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Database of Abstracts of Reviews of Effects (DARE): Quality-assessed Reviews [Internet]. York (UK): Centre for Reviews and Dissemination (UK); 1995-.

Database of Abstracts of Reviews of Effects (DARE): Quality-assessed Reviews [Internet].

Diabetes education for children with type 1 diabetes mellitus and their families

R Couch, M Jetha, DM Dryden, N Hooton, Y Liang, T Durec, E Sumamo, C Spooner, A Milne, K O'Gorman, and TP Klassen.

Review published: 2008.

CRD summary

This review concluded that there was insufficient evidence to identify a particular diabetes education intervention targeted at children with type 1 diabetes and/or their families that was more effective than standard care at improving diabetes control or other outcomes. The authors' conclusions seemed reasonable given the varied and poor quality evidence available and are likely to be reliable.

Authors' objectives

To assess the effect of diabetes education for children with type 1 diabetes and their families on metabolic control, diabetes-related hospitalisations, complications, knowledge, quality of life and other psychosocial outcomes.


Twenty-one electronic databases, including MEDLINE, EMBASE CINAHL, PsycINFO and Cochrane Central Register of Controlled Trials were searched for English-language articles up to March 2007. Websites of relevant professional associations and reference lists of relevant papers and reviews were searched.

Study selection

Studies that investigated a diabetes education programme for children with type 1 diabetes under 18 years old or their families were included. Any design was eligible provided there were more than 10 participants. Education programmes were required to incorporate at least one of nine named content areas. Nine different types of interventions were investigated in the included studies. These ranged from general diabetes education to family therapy and cognitive-behaviour therapy (CBT). Duration ranged from one day to two years. In most studies the comparator was standard care, but in most instances it was unclear what this entailed. The mean age of participants ranged from 2.7 to 16 years. The outcomes of interest were metabolic control (HbA1c) hospitalisation, emergency department utilisation, short- and long-term complications, quality of life, school attendance and performance, self-confidence and psychosocial outcomes. Two reviewers independently assessed studies for inclusion.

Assessment of study quality

Randomised controlled trials (RCTs) and controlled clinical trials (CCTs) were assessed for randomisation, allocation concealment, double blinding, blinding of outcome assessors and reporting of withdrawals and drop outs using the Jadad and Schulz scales. Other study designs were assessed using the Thomas Quality Assessment Tool for Quantitative Studies. Two reviewers independently assessed study quality.

Data extraction

For the outcomes of interest, change from baseline data were extracted where available. Dichotomous data were extracted as relative risk and for continuous data the mean difference was extracted. It was recorded whether or not there was a significant difference between intervention and control. One reviewer extracted data into a standardised form, checked by a second reviewer.

Methods of synthesis

A narrative synthesis was conducted. Studies were stratified first by outcome, then by each of the nine types of interventions and population subgroup (general population, children with newly diagnosed diabetes and children with poor metabolic control).

Results of the review

Eighty studies were included. The number of participants ranged from 11 to 332. There were 42 RCTs, 11 CCTs, 20 before and after studies and seven cohort studies. Where reported, length of follow-up ranged from two days to four years. With the exception of four RCTs, studies were rated as being poor quality with serious threats to validity. Within each intervention category there was considerable variability in the content, duration and method of delivery of the intervention. With the exception of HbA1c, there was also considerable variability between studies in the outcome measures used to measure the same outcome. Across all the outcomes the evidence for the effectiveness of the education interventions was inconsistent. Some studies showed a benefit and others did not. Most studies showed no evidence of an improvement in the key outcome HbA1c levels with educational interventions compared to standard care. There was evidence for a statistically significant reduction in complications in some studies of general diabetes education, cognitive behavioural therapy and skills training; other studies found no difference. There was some evidence of reduced health service utilisation, but again the evidence was mixed and there was considerable heterogeneity across the studies.

Authors' conclusions

There was insufficient evidence to identify a particular diabetes education intervention that was more effective than standard care at improving diabetes control or quality of life, or which reduced short-term complications due to the heterogeneity of the interventions, outcome measures and duration of follow-up.

CRD commentary

There was a clearly stated review question. An extensive range of sources was searched for relevant studies. Appropriate methods were used to reduce error and bias in the review processes. The included studies were highly heterogeneous. This was partly a reflection of the very broad review question and inclusion criteria. The authors attempted to address this by stratifying studies in their narrative synthesis. Study quality was assessed and considered as part of the synthesis. Many of the studies received a low grading because of the lack of double-blinding, something that would be extremely difficult to achieve with this type of educational intervention. The authors acknowledged this limitation in their discussion and it should be borne in mind when interpreting the results of the review. The authors' conclusions seemed reasonable and are likely to be reliable.

Implications of the review for practice and research

Practice: The authors did not state any implications for practice

Research: The authors stated that appropriately powered well-designed RCTs were required to assess the benefits on HbA1c and short-term complications of CBT, behavioural therapy, family systems therapy, motivational interviewing, frequency of contact with health care professionals, nutrition therapy and intensive diabetes management, particularly for children with poorly controlled diabetes. Future trials should specify what was meant by standard care and include quality of life and long-term complications as an outcome.


Agency for Healthcare Research and Quality (AHRQ) Contract No. 290-02-0023.

Bibliographic details

Couch R, Jetha M, Dryden D M, Hooton N, Liang Y, Durec T, Sumamo E, Spooner C, Milne A, O'Gorman K, Klassen T P. Diabetes education for children with type 1 diabetes mellitus and their families. Rockville, MD, USA: Agency for Healthcare Research and Quality. Evidence Report/Technology Assessment; 166. 2008. [PubMed: 18620470]

Indexing Status

Subject indexing assigned by NLM


Child; Cognitive Therapy; Diabetes Mellitus Type 1 /complications /therapy; Family; Hemoglobin A, Glycosylated /analysis; Humans; Patient Education as Topic; Quality of Life; Self Care



Database entry date


Record Status

This is a critical abstract of a systematic review that meets the criteria for inclusion on DARE. Each critical abstract contains a brief summary of the review methods, results and conclusions followed by a detailed critical assessment on the reliability of the review and the conclusions drawn.

CRD has determined that this article meets the DARE scientific quality criteria for a systematic review.

Copyright © 2014 University of York.

PMID: 18620470

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