body weight, BMI and waist circumference, reduced requirement for diabetes medication, increased consumption of fruit and vegetables, enjoyment of food, knowledge of diabetes, self-empowerment, self-management skills and treatment satisfaction.