Impact of Educational Chronic Care Model on Diabetic Patients: A Prospective Cohort Study

Impact of Educational Chronic Care Model on Diabetic Patients: A Prospective Cohort Study | Research Square window.SnipcartSettings = { analytics: { enabled: false } }; (function() { var accessVector = localStorage.getItem('access_vector') || ''; window.dataLayer = window.dataLayer || []; if (accessVector) { window.dataLayer.push({ user: { profile: { profileInfo: { snid: accessVector } } } }); } })(); (function(w,d,s,l,i){w[l]=w[l]||[];w[l].push({'gtm.start':new Date().getTime(),event:'gtm.js'});var f=d.getElementsByTagName(s)[0],j=d.createElement(s),dl=l!='dataLayer'?'&l='+l:'';j.async=true;j.src='https://www.googletagmanager.com/gtm.js?id='+i+dl;f.parentNode.insertBefore(j,f);})(window,document,'script','dataLayer','GTM-K279D39R'); Browse Preprints In Review Journals COVID-19 Preprints AJE Video Bytes Research Tools Research Promotion AJE Professional Editing AJE Rubriq About Preprint Platform In Review Editorial Policies Our Team Advisory Board Help Center Sign In Submit a Preprint Cite Share Download PDF Research article Impact of Educational Chronic Care Model on Diabetic Patients: A Prospective Cohort Study Ahmed Mahmoud Elmalky, Abdulsalam S. Alharbi, Abdulkarim M. Alsaqabi This is a preprint; it has not been peer reviewed by a journal. https://doi.org/ 10.21203/rs.3.rs-47906/v1 This work is licensed under a CC BY 4.0 License Status: Posted Version 1 posted You are reading this latest preprint version Abstract Background Lack of knowledge and understanding about diabetes are important barriers to cure. Treatment of diabetes alone without education is not sufficient. Nowadays, health education could reach us on mobiles. Aim Our aim is how to make advice-giving becomes a system to treat our patients. The theme of this study is diabetes education. And to know how far the prompt well-structured education could affect the clinical status and the quality of life of a poorly controlled diabetic patients. Methods 702 patients with type 1 diabetes were followed for 2 years (2017, 2018), by condensed friendly education and training sessions. Our activities were mainly through direct individual approach and social media, structured in the form of visits. The study was done in a specialized clinics of diabetes (SDC) in a tertiary university hospital. We evaluated the clinical status, psychological, sociocultural and satisfaction of the patients, pre and post education. We assessed our patients at the beginning of the study, throughout, and at the time of discharge. Quantitative and qualitative data were compared statistically by paired t test and chi-square test at 0.05 level of significance. Results 96.7% of our patients were completely satisfied by what they have achieved through this project. The average HbA1C become less than eight in 54% of patients. Patients with HbA1C 8-9%, BP <140/80, and LDL <3.36 mmol/l, were 46%, 51% and 79% respectively. The average blood pressure for 56% of patients was 132/77. The average LDL level among 71% of patients was 2.25. 27% of patients had average discharged HbA1c of 7.3. Net promotor score of SDC was 85%, were promotors, passives and detractors were 87.8%, 9.5% and 2.8% respectively. P value <0.05 Conclusion Education self-management support programs are cost-effective and superior to usual care. Education programs were more effective in lowering HbA1c. Attendees finding it valuable and enjoyable. Endocrinology & Metabolism Educational Chronic Care Model Diabetic Patients Figures Figure 1 Figure 2 Figure 3 Figure 4 Figure 5 Figure 6 Figure 7 Figure 8 1. Introduction To improve the lives of people with diabetes and prevent its complications through innovative care, treatment, patient education, professional training and research. This is a worthy goal to struggle for. Glycemic control and improvement could be achieved by structured education programs and behavioral changes. , Glycemic control can preserve long-term clinical outcomes and prevent or delay the development of macro- and microvascular sequelae of diabetes. , Effective programs are best delivered through face-to-face approach in combination with far-reaching, E-learning approach. They incorporate perceptive restructuring together with better interaction. 3 , , Because of the economic growth, almost all people now are using online social media on their smart phones, relying on them as communication channels. Kingdom of Saudi Arabia (KSA) has the highest rank in the world of smart-phone users, according to the report of the United Nations submitted in the Conference of Trade and Development. Healthcare researchers and providers invest this opportunity to better educate diabetic patients for better disease management. Many studies showed the advantage of using social media campaigns in patient education. , and In China, the glycemic control among diabetic patients is still low, due to poor patient education. This study assesses the effect of social media in combination with face-to-face group education in improving the clinical status and quality of life, among multi-national type 1 diabetic patients in Saudi Arabia. 2. Materials And Methods: 2.1. Participants and sample size: From January to December 2017–2018, a total of 702 patients with TIDM, aged from 14 to 60 years were selected as convenient sample from specialized diabetic clinics at the King Saud University Medical City Tertiary Hospital, of 920 beds. 2.2. Aim of the study: Our aim is how to make advice-giving becomes a system to treat our patients. This -two years- prospective cohort study compared the effect of health education through individual approach combined with usage of social media groups, on uncontrolled type 1 diabetes. The same group of patients subjected to pre-intervention evaluation and post-intervention evaluation. We used clinical outcome, quality of life and psychological improvement as variables to measure in the study. 2.3. Ethics Committee Approval and Consenting: We had approval from Research Ethics Committee on this study of the King Saud University Medical City. All patients participated in this study signed an informed consent. The research has been approved by the Clinical research Ethics commission of the Medical College. Crafted informed consents were acquired from all patients prior to the start of this study. 2.4. Inclusion and Exclusion Criteria: Patients with diabetes have been included in the study as follows: doctors diagnosed TIDM according to the guidelines of the World Health Organization (WHO), patients should have a mobile phone, gave consent to receive messages and also had the ability to understand text messages and to engage willingly in this research. Patients have also been excluded whether they have been diagnosed with type II diabetes, specific diabetes or a history of serious medical conditions such as kidney or liver failure, serious vision problems, mental illnesses or other metabolic diseases. 2.5. Number and frequency of sessions: Our patients were visiting the clinic 3–5 times per week, during the first six months. Then they have had multiple visits to be followed; three visits per month to the completion of follow up. In each visit, they received the care, had their lab investigations, took their medications, attended the education sessions, and repeated the arrangement of their schedule. 2.6. Professional background of educators: The doctors provided the educational related messages and selected them were board qualified and specialists in the field of diabetes research. They trained the nursing staff that sent the educational messages. The trained nurses followed up with patients with diabetes. Nurses had graduated from college or above and served for at least 3 years. 2.7. Data Collection Process A qualified nurses and physicians in our unit collected the data in hard copies, soft copies on the electronic patient files, structured forms and questionnaires. Basic information on socioeconomic and demographic characteristics such as age, sex, educational achievement level, personal health and lifestyle such as a regular physical activity has been obtained. Data collected; at baseline, 6 months and 12 months, as well as at each visit. We collected data about; physical assessment results, laboratory investigation results and education program outcomes. Data on self-care activities were collected from all patients. Laboratory investigation results such as; fasting blood glucose and 2-hour postprandial glucose, LDL, BP, and glycosylated hemoglobin (HbAlc). 2.8. Research Tools: We used three tools; educational program, measurement tools (physical assessment, and laboratory investigations): 2.9. Educational program: Education is intended to promote responsible decision-making, issue-solving, constructive engagement with the health education group and self-care, as well as to enhance clinical performance, quality of life and fitness status. Such goals are achieved by comprehensive health education in a community given by health educators every month for more than 2 years. A total of 702 persons were invited to take part in the program. Reasons for decreasing involvement involved regular travel, job too hard, loss of confidence, and not being able to reach software applications or phone. The data obtained were socio-demographic factors, eating patterns, smoking, physical exercise, foot-body-care, capillary glycaemia self-monitoring, and medication compliance. Together with subsequent morbidity, such as obesity; hypertension; dyslipidemia; ischemic cardiac failure, including “acute myocardial infarction”, angina, stroke; and other complications (neuropathy, micro-macrovascular, retinopathy). During the follow-up visits, data were obtained on different variables (HbA1c, total cholesterol, low-density lipoprotein (LDL) cholesterol, systolic blood pressure (SBP), diastolic blood pressure (DBP), high-density lipoprotein (HDL) cholesterol, and BMI). The systemic model of health education was focused on the following dimensions: 2.9.1. Image education: Patients were supplied by videos on DM which are focused on audiovisual strategies to raise understanding of the value of diabetes. Picture education will provide patients with more information regarding DM pathophysiology, impermissibility, risks, and diagnosis, while growing awareness about the significance of managing risk factors. Often members of the family would engage in picture education; they were all invited. The intervention was in the form of focus group face-to-face well-structured education sessions, individual approach one-to-one interviews, using education curriculum and well prepared education materials. Also, these were combined with telemedicine apps, WhatsApp groups, mobile services and support groups. 2.9.2. Visit to the Presentation Room: With on-site appointments, patients may obtain basic awareness of the impact of medications on the bloodstream, the diet pattern, alternate medicine choices, insulin self-injection, dosage guidelines, alert indicators of hypoglycemia, and carbohydrate-counting strategies. Patients subdivided into one face-to-face group discussion and individual approach through personal interviews, through which the nurse began to provide the patient with direct education and training using specific educational material aside with friendly psychological support and confidence-building talk. The learning strategy is more pragmatic and focused on the day-to-day interactions of people dealing with an illness compared to earlier treatment approaches that were based on information. They stress the necessity of increasing the dignity and security of clinicians. There should be ongoing training. One must learn to incorporate the information that he accumulates in daily practice. 2.9.3. Distribution of instructional content: In order to enhance diabetes self-care and to be an involved member in the whole process, our community has created a low-literacy colored brochures. Patients in the program were provided with a paper guide comprising the question-explanation resources on diabetes and care aims. 2.9.4. Therapy in personalized medicinal care: In a detailed and personally arranged diet plan, the interests, cultural context and conditions of every participant as well as the overall recovery system are addressed. Due to the difficulty of the medical and dietary problems with most patients, our staff proposed a simpler scheme named "restricted plate diet" Fig. 9, It comprises of three sections: ½ plate vegetables, ¼ plate staple food (carbohydrate) and ¼ plate lean red meat (protein) and dishes remain variable not the same. 2.9.5. Personal exercise programs: Exercises involve riding, jogging, running, surfing, gymnastics, table tennis, and music. Physical activity goals, techniques, rates and intensities must be discussed for patients who are extremely open to the identification of challenges and to helping patients pursue alternatives. Patients that show signs of cardiac ischemia should be forwarded for further examination and diagnosis. 2.9.6. Groups and lectures: WhatsApp group and Regular Medical Meetings. Face-to-face seminars were the most common mode of presentation, and there was a monthly frequent educational lectures. The WhatsApp community offers a way of delivering quality health information for patients. If the results are usually below the defined goal levels, patients will be checked and reported on a daily basis to the WhatsApp Health Care Team or on an occasional visit to cause improvements in treatment if appropriate. The main objectives of the lectures are to offer feedback on the aim of reducing the possibility of complications, to share knowledge and methods for addressing challenges, to recommend approaches for meeting targets, to help track complications and to offer skills training. 2.9.7. Complication evaluation: The key task of the team is to examine complications (nephropathy, artery disorder, retinopathy, and neuropathy) and discover strategies for patients to exercise safe. The group offered advice on complications monitoring, established recovery schedules, evaluated success in achieving care goals, and helped establish approaches to fulfill recovery targets and prevent complications. 2.9.8. Modification of life style: Lifestyle modification consists of weight loss; decreased saturated fat, trans-fat and cholesterol intake; lowered sodium and improved potassium intake; smoking cessation; and enhanced physical activity. Lifestyle modification elements include activity guidelines, professional diet guidance and thorough diabetes awareness with the goal of transforming the diabetes treatment model from a patient-focused system to a patient-focused physician. 15 2.9.9. Systemic Healthcare Program: To order to effectively follow this procedure, the individual must engage actively in the implementation of a recovery program, adhere to the values of self-care, make day-to-day “self-care” choices, interact openly and with adequate consistency with the team, and minimize the regular consumption of food. Boost physical exercise, feed less meals a day, blood glucose self-monitoring, increase compliance to medications, and develop insulin therapy skills. 2.9.10. Glycemic control self-monitoring: Patients were advised to track their blood sugars, report values, and keep a record book for appointments. Most patients do routine blood glucose self-monitoring, report findings as advised, and review them with the health care staff. Patients should consult with the staff when goals are not met or where difficulties or obstacles are found. Evaluation of therapeutic effect monthly: Reinforcing care, establishing the target of wellness promotion and problem-solving everyday life are needed; doctors have specific monitoring goals for patients like HbA1c, LDL/HDL cholesterol, blood pressure, and total cholesterol. Patients need to be motivated to incorporate behavioral therapy into their everyday lives and to engage more fully in the process. Patients can interact with the staff equally and regularly. Continuous training workshops on self-care, general and specific nutrition, medications, fitness, blood sugar screening, foot care, changes in lifestyle, and tobacco smoking. What about diabetes? How am I going to know if I have diabetes? How is my diabetes going to be treated? What kind of complications are possible? How can I avoid problems with my health? How is my diabetes drug going to help me? Drug name, type of drug, what does it do? Things to look for. Diabetes ABCs, "A" means "A1C," "B" means "blood pressure," "C" means "cholesterol". Diabetic patients have all provided traditional medical care and diabetes nursing education and will also be driven by telemedicine applications, WhatsApp groups, mobile services and support groups. We were responsible for sending and describing the information related to diabetes to our patients, including blood glucose self-monitoring, a healthy lifestyle, physical exercise, adherence with prescribed medication, low and high blood glucose regulation, and weight control for diabetes patients. Improvement proposed measures: A more development program was formulated on the grounds of medication effectiveness, blood pressure, risks and allergic reactions. Repeated nutritional histories and subsequent minor improvements discussed every several weeks to months by the community render it easier to determine how the adjustments already accepted have been adopted, to reinforce the value of nutritional measures, and to enable patients to exercise good food options. Personal follow-up scheme: Effective follow-up will be an important part of the long-term maintenance. The patient follow-up program covered follow-up duration, risk conditions, foot protection, insulin self-injection, early symptoms of hypoglycemia, diabetes-related problems, and hypoglycemia. Such initiatives will regularly enhance behavioral improvement and long-term sustainability. 2.10. Measurement tools All patients underwent physical assessments, which include vitals, anthropometric measures (such as height, weight, BMI) and blood chemical tests (such as glucose levels, glycosylated hemoglobin, LDL, and triglycerides) were carried out by medical professionals using conventional methods. Patient evaluation was set up; pre and post intervention, through measurement of glycosylated hemoglobin, baseline and discharge glycosylated hemoglobin, Measurement of blood pressure, and LDL. Measurement of patient satisfaction through patient satisfaction survey and evaluation of patients’ feelings and self-esteem by; Net promoter score, SDC score, diabetes knowledge score, words from our patients. Patient evaluation was done as primary and secondary end points. Reinforcement of education Another problem is the enforcement of the value of regular training sessions. As at the beginning of the process the best results achieved through academic stimulation are seen but usually diminish afterwards. To prevent attrition, a few days before the learning meeting, it may be helpful to inform the patients by their clinicians about the appointment by phone or text message. Barriers to self-management There are many obstacles to diabetes education and self-management. A few are human such as empowerment, education, inspiration, problem-solving skills, anxiety, gender, cognitive impairment, certain disorders, etc. and others are linked to the setting and community. Instructors must recognize some obstacles through open and trusting interaction with participants. Single face-to-face meetings can be more effective for this reason than group meetings. However, even when the education program is focused on group sessions, single lessons can be used chronologically. Cultural and linguistic discrepancies of minority groups represent significant barriers. It is essential for these group members to use special tools for adapting education. Outcome indicators Primary outcome Normal Glycated Hemoglobin (HbA1c) was the primary goal. A Diabetes Control and Complications Trial (DCCT) method were used to measure glycated hemoglobin. Clinical outcomes: Body weight: Calibrated electronic scales were used to measure body weight. Of measuring height, a portable sonic machine was used. The value of Body mass index (kg / m2) was determined from measures of height and weight. The Tanita Body Fat Control measured the precision of body fat to ± 0.5%. The correct waist circumference assessment procedure has been used. Laboratory Results: A complete lipid profile has been obtained. Blood pressure was measured using a digital blood pressure monitor by accepted methods. Current guideline studies also provided appropriate levels of blood lipids and blood pressure. Medication prescribed: Drugs approved for diabetes treatment were tested every 14 months and compared at baseline with those prescribed. We defined the increase in medication by launching a new drug, increasing the dose of oral hypoglycemic drugs or use of insulin. However, a decrease of medication was described as a decrease in oral hypoglycemic drug type, quantity or the number of insulin units administered. Lifestyle The outcomes of lifestyle were evaluated regularly, 6 months, 12 months and 24 months. To what degree we were effective for encouraging, improving adaptation and strengthening family relationships of our patients. How many occasions have they been through periods of hopelessness and despair after the end of the study? To what extent we made our patient believe in self-efficacy and have a positive outlook on life? To what extent did our patients build a strong favorable doctor-patient interaction? And become more effective in coping with actions and had a better health-related quality of life with a favorable impact on their life. Variables of socialization, particularly skills for problem-solving and self-efficacy. Mental well-being. Identify and encourage personal goals and habits to accomplish self-determined objectives. How to build trust in an interpersonal relationship. Psychological We used Net promoter score, SDC score, and patient words through customer satisfaction surveys. Assessment of pre- and post-intervention patients ' self-esteem and psychosocial status. We evaluated the degree to which the educational sessions render our patients feel empowerment, emotional adjustment, and the real quality of life changes. How they adopt new challenges, essential survival skills. The extent to which they become fully consistent with a healthy, great life with social and psychological concerns. Statistical analysis The action program and the personal appointment groups were attributed by evaluating the cohort by time interface term from frequent measurement analysis of variability with Greenhouse-Geisser sphericity adjustment, taking the primary outcome of HbA1cas and analyzing others as developing a hypothesis. With Microsoft Windows version 11.0 (SPSS Inc., Chicago, Illinois, United States), Stata version Nine (Stata Corp, Baton rouge, TX, USA) was used. If appropriate, the CONSORT claim was adhered to and as far as possible an attempt to examine was carried out. Based on the t-test and chi-square test, we analyzed differences among groups. An analysis of the intention to treat, along with all other individuals involved, was carried out. Differences from baseline assessment were evaluated using multiple variability measurement methods to determine the discrepancies between self-care behaviors and HbA1c in the same group, pre and post-intervention. Pearson or Spearman rho correlations have been used to examine the relationships between data. Multiple regressions have been used to identify glycemic control predictors. 3. Results Table 1 shows the baseline distribution in our patients of the comorbidity characteristics. The ANOVA analysis showed significant differences, before, during and after implementation of the program, in terms of Hb1AC, BP and LDL. Table 1 Demographic characteristics of 702 type 1 diabetic patients at the start of study Demographic Characteristics (baseline) Mean (SD), Number (%) Age (years) 39.7 (± 5.4) Gender Male 309 (44) Female 393 (56) Nationality Saudi 611 (87) Yemeni 23 (3.2) India 18 (2.5) Egypt 13 (1.8) Syrian 11 (1.5) Jordan 10 (1.4) Philippines 9 (1.2) Sudan 7 (0.9) Education Never 13 (1.8) Primary 56 (7.9) Secondary 114 (16.2) College 344 (49) Tertiary 175 (24.9) Marital status Single 211 (30) Married 491 (70) Occupation Office 205 (29.2) Factory 129 (18.3) Fieldwork 105 (14.9) Housewife 102 (14.5) Professional 91 (12.9) Retired 70 (9.9) Duration of diabetes (years) 16.8 (± 4.3) Treatment mode Oral drug 34 (4.8) Insulin 378 (53.8) Combined treatment 290 (41.3) Body weight (kg) 88.7 (± 7.1) Body mass index 31.7 (± 4.6) 702 potentially eligible patients sought enrollment and achievement of enrollment and were referred to a comprehensive model of clinical care. Demographic and socio-cultural characteristics in terms of age, length of T1DM and sex. The specific health features, compliance to treatment, distribution of morbidity, commitment to diet, and medical risks as seen in Table 1 . The systematic model of health education resulted in favorable variations in HbA1c, LDL cholesterol and SBP (P < 0 05); statistically significant differences were observed during the study (Fig. 1, Table 2 ). The non-adjusted effect of the systematic health education model on parameter changes was higher for LDL, HbA1c, and SBP; this showed significant differences during the study (P < 0 05). After an updated study, the HbA1c decreased by 0.67 per cent (P < 0 01) in the systemic model of health education. In comparison, SBP decreased by 10.83 mmHg (P < 0 01) and the amount of DBP, HDL and total cholesterol decreased significantly and did not important. (Fig. 2, 3) Table 2 List of potential themes included in a therapeutic patient education for type 1 diabetic patients 1. Basic knowledge of diabetes and its complications 2. Healthy diet 3. Regular physical activity 4. Glucose control, modification of diet and treatment before, during and after vigorous physical activity 5. Self-monitoring blood glucose 6. Prevention and early identification of hypoglycemia 7. Prevention and early identification of hyperglycemia 8. Management of hypo- or hyperglycemia 9. Modification of the treatment on the basis of self-monitoring blood glucose before medical check 10. Giving up smoking 11. Periodic administration of questionnaires on erectile dysfunction 12. Periodic administration of questionnaires on quality of life 13. Identification and correct interpretation of some specific symptoms, such as erectile dysfunction, claudication intermittent, unusual dyspnea, paresthesia 14. Check blood pressure 15. Adherence to medication 16. Regular prevention and early identification of diabetic foot 17. Regular medical checks 18. Regular sessions of patient education 19. Management of insulin therapy 20. Specific management of gestational diabetes or diabetes during pregnancy 21. Management of continuous subcutaneous insulin infusion 22. Information on bureaucratic issues, such as guide authorization, voyager, military service, job The BMI did not change substantially during the study and the adjusted effect of the systematic health education model was-0.23 (Table 2 ). Though, after 2 years of follow-up, the systematic health education model demonstrated efficacy in the percentage of patients targeted for cardiovascular risk factors: LDL cholesterol < 100 mg / dl (P = 0 02), HbA1c < 7% (P < 0 01), BP regulation (< 130/80 mmHg) (P = 0 03), SBP < 130 mmHg (P = 0 03), and global monitoring (metabolic and BP) (P < 0 01). However, it was not important for the parameters DBP < 80 mmHg and BMI < 25 kg / m2 (Table 3 ). Table 3 baseline clinical characteristics of participants in comparison with 2 years after Base line characteristics 2 years after %change SE 95% CI t-statistic Difference P value Exercise (hours/week) 2 (0.3) 5 (2.1) + 150 0.080 2.8429 to 3.1571 37.470 3.0 < 0.0001 Compliance with diet %(95%CI) 40.5 (36.3–44.7) 75.5 (70.4–80.2) + 87.5 0.253 34.5039 to 35.4961 138.393 35.0 < 0.0001 Self-control %(95%CI) 33.5 (31.8–35.2) 66.1 (61.4–70.3) + 100 0.253 32.1039 to 33.0961 128.903 32.6 < 0.0001 Foot care %(95%CI) 23.1 (19.2–27.3) 59.3 (55.7–66.5) + 156 0.253 35.7039 to 36.6961 143.138 36.2 < 0.0001 Therapeutic compliance %(95%CI) 49.3 (45.4–53.5) 88.5 (85.9–91.5) + 79.5 0.272 38.6661 to 39.7339 144.030 39.2 < 0.0001 HbA1c (%) 9.9 (2.1) 7.9 (1.1) -25.3 0.136 -2.2669 to -1.7331 -14.697 -2.0 < 0.0001 LDL cholesterol (mg/dl) 2.59 (0.9) 2.07 (0.8) -25.1 0.056 -0.6301 to -0.4099 -9.268 -0.52 < 0.0001 Systolic blood pressure (mmHg) 134.3 (18.2) 129 (15.5) -4.1 0.514 -6.3078 to -4.2922 -10.316 -5.3 < 0.0001 Diastolic blood pressure (mmHg) 77.22 (10.5) 75.1 (8.1) -2.79 0.325 -2.7369 to -1.4631 -6.468 -2.1 < 0.0001 Body Mass Index (Kg/m 2 ) 32.3 (2.6) 27.2 (3.4) -18.75 0.189 -5.4702 to -4.7298 -27.025 -5.1 < 0.0001 Values are given as mean (SD) otherwise specified, CI: confidence interval. 96.7% of our patients were completely satisfied by what they have achieved through this project. The average HbA1C become less than eight in 54% of patients. Patients with HbA1C 8–9%, BP < 140/80, and LDL < 3.36 mmol/l, were 46%, 51% and 79% respectively. The average blood pressure for 56% of patients was 132/77. The average LDL level among 71% of patients was 2.25. 27% of patients had average discharged HbA1c of 7.3. Net promotor score of SDC was 85%, were promotors, passives and detractors were 87.8%, 9.5% and 2.8% respectively. P value < 0.05 (Table 4 , Fig. 4) Table 4 Patient satisfaction survey Please specify your level of satisfaction with the following points: Satisfied Neutral Dissatisfied P value 1. Easy registration process 95% 3.3% 1.7% 2. care of staff at the registration area 96.7% 1.7% 1.7% 3. Waiting time in the clinic. 87.8% 6.1% 6.1% 4. Kindness and care of the medical staff. 97.2% 1.7% 1.2% 5. Explanation provided by the medical team about your health status. 95.5% 3.9% 0.6% 6. The medical team's attention about your questions and concerns. 96.2% 2.2% 1.7% 7. your involvement in treatment decisions 95.5% 3.9% 0.6% 8. Instructions which given by medical team regarding your health status 96.1% 1.1% 2.8% < 0.05 9. Your trust in medical team 96.6% 2.2% 1.2% 10. The time the medical team spent with you 96.1% 2.2% 1.7% 11. The medical team's response to your needs 95.5% 1.7% 2.8% 12. Patient confidentiality 97.3% 2.2% 0.6% 13. The medical team cooperation in the provision of care for you 96.7% 1.7% 1.7% 14. The possibility of recommending SDC to others 96.7% 2.8% 0.6% 15. Your overall evaluation of the care you received at SDC. 96.7% 1.7% 1.7% 4. Discussion This prospective, study is considered as a strategic integrated project. It was established, as a clinical project including its infrastructure, man power, material, budget, policies and procedures. This project was established for full integrated management of diabetic patients. Our care rendered to the patients has been reflected on their outcomes. Therapy together with health education through social media, what-Sapp groups and focus group discussion together with individual face to face interviews, had a good impact on our patients. It was an effective intervention that had an observed effect on patients’ outcomes. We evaluated our patients, pre and post intervention to see the change in some pre-specified variables. (Fig. 5, 6) We noticed the change in their clinical statuses, anthropometric measures, laboratory results, psychosocial lives, lifestyles, and quality of lives. 702 patients is a good number to start a prospective study, with zero percent attrition or drop-outs. Indeed, building up of good friendly relationships, trust and rapport with your patients from the beginning, is better than insulin. Health education, patient motivation, self-management knowledge, skills, is useful in improving metabolic control. This will reduce the patient and family costs in secondary and tertiary management. Moreover, this improvement observed and maintained at 24 months. There is no longer a need to justify the value of patient education: education is part of a patient-centered humanistic therapeutic approach; it enables patients to be actively involved in their own recovery with the goal of increasing the quality of life and adherence with medication, as well as minimizing possible complications. Thus, our healthcare professionals are therefore educating, advising, preparing, engaging with, inspire and support physicians in disease follow-up which takes long time. Our study showed a portrayal in cognitive and behavioral therapy and inspirational interviews as a main contributor to clinical patient education, which occurs in an environment of understanding and emotions, correlated with several psycho-educational strategies. This paradigm had an obvious effect on clinical and laboratory outcomes, as well as, the psychological aspect and the quality of life. Many studies have shown that diabetic patients' education is a patient-centered humanitarian strategy that encourages clinicians to be protagonists in their own care, improve their well-being, and reduce the likelihood of possible complications. (Fig. 7) Group preparation for patient education must start as soon as a training need is defined through diagnosis. Early diagnosis and education offers time to identify and overcome challenges, creates constructive practice opportunities and promotes the ability to solve and deal with issues and problems. Our aim was to provide the patient (or healthcare provider) with time to perform survival skills and self-management. Our key nutritional targets were to improve glycemic control, offer appropriate nutrients and calories to satisfy metabolic needs, and establish a follow-up treatment life-plan. Some of the problems that may hinder the accomplishment of these targets in our facilities include: meal time planning and need-based modifications; in case of surgery laboratory testing, and procedures. When the patients lose their appetite or loss of ability of eating after drug administration or after acute diseases, glycemic control becomes very difficult. Other problems such as; inconsistent consumption of sugar, nutrition that is not addressed in the diet plan, inefficient food distribution arrangement with point of care sugar level monitoring and insulin treatment, lack of principles understanding by doctors, patients and families of the existing values of diabetes health, variability of requirements of insulin among patients, either on enteral or parenteral nutrition, decreased exercise and sedentary life. (Fig. 8) We met maximum glycemic targets for our patients. To achieve optimal glycemic control and glycemic targets thus reducing hypoglycemia, successful insulin therapy needs to be understood and used. Recent studies have highlighted the significance of preventing hypoglycemia to minimize risk, but avoiding hyperglycemia is equally as important. It is advised to develop guidelines, order sets, and glycemic goals by an interdisciplinary group of administrative support. Developing and enforcing hospital-wide protocols and uniform insulin order sets will assist patients in choosing the right insulin protocol while preventing adverse events. The use of a responsive "sliding scale" should be discontinued, and the standard of care should be therapeutic insulin schemes including basal, postprandial and corrective insulin. Throughout tandem with a patient-centered strategy, the diabetes educator can also promote the production and use of structured insulin order sets and procedures to avoid hypoglycemic episodes, achieve optimal performance, and mitigate harm capacity. The diabetes educator should also promote the development and use of protocols to manage and control hypoglycemia and make recommendations for improvement. When indicated for all patients with hyperglycemia or at high risk of hyperglycemia, our clinicians followed them through routine check of glycated hemoglobin and daily glucose monitoring. This includes diagnosis of cases with diabetes as well as patients received high-dose corticosteroids, immune suppressants, and intravenous and oral nutrition. After blood transfusions or with a record of uncontrolled glucose levels, the glycated hemoglobin level may not be accurate, or if there are hemoglobinopathies in case of dialysis patients or those receiving chemotherapy. In pediatric, obstetric, and emergency patients, point-of-care ketone screening should be recommended. With this objective in mind, the diabetes educator may engage in the foregoing educational activities: evaluating the knowledge and skills of patients having diabetes; improving self-management skills; providing training in a variety of contexts, including staff induction, medical areas and big rounds; designing curricula for sharing with other team leaders; using a variety of educational tools; for example; case studies, workshops of self-learning, journal societies, templates of survival skills and flash cards to meet the needs and preferences of all environments and learners. In our study, every patient had a good experience and take-home message after two years of hard work. After a countless episodes of depression, suicidal attempts, anxiety, upset, loss of hope, loss of self-esteem, loss of self-confidence and feelings of uselessness in life. Most of our patients, if not all of them, become full of hope and enthusiasm. Some of them become body builders; others win medals in championships of biking and mountain climbing, and many other examples, no space to mention. For present, however, it is important to maintain the education systems while at the same time continuing to investigate the effects of social media in order to identify certain categories of patients who may prosper from this tool. Regular medical interaction may be more relevant to patients and families modifying their insulin protocol, promoting self-management and encouragement. It will also be very beneficial in pre-gestational diabetes, patients with constant subcutaneous insulin infusion and patients with a high risk of developing serious acute complications correlated with other therapies (corticosteroids). In order to know the impact on health care system and leadership performance to patients with chronic disorders, it is also important to identify the implications of education on the interaction of primary and secondary management. To summarize, using an immersive tele-education system embedded into an intense face-to-face follow-up, produces significant changes in metabolic profile, quality of life, and self-care compared to traditional drug prescribing and reconciliation follow-up. Improving contact services, though, is important to provide effective cost reductions to the healthcare and diabetes community. Conclusion As a consequence of all the variables listed above, it can be inferred that the comprehensive health education approach is a valuable tool for the treatment of T1DM, as it leads to a decrease in HbA1c, LDL cholesterol and SBP rates, as well as to that conformity with the regulation criterion, except for DBP and BMI. Since health education will result in cost reductions and better results, Medicare and other payers would be protected by health education. In order to address this scarcity, DM-care educators will provide comprehensive health education to raise understanding of the seriousness of diabetes, its risk factors, and approaches to avoid diabetes and its complications in at-risk populations. Abbreviations Specialized clinics of diabetes (SDC) Glycosylated hemoglobin (HbA1C) Blood pressure (BP) Low density lipoproteins (LDL) Type I diabetes milletus (TIDM) World Health Organization (WHO) Systolic blood pressure (SBP), Diastolic blood pressure (DBP), High-density lipoprotein (HDL) Diabetes Control and Complications Trial (DCCT) Declarations Data Availability The data used to support the findings of this study are available from the corresponding author upon request. Funding The author declared they did not receive any funds Consent for publication Consent for publication was obtained from all authors Ethical Approval and Consent to participate Informed consent was obtained from all participants. And ethical IRB approval obtained # (IRB/KSUMC/978/2rkj-9834) Conflicts of Interest ( Competing interests) The authors declare that they have no conflicts of interest. Authors ’ Contributions Crafted a research plan and prepared a report. Checked out the manuscript. Writers contributed to the writing of the text and read and support the final document. Acknowledgments The writers are indebted to the Diabetes Health Education Association, which has sponsored the training of patients, the administration of the group appraisal clinic and the calculation of biochemistry. The writers would like to thank and recognize all the participants who have contributed to this research. References Norris S, Lau J, Smith S et al. Self-management education for adults with type 2 diabetes: a meta-analysis of the effect on glycaemic control. Diabetes Care 2002; 25: 1159–71. Minet L, Mollen S, Vach W et al. Mediating the effect of self-management intervention in type 2- diabetes: a metaanalysis of 47 randomised controlled trials. Patient Educ Couns 2010; 80: 29–42. Holman RR, Paul SK, Bethel A et al. 10-Year follow-up of intensive glucose control in type 2 diabetes. N Engl J Med 2008; 359: 1577–89. The Diabetes Control and Complication Trial/Epidemiology of Diabetes Interventions and Complications (DCCT/EDIC) Study Research Group. Intensive diabetes treatment and cardiovascular disease in patients with Type 1 diabetes. N Engl J Med 2005; 353: 2643–53. Ellis SE, Speroff T, Dittus RS et al. Diabetes patient education: a meta-analysis and meta-regression. Patient Educ Couns 2004; 52: 97–105. Jarvis J, Skinner TC, Carey ME et al. How can structured self-management patient education improve outcomes in people with type 2 diabetes? Diabetes Obes Metab 2010; 12: 12–9. Labate C. The influence of social media on diabetes treatment and self-care. Diabetes Voice 2013;58:14-15 [FREE Full text] Alanzi T, Istepanian R, Philip N. Design and usability evaluation of social mobile diabetes management system in the Gulf Region. JMIR Res Protoc 2016 Sep 26;5(3):e93 [FREE Full text] [doi: 10.2196/resprot.4348] [Medline: 27670696] Cooper A, Kar P. A new dawn: the role of social media in diabetes education. J Diabetes Nurs 2014;18:68-71 [FREE Full text] Zowawi HM, Abedalthagafi M, Mar FA, Almalki T, Kutbi AH, Harris-Brown T, et al. The potential role of social media platforms in community awareness of antibiotic use in the Gulf Cooperation Council States: luxury or necessity? J Med Internet Res 2015 Oct 15;17(10):e233 [FREE Full text] [doi: 10.2196/jmir.3891] [Medline: 26471079] Petrovski G, Zivkovic M, Stratrova SS. Social media and diabetes: can Facebook and Skype improve glucose control in patients with type 1 diabetes on pump therapy? One-year experience. Diabetes Care 2015 Apr; 38(4):e51-e52. [doi: 10.2337/dc14-2487] [Medline: 25805869] Chen R, Ji L, Chen L, et al. Glycemic control rate of T2DM outpatients in China: a multi-center survey. Med Sci Monit 2015; 21:1440–6. Hammami, Muhammad. “Prevention of Diabetes MellitusPrevention of Diabetes Mellitus, WHO Study Group on Prevention of Diabetes Mellitus, WHO Technical Report Series No. 844, World Health Organization, Geneva, Switzerland, 1994. Sw Fr 15, ISBN 92-4-120844-9.” Annals of Saudi Medicine 15, no. 3 (1995): 297–97. https://doi.org/10.5144/0256-4947.1995.297 . R. B. Haynes, D. L. Sackett, J. C. Snow, and D. L. Sackett, “Annotated and indexed bibliography on compliance with therapeutic and preventive regimens,” in Compliance in Health Care, R. B. Haynes, D. W. Taylor, and D. L. Sackett, Eds., pp. 337–342, Johns Hopkins University Press, Baltimore, MD, USA, 1979. J. B. Buse, K. S. Polonsky, and C. F. Burant, “Type 2 Diabetes Mellitus,” in Williams Textbook of Endocrinology, S. Melmed, K. S. Polonsky, P. R. Larsen, and H. M. Kronenberg, Eds., Saunders, Philadelphia, PA, USA, 12th edition, 2011. Rohlfing, C. L., H.-M. Wiedmeyer, R. R. Little, J. D. England, A. Tennill, and D. E. Goldstein. “Defining the Relationship Between Plasma Glucose and HbA1c: Analysis of Glucose Profiles and HbA1c in the Diabetes Control and Complications Trial.” Diabetes Care 25, no. 2 (January 2002): 275–78. https://doi.org/10.2337/diacare.25.2.275 . Stein, Risa J., C. Keith Haddock, Walker S.c. Poston, Dana Catanese, and John A. Spertus. “Precision in Weighing: A Comparison of Scales Found in Physician Offices, Fitness Centers, and Weight Loss Centers.” Public Health Reports 120, no. 3 (2005): 266–70. https://doi.org/10.1177/003335490512000308 . Barreira, T. V., A. E. Staiano, and P. T. Katzmarzyk. “Validity Assessment of a Portable Bioimpedance Scale to Estimate Body Fat Percentage in White and African-American Children and Adolescents.” Pediatric Obesity 8, no. 2 (2012). https://doi.org/10.1111/j.2047-6310.2012.00122.x . Vischer, Annina S., and Thilo Burkard. “Principles of Blood Pressure Measurement – Current Techniques, Office vs Ambulatory Blood Pressure Measurement.” Advances in Experimental Medicine and Biology Hypertension: from Basic Research to Clinical Practice, 2016, 85–96. https://doi.org/10.1007/5584_2016_49 . Rocks, Brendan. “Interval Estimation for the ‘Net Promoter Score.’” The American Statistician 70, no. 4 (2016): 365–72. https://doi.org/10.1080/00031305.2016.1158124 . Clement-Spychala, Meagan E., David Couper, Keith E. Muller, and Hongtu Zhu. “Approximating the Geisser-Greenhouse Sphericity Estimator and Its Applications to Diffusion Tensor Imaging.” Statistics and Its Interface 3, no. 1 (2010): 81–90. https://doi.org/10.4310/sii.2010.v3.n1.a7 . B. Pétré, R. Gagnayre, V. De Andrade, O. Ziegler, and M. Guillaume, “From therapeutic patient education principles to educative attitude: the perceptions of health care professionals—a pragmatic approach for defining competencies and resources,” Patient Preference and Adherence, vol. 11, pp. 603–617, 2017. J. Beck, D. A. Greenwood, L. Blanton et al., “2017 national standards for diabetes self-management education and support,” Diabetes Care, vol. 40, no. 10, pp. 1409–1419, 2017. H. Riemenschneider, S. Saha, S. van den Broucke et al., “State of diabetes self-management education in the European Union member states and non-EU countries: the diabetes literacy project,” Journal of Diabetes Research, vol. 2018, Article ID 1467171, 10 pages, 2018. M. M. Funnell, T. L. Brown, B. P. Childs et al., “National standards for diabetes self-management education,” Diabetes Care, vol. 33, Supplement 1, pp. S89–S96, 2010. Cite Share Download PDF Status: Posted Version 1 posted You are reading this latest preprint version Research Square lets you share your work early, gain feedback from the community, and start making changes to your manuscript prior to peer review in a journal. As a division of Research Square Company, we’re committed to making research communication faster, fairer, and more useful. We do this by developing innovative software and high quality services for the global research community. Our growing team is made up of researchers and industry professionals working together to solve the most critical problems facing scientific publishing. Also discoverable on Platform About Our Team In Review Editorial Policies Advisory Board Help Center Resources Author Services Accessibility API Access RSS feed Manage Cookie Preferences © Research Square 2026 | ISSN 2693-5015 (online) Privacy Policy Terms of Service Do Not Sell My Personal Information {"props":{"pageProps":{"initialData":{"identity":"rs-47906","acceptedTermsAndConditions":true,"allowDirectSubmit":true,"archivedVersions":[],"articleType":"Research article","associatedPublications":[],"authors":[{"id":1136408,"identity":"2a97344f-6331-4af6-a382-32143f9c0de8","order_by":0,"name":"Ahmed Mahmoud Elmalky","email":"data:image/png;base64,iVBORw0KGgoAAAANSUhEUgAAAZAAAAAyAQMAAABI0h/eAAAABlBMVEX///8AAABVwtN+AAAACXBIWXMAAA7EAAAOxAGVKw4bAAAA60lEQVRIie3OuwrCMBSA4RMEXSpZI3h5hUihCA7imzQI7dLBsYNDHIxLoauPURDcpWCXiGuLg7o4OTg6iBgR11A3wfyQQOB8nACYTD9ZhQOMXcDW+1WGIEWoC43oa0JlWYLn01lyox5byuxMIOwzjtOjlhC5FkVEA7baRg4B6TNOPKpfkzORWzRkq51VJUikioCedA4nUdwVWca1M0EPRXB21RKaI7G31MeSOncI4opAoN/SlUzsm9SzF1LaPXfj24IEYy1pZ+mmuISjVhz5p/w66bdinCVa8mnIX7erTrXUvGpQdtBkMpn+sCfngUxKwv/YKQAAAABJRU5ErkJggg==","orcid":"https://orcid.org/0000-0003-0877-6084","institution":"King Saud Medical City","correspondingAuthor":true,"submittingAuthor":false,"prefix":"","firstName":"Ahmed","middleName":"Mahmoud","lastName":"Elmalky","suffix":""},{"id":1136409,"identity":"d36160bf-4f6b-48d8-bd53-8df479a003fe","order_by":1,"name":"Abdulsalam S. Alharbi","email":"","orcid":"","institution":"Prince Sattam bin Abdulaziz University","correspondingAuthor":false,"submittingAuthor":false,"prefix":"","firstName":"Abdulsalam","middleName":"S.","lastName":"Alharbi","suffix":""},{"id":1136410,"identity":"45da1201-25df-4132-87fe-e4f16d9bb2fe","order_by":2,"name":"Abdulkarim M. Alsaqabi","email":"","orcid":"","institution":"University of Strathclyde","correspondingAuthor":false,"submittingAuthor":false,"prefix":"","firstName":"Abdulkarim","middleName":"M.","lastName":"Alsaqabi","suffix":""}],"badges":[],"createdAt":"2020-07-23 10:36:56","currentVersionCode":1,"declarations":"","doi":"10.21203/rs.3.rs-47906/v1","doiUrl":"https://doi.org/10.21203/rs.3.rs-47906/v1","draftVersion":[],"editorialEvents":[],"editorialNote":"","failedWorkflow":false,"files":[{"id":1770092,"identity":"93a45863-2def-45ad-89db-7ef700e967e5","added_by":"auto","created_at":"2020-08-03 21:19:29","extension":"png","order_by":1,"title":"Figure 1","display":"","copyAsset":false,"role":"figure","size":17557,"visible":true,"origin":"","legend":"Glycemic improvement in all SDCs","description":"","filename":"figure1.png","url":"https://assets-eu.researchsquare.com/files/rs-47906/v1/figure1.png"},{"id":1770093,"identity":"fa3b503a-b531-4a8d-92bb-d0eb09885770","added_by":"auto","created_at":"2020-08-03 21:19:29","extension":"png","order_by":2,"title":"Figure 2","display":"","copyAsset":false,"role":"figure","size":15969,"visible":true,"origin":"","legend":"Average blood pressure","description":"","filename":"figure2.png","url":"https://assets-eu.researchsquare.com/files/rs-47906/v1/figure2.png"},{"id":1770094,"identity":"8faa5d3d-8eb4-4c87-8378-4fd6dac04fbd","added_by":"auto","created_at":"2020-08-03 21:19:29","extension":"png","order_by":3,"title":"Figure 3","display":"","copyAsset":false,"role":"figure","size":11882,"visible":true,"origin":"","legend":"LDL improvement","description":"","filename":"figure3.png","url":"https://assets-eu.researchsquare.com/files/rs-47906/v1/figure3.png"},{"id":1770095,"identity":"d8ecdd3a-1405-4b22-be29-62de9258c001","added_by":"auto","created_at":"2020-08-03 21:19:29","extension":"png","order_by":4,"title":"Figure 4","display":"","copyAsset":false,"role":"figure","size":17883,"visible":true,"origin":"","legend":"Discharged patients ","description":"","filename":"figure4.png","url":"https://assets-eu.researchsquare.com/files/rs-47906/v1/figure4.png"},{"id":1770096,"identity":"5be851e5-282c-4195-b6a5-6fefadc1e43e","added_by":"auto","created_at":"2020-08-03 21:19:29","extension":"png","order_by":5,"title":"Figure 5","display":"","copyAsset":false,"role":"figure","size":214487,"visible":true,"origin":"","legend":"one of our patient meetings ","description":"","filename":"figure5.png","url":"https://assets-eu.researchsquare.com/files/rs-47906/v1/figure5.png"},{"id":1770097,"identity":"ffbd0eec-cb4a-4364-8095-5f9b936eef9e","added_by":"auto","created_at":"2020-08-03 21:19:30","extension":"png","order_by":6,"title":"Figure 6","display":"","copyAsset":false,"role":"figure","size":165455,"visible":true,"origin":"","legend":"online educational sessions with patients","description":"","filename":"figure6.png","url":"https://assets-eu.researchsquare.com/files/rs-47906/v1/figure6.png"},{"id":1770098,"identity":"74f87528-387b-49c6-bdeb-8d68a8385c06","added_by":"auto","created_at":"2020-08-03 21:19:30","extension":"png","order_by":7,"title":"Figure 7","display":"","copyAsset":false,"role":"figure","size":59369,"visible":true,"origin":"","legend":"SDC score","description":"","filename":"figure7.png","url":"https://assets-eu.researchsquare.com/files/rs-47906/v1/figure7.png"},{"id":1770099,"identity":"98c8f2f5-f090-4c00-b729-57b3a2e3e3ed","added_by":"auto","created_at":"2020-08-03 21:19:30","extension":"png","order_by":8,"title":"Figure 8","display":"","copyAsset":false,"role":"figure","size":596418,"visible":true,"origin":"","legend":"Dashboard of patients views and opinions ","description":"","filename":"figure8.png","url":"https://assets-eu.researchsquare.com/files/rs-47906/v1/figure8.png"},{"id":13567048,"identity":"2ab1eecb-5c44-4f24-a438-e6375542e8a3","added_by":"auto","created_at":"2021-09-17 03:31:24","extension":"pdf","order_by":0,"title":"","display":"","copyAsset":false,"role":"manuscript-pdf","size":1592841,"visible":true,"origin":"","legend":"","description":"","filename":"manuscript.pdf","url":"https://assets-eu.researchsquare.com/files/rs-47906/v1/efd96e4d-8a6b-4ba5-b252-525c45f85383.pdf"}],"financialInterests":"","formattedTitle":"Impact of Educational Chronic Care Model on Diabetic Patients: A Prospective Cohort Study","fulltext":[{"header":"1. Introduction","content":" \u003cp\u003eTo improve the lives of people with diabetes and prevent its complications through innovative care, treatment, patient education, professional training and research. This is a worthy goal to struggle for. Glycemic control and improvement could be achieved by structured education programs and behavioral changes. \u003ca class=\"FNLink\" href=\"#Fn2\" id=\"#FNLinkFn2\"\u003e\u003c/a\u003e\u003csup\u003e,\u003c/sup\u003e \u003ca class=\"FNLink\" href=\"#Fn3\" id=\"#FNLinkFn3\"\u003e\u003c/a\u003e Glycemic control can preserve long-term clinical outcomes and prevent or delay the development of macro- and microvascular sequelae of diabetes. \u003ca class=\"FNLink\" href=\"#Fn4\" id=\"#FNLinkFn4\"\u003e\u003c/a\u003e\u003csup\u003e,\u003c/sup\u003e \u003ca class=\"FNLink\" href=\"#Fn5\" id=\"#FNLinkFn5\"\u003e\u003c/a\u003e Effective programs are best delivered through face-to-face approach in combination with far-reaching, E-learning approach. They incorporate perceptive restructuring together with better interaction. \u003csup\u003e3 ,\u003c/sup\u003e \u003ca class=\"FNLink\" href=\"#Fn6\" id=\"#FNLinkFn6\"\u003e\u003c/a\u003e\u003csup\u003e,\u003c/sup\u003e\u003ca class=\"FNLink\" href=\"#Fn7\" id=\"#FNLinkFn7\"\u003e\u003c/a\u003e\u003c/p\u003e \u003cp\u003eBecause of the economic growth, almost all people now are using online social media on their smart phones, relying on them as communication channels. \u003ca class=\"FNLink\" href=\"#Fn8\" id=\"#FNLinkFn8\"\u003e\u003c/a\u003e Kingdom of Saudi Arabia (KSA) has the highest rank in the world of smart-phone users, according to the report of the United Nations submitted in the Conference of Trade and Development. \u003ca class=\"FNLink\" href=\"#Fn9\" id=\"#FNLinkFn9\"\u003e\u003c/a\u003e Healthcare researchers and providers invest this opportunity to better educate diabetic patients for better disease management. Many studies showed the advantage of using social media campaigns in patient education. \u003ca class=\"FNLink\" href=\"#Fn10\" id=\"#FNLinkFn10\"\u003e\u003c/a\u003e\u003csup\u003e,\u003c/sup\u003e \u003ca class=\"FNLink\" href=\"#Fn11\" id=\"#FNLinkFn11\"\u003e\u003c/a\u003e \u003csup\u003eand\u003c/sup\u003e \u003ca class=\"FNLink\" href=\"#Fn12\" id=\"#FNLinkFn12\"\u003e\u003c/a\u003e In China, the glycemic control among diabetic patients is still low, due to poor patient education. \u003ca class=\"FNLink\" href=\"#Fn13\" id=\"#FNLinkFn13\"\u003e\u003c/a\u003e This study assesses the effect of social media in combination with face-to-face group education in improving the clinical status and quality of life, among multi-national type 1 diabetic patients in Saudi Arabia.\u003c/p\u003e "},{"header":"2. Materials And Methods:","content":" \u003cdiv id=\"Sec3\" class=\"Section2\"\u003e \u003ch2\u003e2.1. Participants and sample size:\u003c/h2\u003e \u003cp\u003eFrom January to December 2017\u0026ndash;2018, a total of 702 patients with TIDM, aged from 14 to 60\u0026nbsp;years were selected as convenient sample from specialized diabetic clinics at the King Saud University Medical City Tertiary Hospital, of 920 beds.\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec4\" class=\"Section2\"\u003e \u003ch2\u003e2.2. Aim of the study:\u003c/h2\u003e \u003cp\u003eOur aim is how to make advice-giving becomes a system to treat our patients. This -two years- prospective cohort study compared the effect of health education through individual approach combined with usage of social media groups, on uncontrolled type 1 diabetes. The same group of patients subjected to pre-intervention evaluation and post-intervention evaluation. We used clinical outcome, quality of life and psychological improvement as variables to measure in the study.\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec5\" class=\"Section2\"\u003e \u003ch2\u003e2.3. Ethics Committee Approval and Consenting:\u003c/h2\u003e \u003cp\u003eWe had approval from Research Ethics Committee on this study of the King Saud University Medical City. All patients participated in this study signed an informed consent. The research has been approved by the Clinical research Ethics commission of the Medical College. Crafted informed consents were acquired from all patients prior to the start of this study.\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec6\" class=\"Section2\"\u003e \u003ch2\u003e2.4. Inclusion and Exclusion Criteria:\u003c/h2\u003e \u003cp\u003ePatients with diabetes have been included in the study as follows: doctors diagnosed TIDM according to the guidelines of the World Health Organization (WHO), \u003ca class=\"FNLink\" href=\"#Fn14\" id=\"#FNLinkFn14\"\u003e\u003c/a\u003e patients should have a mobile phone, gave consent to receive messages and also had the ability to understand text messages and to engage willingly in this research. Patients have also been excluded whether they have been diagnosed with type II diabetes, specific diabetes or a history of serious medical conditions such as kidney or liver failure, serious vision problems, mental illnesses or other metabolic diseases.\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec7\" class=\"Section2\"\u003e \u003ch2\u003e2.5. Number and frequency of sessions:\u003c/h2\u003e \u003cp\u003eOur patients were visiting the clinic 3\u0026ndash;5 times per week, during the first six months. Then they have had multiple visits to be followed; three visits per month to the completion of follow up. In each visit, they received the care, had their lab investigations, took their medications, attended the education sessions, and repeated the arrangement of their schedule.\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec8\" class=\"Section2\"\u003e \u003ch2\u003e2.6. Professional background of educators:\u003c/h2\u003e \u003cp\u003eThe doctors provided the educational related messages and selected them were board qualified and specialists in the field of diabetes research. They trained the nursing staff that sent the educational messages. The trained nurses followed up with patients with diabetes. Nurses had graduated from college or above and served for at least 3\u0026nbsp;years.\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec9\" class=\"Section2\"\u003e \u003ch2\u003e2.7. Data Collection Process\u003c/h2\u003e \u003cp\u003eA qualified nurses and physicians in our unit collected the data in hard copies, soft copies on the electronic patient files, structured forms and questionnaires. Basic information on socioeconomic and demographic characteristics such as age, sex, educational achievement level, personal health and lifestyle such as a regular physical activity has been obtained. Data collected; at baseline, 6 months and 12 months, as well as at each visit. We collected data about; physical assessment results, laboratory investigation results and education program outcomes. Data on self-care activities were collected from all patients. Laboratory investigation results such as; fasting blood glucose and 2-hour postprandial glucose, LDL, BP, and glycosylated hemoglobin (HbAlc).\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec10\" class=\"Section2\"\u003e \u003ch2\u003e2.8. Research Tools:\u003c/h2\u003e \u003cp\u003eWe used three tools; educational program, measurement tools (physical assessment, and laboratory investigations):\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec11\" class=\"Section2\"\u003e \u003ch2\u003e2.9. Educational program:\u003c/h2\u003e \u003cp\u003eEducation is intended to promote responsible decision-making, issue-solving, constructive engagement with the health education group and self-care, as well as to enhance clinical performance, quality of life and fitness status. Such goals are achieved by comprehensive health education in a community given by health educators every month for more than 2\u0026nbsp;years. A total of 702 persons were invited to take part in the program. Reasons for decreasing involvement involved regular travel, job too hard, loss of confidence, and not being able to reach software applications or phone. The data obtained were socio-demographic factors, eating patterns, smoking, physical exercise, foot-body-care, capillary glycaemia self-monitoring, and medication compliance.\u003ca class=\"FNLink\" href=\"#Fn15\" id=\"#FNLinkFn15\"\u003e\u003c/a\u003e Together with subsequent morbidity, such as obesity; hypertension; dyslipidemia; ischemic cardiac failure, including \u0026ldquo;acute myocardial infarction\u0026rdquo;, angina, stroke; and other complications (neuropathy, micro-macrovascular, retinopathy). During the follow-up visits, data were obtained on different variables (HbA1c, total cholesterol, low-density lipoprotein (LDL) cholesterol, systolic blood pressure (SBP), diastolic blood pressure (DBP), high-density lipoprotein (HDL) cholesterol, and BMI). The systemic model of health education was focused on the following dimensions:\u003c/p\u003e \u003cdiv id=\"Sec12\" class=\"Section3\"\u003e \u003ch2\u003e2.9.1. Image education:\u003c/h2\u003e \u003cp\u003ePatients were supplied by videos on DM which are focused on audiovisual strategies to raise understanding of the value of diabetes. Picture education will provide patients with more information regarding DM pathophysiology, impermissibility, risks, and diagnosis, while growing awareness about the significance of managing risk factors. Often members of the family would engage in picture education; they were all invited. The intervention was in the form of focus group face-to-face well-structured education sessions, individual approach one-to-one interviews, using education curriculum and well prepared education materials. Also, these were combined with telemedicine apps, WhatsApp groups, mobile services and support groups.\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec13\" class=\"Section3\"\u003e \u003ch2\u003e2.9.2. Visit to the Presentation Room:\u003c/h2\u003e \u003cp\u003eWith on-site appointments, patients may obtain basic awareness of the impact of medications on the bloodstream, the diet pattern, alternate medicine choices, insulin self-injection, dosage guidelines, alert indicators of hypoglycemia, and carbohydrate-counting strategies.\u003c/p\u003e \u003cp\u003ePatients subdivided into one face-to-face group discussion and individual approach through personal interviews, through which the nurse began to provide the patient with direct education and training using specific educational material aside with friendly psychological support and confidence-building talk.\u003c/p\u003e \u003cp\u003eThe learning strategy is more pragmatic and focused on the day-to-day interactions of people dealing with an illness compared to earlier treatment approaches that were based on information. They stress the necessity of increasing the dignity and security of clinicians. There should be ongoing training. One must learn to incorporate the information that he accumulates in daily practice.\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec14\" class=\"Section3\"\u003e \u003ch2\u003e2.9.3. Distribution of instructional content:\u003c/h2\u003e \u003cp\u003eIn order to enhance diabetes self-care and to be an involved member in the whole process, our community has created a low-literacy colored brochures. Patients in the program were provided with a paper guide comprising the question-explanation resources on diabetes and care aims.\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec15\" class=\"Section3\"\u003e \u003ch2\u003e2.9.4. Therapy in personalized medicinal care:\u003c/h2\u003e \u003cp\u003eIn a detailed and personally arranged diet plan, the interests, cultural context and conditions of every participant as well as the overall recovery system are addressed. Due to the difficulty of the medical and dietary problems with most patients, our staff proposed a simpler scheme named \"restricted plate diet\" Fig.\u0026nbsp;9, It comprises of three sections: \u0026frac12; plate vegetables, \u0026frac14; plate staple food (carbohydrate) and \u0026frac14; plate lean red meat (protein) and dishes remain variable not the same.\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec16\" class=\"Section3\"\u003e \u003ch2\u003e2.9.5. Personal exercise programs:\u003c/h2\u003e \u003cp\u003eExercises involve riding, jogging, running, surfing, gymnastics, table tennis, and music. Physical activity goals, techniques, rates and intensities must be discussed for patients who are extremely open to the identification of challenges and to helping patients pursue alternatives. Patients that show signs of cardiac ischemia should be forwarded for further examination and diagnosis.\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec17\" class=\"Section3\"\u003e \u003ch2\u003e2.9.6. Groups and lectures:\u003c/h2\u003e \u003cp\u003eWhatsApp group and Regular Medical Meetings. Face-to-face seminars were the most common mode of presentation, and there was a monthly frequent educational lectures. The WhatsApp community offers a way of delivering quality health information for patients. If the results are usually below the defined goal levels, patients will be checked and reported on a daily basis to the WhatsApp Health Care Team or on an occasional visit to cause improvements in treatment if appropriate. The main objectives of the lectures are to offer feedback on the aim of reducing the possibility of complications, to share knowledge and methods for addressing challenges, to recommend approaches for meeting targets, to help track complications and to offer skills training.\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec18\" class=\"Section3\"\u003e \u003ch2\u003e2.9.7. Complication evaluation:\u003c/h2\u003e \u003cp\u003eThe key task of the team is to examine complications (nephropathy, artery disorder, retinopathy, and neuropathy) and discover strategies for patients to exercise safe.\u003ca class=\"FNLink\" href=\"#Fn16\" id=\"#FNLinkFn16\"\u003e\u003c/a\u003e The group offered advice on complications monitoring, established recovery schedules, evaluated success in achieving care goals, and helped establish approaches to fulfill recovery targets and prevent complications.\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec19\" class=\"Section3\"\u003e \u003ch2\u003e2.9.8. Modification of life style:\u003c/h2\u003e \u003cp\u003eLifestyle modification consists of weight loss; decreased saturated fat, trans-fat and cholesterol intake; lowered sodium and improved potassium intake; smoking cessation; and enhanced physical activity. Lifestyle modification elements include activity guidelines, professional diet guidance and thorough diabetes awareness with the goal of transforming the diabetes treatment model from a patient-focused system to a patient-focused physician.\u003csup\u003e15\u003c/sup\u003e\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec20\" class=\"Section3\"\u003e \u003ch2\u003e2.9.9. Systemic Healthcare Program:\u003c/h2\u003e \u003cp\u003eTo order to effectively follow this procedure, the individual must engage actively in the implementation of a recovery program, adhere to the values of self-care, make day-to-day \u0026ldquo;self-care\u0026rdquo; choices, interact openly and with adequate consistency with the team, and minimize the regular consumption of food. Boost physical exercise, feed less meals a day, blood glucose self-monitoring, increase compliance to medications, and develop insulin therapy skills.\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec21\" class=\"Section3\"\u003e \u003ch2\u003e2.9.10. Glycemic control self-monitoring:\u003c/h2\u003e \u003cp\u003ePatients were advised to track their blood sugars, report values, and keep a record book for appointments. Most patients do routine blood glucose self-monitoring, report findings as advised, and review them with the health care staff. Patients should consult with the staff when goals are not met or where difficulties or obstacles are found.\u003c/p\u003e \u003cp\u003e \u003col\u003e \u003cspan\u003e \u003cli\u003e \u003cp\u003eEvaluation of therapeutic effect monthly:\u003c/p\u003e \u003c/li\u003e \u003c/span\u003e \u003c/ol\u003e \u003c/p\u003e \u003cp\u003eReinforcing care, establishing the target of wellness promotion and problem-solving everyday life are needed; doctors have specific monitoring goals for patients like HbA1c, LDL/HDL cholesterol, blood pressure, and total cholesterol. Patients need to be motivated to incorporate behavioral therapy into their everyday lives and to engage more fully in the process. Patients can interact with the staff equally and regularly.\u003c/p\u003e \u003cp\u003eContinuous training workshops on self-care, general and specific nutrition, medications, fitness, blood sugar screening, foot care, changes in lifestyle, and tobacco smoking. What about diabetes? How am I going to know if I have diabetes? How is my diabetes going to be treated? What kind of complications are possible? How can I avoid problems with my health? How is my diabetes drug going to help me? Drug name, type of drug, what does it do? Things to look for. Diabetes ABCs, \"A\" means \"A1C,\" \"B\" means \"blood pressure,\" \"C\" means \"cholesterol\".\u003c/p\u003e \u003cp\u003eDiabetic patients have all provided traditional medical care and diabetes nursing education and will also be driven by telemedicine applications, WhatsApp groups, mobile services and support groups. We were responsible for sending and describing the information related to diabetes to our patients, including blood glucose self-monitoring, a healthy lifestyle, physical exercise, adherence with prescribed medication, low and high blood glucose regulation, and weight control for diabetes patients.\u003c/p\u003e \u003cp\u003e \u003col\u003e \u003cspan\u003e \u003cli\u003e \u003cp\u003eImprovement proposed measures:\u003c/p\u003e \u003c/li\u003e \u003c/span\u003e \u003c/ol\u003e \u003c/p\u003e \u003cp\u003eA more development program was formulated on the grounds of medication effectiveness, blood pressure, risks and allergic reactions. Repeated nutritional histories and subsequent minor improvements discussed every several weeks to months by the community render it easier to determine how the adjustments already accepted have been adopted, to reinforce the value of nutritional measures, and to enable patients to exercise good food options.\u003c/p\u003e \u003cp\u003e \u003col\u003e \u003cspan\u003e \u003cli\u003e \u003cp\u003ePersonal follow-up scheme:\u003c/p\u003e \u003c/li\u003e \u003c/span\u003e \u003c/ol\u003e \u003c/p\u003e \u003cp\u003eEffective follow-up will be an important part of the long-term maintenance. The patient follow-up program covered follow-up duration, risk conditions, foot protection, insulin self-injection, early symptoms of hypoglycemia, diabetes-related problems, and hypoglycemia. Such initiatives will regularly enhance behavioral improvement and long-term sustainability.\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e \u003cdiv id=\"Sec22\" class=\"Section2\"\u003e \u003ch2\u003e2.10. Measurement tools\u003c/h2\u003e \u003cp\u003eAll patients underwent physical assessments, which include vitals, anthropometric measures (such as height, weight, BMI) and blood chemical tests (such as glucose levels, glycosylated hemoglobin, LDL, and triglycerides) were carried out by medical professionals using conventional methods.\u003c/p\u003e \u003cp\u003ePatient evaluation was set up; pre and post intervention, through measurement of glycosylated hemoglobin, baseline and discharge glycosylated hemoglobin, Measurement of blood pressure, and LDL. Measurement of patient satisfaction through patient satisfaction survey and evaluation of patients\u0026rsquo; feelings and self-esteem by; Net promoter score, SDC score, diabetes knowledge score, words from our patients. Patient evaluation was done as primary and secondary end points.\u003c/p\u003e \u003cp\u003e \u003col\u003e \u003cspan\u003e \u003cli\u003e \u003cp\u003eReinforcement of education\u003c/p\u003e \u003c/li\u003e \u003c/span\u003e \u003c/ol\u003e \u003c/p\u003e \u003cp\u003eAnother problem is the enforcement of the value of regular training sessions. As at the beginning of the process the best results achieved through academic stimulation are seen but usually diminish afterwards. To prevent attrition, a few days before the learning meeting, it may be helpful to inform the patients by their clinicians about the appointment by phone or text message.\u003c/p\u003e \u003cp\u003e \u003col\u003e \u003cspan\u003e \u003cli\u003e \u003cp\u003eBarriers to self-management\u003c/p\u003e \u003c/li\u003e \u003c/span\u003e \u003c/ol\u003e \u003c/p\u003e \u003cp\u003eThere are many obstacles to diabetes education and self-management. A few are human such as empowerment, education, inspiration, problem-solving skills, anxiety, gender, cognitive impairment, certain disorders, etc. and others are linked to the setting and community. Instructors must recognize some obstacles through open and trusting interaction with participants. Single face-to-face meetings can be more effective for this reason than group meetings. However, even when the education program is focused on group sessions, single lessons can be used chronologically. Cultural and linguistic discrepancies of minority groups represent significant barriers. It is essential for these group members to use special tools for adapting education.\u003c/p\u003e \u003cp\u003e \u003col\u003e \u003cspan\u003e \u003cli\u003e \u003cp\u003eOutcome indicators\u003c/p\u003e \u003cp\u003e \u003cdiv class=\"OrderedList\"\u003e \u003cdiv class=\"ListItem\"\u003e \u003cdiv class=\"ItemContent\"\u003e \u003cdiv id=\"Par115\" class=\"OListPara\" name=\"Para\"\u003ePrimary outcome\u003c/div\u003e \u003c/div\u003e \u003c/div\u003e \u003c/div\u003e \u003c/p\u003e \u003c/li\u003e \u003c/span\u003e \u003c/ol\u003e \u003c/p\u003e \u003cp\u003eNormal Glycated Hemoglobin (HbA1c) was the primary goal. A Diabetes Control and Complications Trial (DCCT) method were used to measure glycated hemoglobin. \u003ca class=\"FNLink\" href=\"#Fn17\" id=\"#FNLinkFn17\"\u003e\u003c/a\u003e\u003c/p\u003e \u003cp\u003e \u003col\u003e \u003cspan\u003e \u003cli\u003e \u003cp\u003eClinical outcomes:\u003c/p\u003e \u003cp\u003e \u003cdiv class=\"OrderedList\"\u003e \u003cdiv class=\"ListItem\"\u003e \u003cdiv class=\"ItemContent\"\u003e \u003cdiv id=\"Par122\" class=\"OListPara\" name=\"Para\"\u003eBody weight:\u003c/div\u003e \u003c/div\u003e \u003c/div\u003e \u003c/div\u003e \u003c/p\u003e \u003c/li\u003e \u003c/span\u003e \u003c/ol\u003e \u003c/p\u003e \u003cp\u003eCalibrated electronic scales were used to measure body weight. \u003ca class=\"FNLink\" href=\"#Fn18\" id=\"#FNLinkFn18\"\u003e\u003c/a\u003e Of measuring height, a portable sonic machine was used. The value of Body mass index (kg / m2) was determined from measures of height and weight. The Tanita Body Fat Control measured the precision of body fat to \u0026plusmn;\u0026thinsp;0.5%. \u003ca class=\"FNLink\" href=\"#Fn19\" id=\"#FNLinkFn19\"\u003e\u003c/a\u003e The correct waist circumference assessment procedure has been used.\u003c/p\u003e \u003cp\u003e \u003col\u003e \u003cspan\u003e \u003cli\u003e \u003cp\u003eLaboratory Results:\u003c/p\u003e \u003c/li\u003e \u003c/span\u003e \u003c/ol\u003e \u003c/p\u003e \u003cp\u003eA complete lipid profile has been obtained. Blood pressure was measured using a digital blood pressure monitor by accepted methods.\u003ca class=\"FNLink\" href=\"#Fn20\" id=\"#FNLinkFn20\"\u003e\u003c/a\u003e Current guideline studies also provided appropriate levels of blood lipids and blood pressure.\u003c/p\u003e \u003cp\u003e \u003col\u003e \u003cspan\u003e \u003cli\u003e \u003cp\u003eMedication prescribed:\u003c/p\u003e \u003c/li\u003e \u003c/span\u003e \u003c/ol\u003e \u003c/p\u003e \u003cp\u003eDrugs approved for diabetes treatment were tested every 14 months and compared at baseline with those prescribed. We defined the increase in medication by launching a new drug, increasing the dose of oral hypoglycemic drugs or use of insulin. However, a decrease of medication was described as a decrease in oral hypoglycemic drug type, quantity or the number of insulin units administered.\u003c/p\u003e \u003cp\u003e \u003col\u003e \u003cspan\u003e \u003cli\u003e \u003cp\u003eLifestyle\u003c/p\u003e \u003c/li\u003e \u003c/span\u003e \u003c/ol\u003e \u003c/p\u003e \u003cp\u003eThe outcomes of lifestyle were evaluated regularly, 6 months, 12 months and 24 months. To what degree we were effective for encouraging, improving adaptation and strengthening family relationships of our patients. How many occasions have they been through periods of hopelessness and despair after the end of the study? To what extent we made our patient believe in self-efficacy and have a positive outlook on life? To what extent did our patients build a strong favorable doctor-patient interaction? And become more effective in coping with actions and had a better health-related quality of life with a favorable impact on their life. Variables of socialization, particularly skills for problem-solving and self-efficacy. Mental well-being. Identify and encourage personal goals and habits to accomplish self-determined objectives. How to build trust in an interpersonal relationship.\u003c/p\u003e \u003cp\u003e \u003col\u003e \u003cspan\u003e \u003cli\u003e \u003cp\u003ePsychological\u003c/p\u003e \u003c/li\u003e \u003c/span\u003e \u003c/ol\u003e \u003c/p\u003e \u003cp\u003eWe used Net promoter score, \u003ca class=\"FNLink\" href=\"#Fn21\" id=\"#FNLinkFn21\"\u003e\u003c/a\u003e SDC score, and patient words through customer satisfaction surveys. Assessment of pre- and post-intervention patients ' self-esteem and psychosocial status. We evaluated the degree to which the educational sessions render our patients feel empowerment, emotional adjustment, and the real quality of life changes. How they adopt new challenges, essential survival skills. The extent to which they become fully consistent with a healthy, great life with social and psychological concerns.\u003c/p\u003e \u003cp\u003e \u003col\u003e \u003cspan\u003e \u003cli\u003e \u003cp\u003eStatistical analysis\u003c/p\u003e \u003c/li\u003e \u003c/span\u003e \u003c/ol\u003e \u003c/p\u003e \u003cp\u003eThe action program and the personal appointment groups were attributed by evaluating the cohort by time interface term from frequent measurement analysis of variability with Greenhouse-Geisser sphericity adjustment, \u003ca class=\"FNLink\" href=\"#Fn22\" id=\"#FNLinkFn22\"\u003e\u003c/a\u003e taking the primary outcome of HbA1cas and analyzing others as developing a hypothesis. With Microsoft Windows version 11.0 (SPSS Inc., Chicago, Illinois, United States), Stata version Nine (Stata Corp, Baton rouge, TX, USA) was used. If appropriate, the CONSORT claim was adhered to and as far as possible an attempt to examine was carried out.\u003c/p\u003e \u003cp\u003eBased on the t-test and chi-square test, we analyzed differences among groups. An analysis of the intention to treat, along with all other individuals involved, was carried out. Differences from baseline assessment were evaluated using multiple variability measurement methods to determine the discrepancies between self-care behaviors and HbA1c in the same group, pre and post-intervention. Pearson or Spearman rho correlations have been used to examine the relationships between data. Multiple regressions have been used to identify glycemic control predictors.\u003c/p\u003e \u003c/div\u003e "},{"header":"3. Results","content":" \u003cp\u003eTable\u0026nbsp;\u003cspan refid=\"Tab1\" class=\"InternalRef\"\u003e1\u003c/span\u003e shows the baseline distribution in our patients of the comorbidity characteristics. The ANOVA analysis showed significant differences, before, during and after implementation of the program, in terms of Hb1AC, BP and LDL.\u003c/p\u003e \u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab1\" border=\"1\"\u003e \u003ccaption language=\"En\"\u003e \u003cdiv class=\"CaptionNumber\"\u003eTable 1\u003c/div\u003e \u003cdiv class=\"CaptionContent\"\u003e \u003cp\u003eDemographic characteristics of 702 type 1 diabetic patients at the start of study\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"3\"\u003e \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colspan=\"2\" nameend=\"c2\" namest=\"c1\"\u003e \u003cp\u003eDemographic Characteristics (baseline)\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c3\"\u003e \u003cp\u003eMean (SD), Number (%)\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eAge (years)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e39.7 (\u0026plusmn;\u0026thinsp;5.4)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eGender\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eMale\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e309 (44)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eFemale\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e393 (56)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eNationality\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eSaudi\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e611 (87)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eYemeni\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e23 (3.2)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eIndia\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e18 (2.5)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eEgypt\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e13 (1.8)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eSyrian\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e11 (1.5)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eJordan\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e10 (1.4)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003ePhilippines\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e9 (1.2)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eSudan\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e7 (0.9)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eEducation\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eNever\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e13 (1.8)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003ePrimary\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e56 (7.9)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eSecondary\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e114 (16.2)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eCollege\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e344 (49)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eTertiary\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e175 (24.9)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eMarital status\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eSingle\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e211 (30)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eMarried\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e491 (70)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eOccupation\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eOffice\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e205 (29.2)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eFactory\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e129 (18.3)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eFieldwork\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e105 (14.9)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eHousewife\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e102 (14.5)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eProfessional\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e91 (12.9)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eRetired\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e70 (9.9)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eDuration of diabetes (years)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e16.8 (\u0026plusmn;\u0026thinsp;4.3)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eTreatment mode\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eOral drug\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e34 (4.8)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eInsulin\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e378 (53.8)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eCombined treatment\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e290 (41.3)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eBody weight (kg)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e88.7 (\u0026plusmn;\u0026thinsp;7.1)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eBody mass index\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e31.7 (\u0026plusmn;\u0026thinsp;4.6)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e \u003cp\u003e702 potentially eligible patients sought enrollment and achievement of enrollment and were referred to a comprehensive model of clinical care. Demographic and socio-cultural characteristics in terms of age, length of T1DM and sex. The specific health features, compliance to treatment, distribution of morbidity, commitment to diet, and medical risks as seen in Table\u0026nbsp;\u003cspan refid=\"Tab1\" class=\"InternalRef\"\u003e1\u003c/span\u003e.\u003c/p\u003e \u003cp\u003eThe systematic model of health education resulted in favorable variations in HbA1c, LDL cholesterol and SBP (P\u0026thinsp;\u0026lt;\u0026thinsp;0 05); statistically significant differences were observed during the study (Fig.\u0026nbsp;1, Table\u0026nbsp;\u003cspan refid=\"Tab2\" class=\"InternalRef\"\u003e2\u003c/span\u003e). The non-adjusted effect of the systematic health education model on parameter changes was higher for LDL, HbA1c, and SBP; this showed significant differences during the study (P\u0026thinsp;\u0026lt;\u0026thinsp;0 05). After an updated study, the HbA1c decreased by 0.67 per cent (P\u0026thinsp;\u0026lt;\u0026thinsp;0 01) in the systemic model of health education. In comparison, SBP decreased by 10.83\u0026nbsp;mmHg (P\u0026thinsp;\u0026lt;\u0026thinsp;0 01) and the amount of DBP, HDL and total cholesterol decreased significantly and did not important. (Fig.\u0026nbsp;2, 3)\u003c/p\u003e \u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab2\" border=\"1\"\u003e \u003ccaption language=\"En\"\u003e \u003cdiv class=\"CaptionNumber\"\u003eTable 2\u003c/div\u003e \u003cdiv class=\"CaptionContent\"\u003e \u003cp\u003eList of potential themes included in a therapeutic patient education for type 1 diabetic patients\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"1\"\u003e \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\"\u003e \u003cp\u003e1. Basic knowledge of diabetes and its complications\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e2. Healthy diet\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e3. Regular physical activity\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e4. Glucose control, modification of diet and treatment before, during and after vigorous physical activity\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e5. Self-monitoring blood glucose\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e6. Prevention and early identification of hypoglycemia\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e7. Prevention and early identification of hyperglycemia\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e8. Management of hypo- or hyperglycemia\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e9. Modification of the treatment on the basis of self-monitoring blood glucose before medical check\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e10. Giving up smoking\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e11. Periodic administration of questionnaires on erectile dysfunction\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e12. Periodic administration of questionnaires on quality of life\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e13. Identification and correct interpretation of some specific symptoms, such as erectile dysfunction, claudication intermittent, unusual dyspnea, paresthesia\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e14. Check blood pressure\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e15. Adherence to medication\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e16. Regular prevention and early identification of diabetic foot\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e17. Regular medical checks\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e18. Regular sessions of patient education\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e19. Management of insulin therapy\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e20. Specific management of gestational diabetes or diabetes during pregnancy\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e21. Management of continuous subcutaneous insulin infusion\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e22. Information on bureaucratic issues, such as guide authorization, voyager, military service, job\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e \u003cp\u003eThe BMI did not change substantially during the study and the adjusted effect of the systematic health education model was-0.23 (Table\u0026nbsp;\u003cspan refid=\"Tab2\" class=\"InternalRef\"\u003e2\u003c/span\u003e). Though, after 2\u0026nbsp;years of follow-up, the systematic health education model demonstrated efficacy in the percentage of patients targeted for cardiovascular risk factors: LDL cholesterol\u0026thinsp;\u0026lt;\u0026thinsp;100\u0026nbsp;mg / dl (P\u0026thinsp;=\u0026thinsp;0 02), HbA1c\u0026thinsp;\u0026lt;\u0026thinsp;7% (P\u0026thinsp;\u0026lt;\u0026thinsp;0 01), BP regulation (\u0026lt;\u0026thinsp;130/80\u0026nbsp;mmHg) (P\u0026thinsp;=\u0026thinsp;0 03), SBP\u0026thinsp;\u0026lt;\u0026thinsp;130\u0026nbsp;mmHg (P\u0026thinsp;=\u0026thinsp;0 03), and global monitoring (metabolic and BP) (P\u0026thinsp;\u0026lt;\u0026thinsp;0 01). However, it was not important for the parameters DBP\u0026thinsp;\u0026lt;\u0026thinsp;80\u0026nbsp;mmHg and BMI\u0026thinsp;\u0026lt;\u0026thinsp;25\u0026nbsp;kg / m2 (Table\u0026nbsp;\u003cspan refid=\"Tab3\" class=\"InternalRef\"\u003e3\u003c/span\u003e).\u003c/p\u003e \u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab3\" border=\"1\"\u003e \u003ccaption language=\"En\"\u003e \u003cdiv class=\"CaptionNumber\"\u003eTable 3\u003c/div\u003e \u003cdiv class=\"CaptionContent\"\u003e \u003cp\u003ebaseline clinical characteristics of participants in comparison with 2\u0026nbsp;years after\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"9\"\u003e \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/th\u003e \u003cth align=\"left\" colname=\"c2\"\u003e \u003cp\u003eBase line characteristics\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c3\"\u003e \u003cp\u003e2\u0026nbsp;years after\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c4\"\u003e \u003cp\u003e%change\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c5\"\u003e \u003cp\u003eSE\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c6\"\u003e \u003cp\u003e95% CI\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c7\"\u003e \u003cp\u003et-statistic\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c8\"\u003e \u003cp\u003eDifference\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c9\"\u003e \u003cp\u003eP value\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eExercise (hours/week)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e2 (0.3)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e5 (2.1)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e+\u0026thinsp;150\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e0.080\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e2.8429 to 3.1571\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c7\"\u003e \u003cp\u003e37.470\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c8\"\u003e \u003cp\u003e3.0\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c9\"\u003e \u003cp\u003e\u0026lt;\u0026thinsp;0.0001\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eCompliance with diet %(95%CI)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e40.5 (36.3\u0026ndash;44.7)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e75.5 (70.4\u0026ndash;80.2)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e+\u0026thinsp;87.5\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e0.253\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e34.5039 to 35.4961\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c7\"\u003e \u003cp\u003e138.393\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c8\"\u003e \u003cp\u003e35.0\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c9\"\u003e \u003cp\u003e\u0026lt;\u0026thinsp;0.0001\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eSelf-control %(95%CI)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e33.5 (31.8\u0026ndash;35.2)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e66.1 (61.4\u0026ndash;70.3)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e+\u0026thinsp;100\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e0.253\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e32.1039 to 33.0961\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c7\"\u003e \u003cp\u003e128.903\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c8\"\u003e \u003cp\u003e32.6\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c9\"\u003e \u003cp\u003e\u0026lt;\u0026thinsp;0.0001\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eFoot care %(95%CI)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e23.1 (19.2\u0026ndash;27.3)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e59.3 (55.7\u0026ndash;66.5)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e+\u0026thinsp;156\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e0.253\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e35.7039 to 36.6961\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c7\"\u003e \u003cp\u003e143.138\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c8\"\u003e \u003cp\u003e36.2\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c9\"\u003e \u003cp\u003e\u0026lt;\u0026thinsp;0.0001\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eTherapeutic compliance %(95%CI)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e49.3 (45.4\u0026ndash;53.5)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e88.5 (85.9\u0026ndash;91.5)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e+\u0026thinsp;79.5\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e0.272\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e38.6661 to 39.7339\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c7\"\u003e \u003cp\u003e144.030\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c8\"\u003e \u003cp\u003e39.2\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c9\"\u003e \u003cp\u003e\u0026lt;\u0026thinsp;0.0001\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eHbA1c (%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e9.9 (2.1)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e7.9 (1.1)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e-25.3\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e0.136\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e-2.2669 to -1.7331\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c7\"\u003e \u003cp\u003e-14.697\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c8\"\u003e \u003cp\u003e-2.0\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c9\"\u003e \u003cp\u003e\u0026lt;\u0026thinsp;0.0001\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eLDL cholesterol (mg/dl)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e2.59 (0.9)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e2.07 (0.8)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e-25.1\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e0.056\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e-0.6301 to -0.4099\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c7\"\u003e \u003cp\u003e-9.268\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c8\"\u003e \u003cp\u003e-0.52\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c9\"\u003e \u003cp\u003e\u0026lt;\u0026thinsp;0.0001\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eSystolic blood pressure (mmHg)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e134.3 (18.2)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e129 (15.5)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e-4.1\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e0.514\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e-6.3078 to -4.2922\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c7\"\u003e \u003cp\u003e-10.316\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c8\"\u003e \u003cp\u003e-5.3\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c9\"\u003e \u003cp\u003e\u0026lt;\u0026thinsp;0.0001\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eDiastolic blood pressure (mmHg)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e77.22 (10.5)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e75.1 (8.1)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e-2.79\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e0.325\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e-2.7369 to -1.4631\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c7\"\u003e \u003cp\u003e-6.468\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c8\"\u003e \u003cp\u003e-2.1\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c9\"\u003e \u003cp\u003e\u0026lt;\u0026thinsp;0.0001\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eBody Mass Index (Kg/m\u003csup\u003e2\u003c/sup\u003e)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e32.3 (2.6)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e27.2 (3.4)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e-18.75\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e0.189\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e-5.4702 to -4.7298\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c7\"\u003e \u003cp\u003e-27.025\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c8\"\u003e \u003cp\u003e-5.1\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c9\"\u003e \u003cp\u003e\u0026lt;\u0026thinsp;0.0001\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003ctfoot\u003e \u003ctr\u003e\u003ctd colspan=\"9\"\u003eValues are given as mean (SD) otherwise specified, CI: confidence interval.\u003c/td\u003e\u003c/tr\u003e \u003c/tfoot\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e \u003cp\u003e96.7% of our patients were completely satisfied by what they have achieved through this project. The average HbA1C become less than eight in 54% of patients. Patients with HbA1C 8\u0026ndash;9%, BP\u0026thinsp;\u0026lt;\u0026thinsp;140/80, and LDL\u0026thinsp;\u0026lt;\u0026thinsp;3.36\u0026nbsp;mmol/l, were 46%, 51% and 79% respectively. The average blood pressure for 56% of patients was 132/77. The average LDL level among 71% of patients was 2.25. 27% of patients had average discharged HbA1c of 7.3. Net promotor score of SDC was 85%, were promotors, passives and detractors were 87.8%, 9.5% and 2.8% respectively. P value\u0026thinsp;\u0026lt;\u0026thinsp;0.05 (Table\u0026nbsp;\u003cspan refid=\"Tab4\" class=\"InternalRef\"\u003e4\u003c/span\u003e, Fig.\u0026nbsp;4)\u003c/p\u003e \u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab4\" border=\"1\"\u003e \u003ccaption language=\"En\"\u003e \u003cdiv class=\"CaptionNumber\"\u003eTable 4\u003c/div\u003e \u003cdiv class=\"CaptionContent\"\u003e \u003cp\u003ePatient satisfaction survey\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"5\"\u003e \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\"\u003e \u003cp\u003ePlease specify your level of satisfaction with\u003c/p\u003e \u003cp\u003ethe following points:\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c2\"\u003e \u003cp\u003eSatisfied\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c3\"\u003e \u003cp\u003eNeutral\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c4\"\u003e \u003cp\u003eDissatisfied\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c5\"\u003e \u003cp\u003eP value\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e1. Easy registration process\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e95%\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e3.3%\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e1.7%\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e2. care of staff at the registration area\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e96.7%\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e1.7%\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e1.7%\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e3. Waiting time in the clinic.\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e87.8%\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e6.1%\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e6.1%\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e4. Kindness and care of the medical staff.\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e97.2%\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e1.7%\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e1.2%\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e5. Explanation provided by the medical team about your health status.\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e95.5%\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e3.9%\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e0.6%\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e6. The medical team's attention about your questions and concerns.\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e96.2%\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e2.2%\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e1.7%\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e7. your involvement in treatment decisions\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e95.5%\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e3.9%\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e0.6%\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e8. Instructions which given by medical team regarding your health status\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e96.1%\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e1.1%\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e2.8%\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e\u0026lt;\u0026thinsp;0.05\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e9. Your trust in medical team\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e96.6%\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e2.2%\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e1.2%\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e10. The time the medical team spent with you\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e96.1%\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e2.2%\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e1.7%\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e11. The medical team's response to your needs\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e95.5%\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e1.7%\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e2.8%\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e12. Patient confidentiality\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e97.3%\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e2.2%\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e0.6%\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e13. The medical team cooperation in the provision of care for you\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e96.7%\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e1.7%\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e1.7%\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e14. The possibility of recommending SDC to others\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e96.7%\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e2.8%\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e0.6%\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e15. Your overall evaluation of the care you received at SDC.\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e96.7%\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e1.7%\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e1.7%\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e "},{"header":"4. Discussion","content":" \u003cp\u003eThis prospective, study is considered as a strategic integrated project. It was established, as a clinical project including its infrastructure, man power, material, budget, policies and procedures. This project was established for full integrated management of diabetic patients. Our care rendered to the patients has been reflected on their outcomes. Therapy together with health education through social media, what-Sapp groups and focus group discussion together with individual face to face interviews, had a good impact on our patients.\u003ca class=\"FNLink\" href=\"#Fn23\" id=\"#FNLinkFn23\"\u003e\u003c/a\u003e It was an effective intervention that had an observed effect on patients\u0026rsquo; outcomes. We evaluated our patients, pre and post intervention to see the change in some pre-specified variables. (Fig.\u0026nbsp;5, 6) We noticed the change in their clinical statuses, anthropometric measures, laboratory results, psychosocial lives, lifestyles, and quality of lives.\u003ca class=\"FNLink\" href=\"#Fn24\" id=\"#FNLinkFn24\"\u003e\u003c/a\u003e\u003c/p\u003e \u003cp\u003e702 patients is a good number to start a prospective study, with zero percent attrition or drop-outs. Indeed, building up of good friendly relationships, trust and rapport with your patients from the beginning, is better than insulin. Health education, patient motivation, self-management knowledge, skills, is useful in improving metabolic control. This will reduce the patient and family costs in secondary and tertiary management. Moreover, this improvement observed and maintained at 24 months.\u003c/p\u003e \u003cp\u003eThere is no longer a need to justify the value of patient education: education is part of a patient-centered humanistic therapeutic approach; it enables patients to be actively involved in their own recovery with the goal of increasing the quality of life and adherence with medication, as well as minimizing possible complications. \u003ca class=\"FNLink\" href=\"#Fn25\" id=\"#FNLinkFn25\"\u003e\u003c/a\u003e Thus, our healthcare professionals are therefore educating, advising, preparing, engaging with, inspire and support physicians in disease follow-up which takes long time.\u003c/p\u003e \u003cp\u003eOur study showed a portrayal in cognitive and behavioral therapy and inspirational interviews as a main contributor to clinical patient education, which occurs in an environment of understanding and emotions, correlated with several psycho-educational strategies.\u003ca class=\"FNLink\" href=\"#Fn26\" id=\"#FNLinkFn26\"\u003e\u003c/a\u003e This paradigm had an obvious effect on clinical and laboratory outcomes, as well as, the psychological aspect and the quality of life. Many studies have shown that diabetic patients' education is a patient-centered humanitarian strategy that encourages clinicians to be protagonists in their own care, improve their well-being, and reduce the likelihood of possible complications. (Fig.\u0026nbsp;7)\u003c/p\u003e \u003cp\u003eGroup preparation for patient education must start as soon as a training need is defined through diagnosis. Early diagnosis and education offers time to identify and overcome challenges, creates constructive practice opportunities and promotes the ability to solve and deal with issues and problems. Our aim was to provide the patient (or healthcare provider) with time to perform survival skills and self-management.\u003c/p\u003e \u003cp\u003eOur key nutritional targets were to improve glycemic control, offer appropriate nutrients and calories to satisfy metabolic needs, and establish a follow-up treatment life-plan. Some of the problems that may hinder the accomplishment of these targets in our facilities include: meal time planning and need-based modifications; in case of surgery laboratory testing, and procedures. When the patients lose their appetite or loss of ability of eating after drug administration or after acute diseases, glycemic control becomes very difficult. Other problems such as; inconsistent consumption of sugar, nutrition that is not addressed in the diet plan, inefficient food distribution arrangement with point of care sugar level monitoring and insulin treatment, lack of principles understanding by doctors, patients and families of the existing values of diabetes health, variability of requirements of insulin among patients, either on enteral or parenteral nutrition, decreased exercise and sedentary life. (Fig.\u0026nbsp;8)\u003c/p\u003e \u003cp\u003eWe met maximum glycemic targets for our patients. To achieve optimal glycemic control and glycemic targets thus reducing hypoglycemia, successful insulin therapy needs to be understood and used. Recent studies have highlighted the significance of preventing hypoglycemia to minimize risk, but avoiding hyperglycemia is equally as important.\u003c/p\u003e \u003cp\u003eIt is advised to develop guidelines, order sets, and glycemic goals by an interdisciplinary group of administrative support. Developing and enforcing hospital-wide protocols and uniform insulin order sets will assist patients in choosing the right insulin protocol while preventing adverse events. The use of a responsive \"sliding scale\" should be discontinued, and the standard of care should be therapeutic insulin schemes including basal, postprandial and corrective insulin.\u003c/p\u003e \u003cp\u003eThroughout tandem with a patient-centered strategy, the diabetes educator can also promote the production and use of structured insulin order sets and procedures to avoid hypoglycemic episodes, achieve optimal performance, and mitigate harm capacity. The diabetes educator should also promote the development and use of protocols to manage and control hypoglycemia and make recommendations for improvement.\u003c/p\u003e \u003cp\u003eWhen indicated for all patients with hyperglycemia or at high risk of hyperglycemia, our clinicians followed them through routine check of glycated hemoglobin and daily glucose monitoring. This includes diagnosis of cases with diabetes as well as patients received high-dose corticosteroids, immune suppressants, and intravenous and oral nutrition. After blood transfusions or with a record of uncontrolled glucose levels, the glycated hemoglobin level may not be accurate, or if there are hemoglobinopathies in case of dialysis patients or those receiving chemotherapy. In pediatric, obstetric, and emergency patients, point-of-care ketone screening should be recommended.\u003c/p\u003e \u003cp\u003eWith this objective in mind, the diabetes educator may engage in the foregoing educational activities: evaluating the knowledge and skills of patients having diabetes; improving self-management skills; providing training in a variety of contexts, including staff induction, medical areas and big rounds; designing curricula for sharing with other team leaders; using a variety of educational tools; for example; case studies, workshops of self-learning, journal societies, templates of survival skills and flash cards to meet the needs and preferences of all environments and learners.\u003c/p\u003e \u003cp\u003eIn our study, every patient had a good experience and take-home message after two years of hard work. After a countless episodes of depression, suicidal attempts, anxiety, upset, loss of hope, loss of self-esteem, loss of self-confidence and feelings of uselessness in life. Most of our patients, if not all of them, become full of hope and enthusiasm. Some of them become body builders; others win medals in championships of biking and mountain climbing, and many other examples, no space to mention.\u003c/p\u003e \u003cp\u003eFor present, however, it is important to maintain the education systems while at the same time continuing to investigate the effects of social media in order to identify certain categories of patients who may prosper from this tool. Regular medical interaction may be more relevant to patients and families modifying their insulin protocol, promoting self-management and encouragement. It will also be very beneficial in pre-gestational diabetes, patients with constant subcutaneous insulin infusion and patients with a high risk of developing serious acute complications correlated with other therapies (corticosteroids). In order to know the impact on health care system and leadership performance to patients with chronic disorders, it is also important to identify the implications of education on the interaction of primary and secondary management.\u003c/p\u003e \u003cp\u003eTo summarize, using an immersive tele-education system embedded into an intense face-to-face follow-up, produces significant changes in metabolic profile, quality of life, and self-care compared to traditional drug prescribing and reconciliation follow-up. Improving contact services, though, is important to provide effective cost reductions to the healthcare and diabetes community.\u003c/p\u003e "},{"header":"Conclusion","content":"\u003cp\u003eAs a consequence of all the variables listed above, it can be inferred that the comprehensive health education approach is a valuable tool for the treatment of T1DM, as it leads to a decrease in HbA1c, LDL cholesterol and SBP rates, as well as to that conformity with the regulation criterion, except for DBP and BMI.\u003c/p\u003e \u003cp\u003eSince health education will result in cost reductions and better results, Medicare and other payers would be protected by health education. In order to address this scarcity, DM-care educators will provide comprehensive health education to raise understanding of the seriousness of diabetes, its risk factors, and approaches to avoid diabetes and its complications in at-risk populations.\u003c/p\u003e "},{"header":"Abbreviations","content":"\u003cp\u003e \u003cul\u003e \u003cli\u003e \u003cp\u003eSpecialized clinics of diabetes (SDC)\u003c/p\u003e \u003c/li\u003e \u003cli\u003e \u003cp\u003eGlycosylated hemoglobin (HbA1C)\u003c/p\u003e \u003c/li\u003e \u003cli\u003e \u003cp\u003eBlood pressure (BP)\u003c/p\u003e \u003c/li\u003e \u003cli\u003e \u003cp\u003eLow density lipoproteins (LDL)\u003c/p\u003e \u003c/li\u003e \u003cli\u003e \u003cp\u003eType I diabetes milletus (TIDM)\u003c/p\u003e \u003c/li\u003e \u003cli\u003e \u003cp\u003eWorld Health Organization (WHO)\u003c/p\u003e \u003c/li\u003e \u003cli\u003e \u003cp\u003eSystolic blood pressure (SBP),\u003c/p\u003e \u003c/li\u003e \u003cli\u003e \u003cp\u003eDiastolic blood pressure (DBP),\u003c/p\u003e \u003c/li\u003e \u003cli\u003e \u003cp\u003eHigh-density lipoprotein (HDL)\u003c/p\u003e \u003c/li\u003e \u003cli\u003e \u003cp\u003eDiabetes Control and Complications Trial (DCCT)\u003c/p\u003e \u003c/li\u003e \u003c/ul\u003e \u003c/p\u003e"},{"header":"Declarations","content":"\u003cp\u003e\u003cstrong\u003eData Availability\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe data used to support the findings of this study are available from the corresponding author upon request.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eFunding \u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe author declared they did not receive any funds\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eConsent for publication\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eConsent for publication was obtained from all authors\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eEthical Approval and Consent to participate\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eInformed consent was obtained from all participants. And ethical IRB approval obtained # (IRB/KSUMC/978/2rkj-9834)\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eConflicts of Interest (\u003c/strong\u003eCompeting interests)\u003c/p\u003e\n\u003cp\u003eThe authors declare that they have no conflicts of interest.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAuthors\u003c/strong\u003e\u0026rsquo; \u003cstrong\u003eContributions\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eCrafted a research plan and prepared a report. Checked out the manuscript. Writers contributed to the writing of the text and read and support the final document.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAcknowledgments\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe writers are indebted to the Diabetes Health Education Association, which has sponsored the training of patients, the administration of the group appraisal clinic and the calculation of biochemistry. The writers would like to thank and recognize all the participants who have contributed to this research.\u003c/p\u003e"},{"header":"References","content":"\u003col\u003e\n\u003cli\u003eNorris S, Lau J, Smith S et al. Self-management education for adults with type 2 diabetes: a meta-analysis of the effect on glycaemic control. Diabetes Care 2002; 25: 1159\u0026ndash;71.\u003c/li\u003e\n\u003cli\u003eMinet L, Mollen S, Vach W et al. Mediating the effect of self-management intervention in type 2- diabetes: a metaanalysis of 47 randomised controlled trials. Patient Educ Couns 2010; 80: 29\u0026ndash;42.\u003c/li\u003e\n\u003cli\u003eHolman RR, Paul SK, Bethel A et al. 10-Year follow-up of intensive glucose control in type 2 diabetes. N Engl J Med 2008; 359: 1577\u0026ndash;89.\u003c/li\u003e\n\u003cli\u003eThe Diabetes Control and Complication Trial/Epidemiology of Diabetes Interventions and Complications (DCCT/EDIC) Study Research Group. Intensive diabetes treatment and cardiovascular disease in patients with Type 1 diabetes. N Engl J Med 2005; 353: 2643\u0026ndash;53.\u003c/li\u003e\n\u003cli\u003eEllis SE, Speroff T, Dittus RS et al. Diabetes patient education: a meta-analysis and meta-regression. Patient Educ Couns 2004; 52: 97\u0026ndash;105.\u003c/li\u003e\n\u003cli\u003eJarvis J, Skinner TC, Carey ME et al. How can structured self-management patient education improve outcomes in people with type 2 diabetes? Diabetes Obes Metab 2010; 12: 12\u0026ndash;9.\u003c/li\u003e\n\u003cli\u003eLabate C. The influence of social media on diabetes treatment and self-care. Diabetes Voice 2013;58:14-15 [FREE Full text]\u003c/li\u003e\n\u003cli\u003eAlanzi T, Istepanian R, Philip N. Design and usability evaluation of social mobile diabetes management system in the Gulf Region. JMIR Res Protoc 2016 Sep 26;5(3):e93 [FREE Full text] [doi: 10.2196/resprot.4348] [Medline: 27670696]\u003c/li\u003e\n\u003cli\u003eCooper A, Kar P. A new dawn: the role of social media in diabetes education. J Diabetes Nurs 2014;18:68-71 [FREE Full text]\u003c/li\u003e\n\u003cli\u003eZowawi HM, Abedalthagafi M, Mar FA, Almalki T, Kutbi AH, Harris-Brown T, et al. The potential role of social media platforms in community awareness of antibiotic use in the Gulf Cooperation Council States: luxury or necessity? J Med Internet Res 2015 Oct 15;17(10):e233 [FREE Full text] [doi: 10.2196/jmir.3891] [Medline: 26471079]\u003c/li\u003e\n\u003cli\u003ePetrovski G, Zivkovic M, Stratrova SS. Social media and diabetes: can Facebook and Skype improve glucose control in patients with type 1 diabetes on pump therapy? One-year experience. Diabetes Care 2015 Apr; 38(4):e51-e52. [doi: 10.2337/dc14-2487] [Medline: 25805869]\u003c/li\u003e\n\u003cli\u003eChen R, Ji L, Chen L, et al. Glycemic control rate of T2DM outpatients in China: a multi-center survey. Med Sci Monit 2015; 21:1440\u0026ndash;6.\u003c/li\u003e\n\u003cli\u003eHammami, Muhammad. \u0026ldquo;Prevention of Diabetes MellitusPrevention of Diabetes Mellitus, WHO Study Group on Prevention of Diabetes Mellitus, WHO Technical Report Series No. 844, World Health Organization, Geneva, Switzerland, 1994. Sw Fr 15, ISBN 92-4-120844-9.\u0026rdquo; Annals of Saudi Medicine 15, no. 3 (1995): 297\u0026ndash;97. \u003ca href=\"https://doi.org/10.5144/0256-4947.1995.297\"\u003ehttps://doi.org/10.5144/0256-4947.1995.297\u003c/a\u003e.\u003c/li\u003e\n\u003cli\u003eR. B. Haynes, D. L. Sackett, J. C. Snow, and D. L. Sackett, \u0026ldquo;Annotated and indexed bibliography on compliance with therapeutic and preventive regimens,\u0026rdquo; in Compliance in Health Care, R. B. Haynes, D. W. Taylor, and D. L. Sackett, Eds., pp. 337\u0026ndash;342, Johns Hopkins University Press, Baltimore, MD, USA, 1979.\u003c/li\u003e\n\u003cli\u003eJ. B. Buse, K. S. Polonsky, and C. F. Burant, \u0026ldquo;Type 2 Diabetes Mellitus,\u0026rdquo; in Williams Textbook of Endocrinology, S. Melmed, K. S. Polonsky, P. R. Larsen, and H. M. Kronenberg, Eds., Saunders, Philadelphia, PA, USA, 12th edition, 2011.\u003c/li\u003e\n\u003cli\u003eRohlfing, C. L., H.-M. Wiedmeyer, R. R. Little, J. D. England, A. Tennill, and D. E. Goldstein. \u0026ldquo;Defining the Relationship Between Plasma Glucose and HbA1c: Analysis of Glucose Profiles and HbA1c in the Diabetes Control and Complications Trial.\u0026rdquo; Diabetes Care 25, no. 2 (January 2002): 275\u0026ndash;78. \u003ca href=\"https://doi.org/10.2337/diacare.25.2.275\"\u003ehttps://doi.org/10.2337/diacare.25.2.275\u003c/a\u003e.\u003c/li\u003e\n\u003cli\u003eStein, Risa J., C. Keith Haddock, Walker S.c. Poston, Dana Catanese, and John A. Spertus. \u0026ldquo;Precision in Weighing: A Comparison of Scales Found in Physician Offices, Fitness Centers, and Weight Loss Centers.\u0026rdquo; Public Health Reports 120, no. 3 (2005): 266\u0026ndash;70. \u003ca href=\"https://doi.org/10.1177/003335490512000308\"\u003ehttps://doi.org/10.1177/003335490512000308\u003c/a\u003e.\u003c/li\u003e\n\u003cli\u003eBarreira, T. V., A. E. Staiano, and P. T. Katzmarzyk. \u0026ldquo;Validity Assessment of a Portable Bioimpedance Scale to Estimate Body Fat Percentage in White and African-American Children and Adolescents.\u0026rdquo; Pediatric Obesity 8, no. 2 (2012). \u003ca href=\"https://doi.org/10.1111/j.2047-6310.2012.00122.x\"\u003ehttps://doi.org/10.1111/j.2047-6310.2012.00122.x\u003c/a\u003e.\u003c/li\u003e\n\u003cli\u003eVischer, Annina S., and Thilo Burkard. \u0026ldquo;Principles of Blood Pressure Measurement \u0026ndash; Current Techniques, Office vs Ambulatory Blood Pressure Measurement.\u0026rdquo; Advances in Experimental Medicine and Biology Hypertension: from Basic Research to Clinical Practice, 2016, 85\u0026ndash;96. \u003ca href=\"https://doi.org/10.1007/5584_2016_49\"\u003ehttps://doi.org/10.1007/5584_2016_49\u003c/a\u003e.\u003c/li\u003e\n\u003cli\u003eRocks, Brendan. \u0026ldquo;Interval Estimation for the \u0026lsquo;Net Promoter Score.\u0026rsquo;\u0026rdquo; The American Statistician 70, no. 4 (2016): 365\u0026ndash;72. \u003ca href=\"https://doi.org/10.1080/00031305.2016.1158124\"\u003ehttps://doi.org/10.1080/00031305.2016.1158124\u003c/a\u003e.\u003c/li\u003e\n\u003cli\u003eClement-Spychala, Meagan E., David Couper, Keith E. Muller, and Hongtu Zhu. \u0026ldquo;Approximating the Geisser-Greenhouse Sphericity Estimator and Its Applications to Diffusion Tensor Imaging.\u0026rdquo; Statistics and Its Interface 3, no. 1 (2010): 81\u0026ndash;90. \u003ca href=\"https://doi.org/10.4310/sii.2010.v3.n1.a7\"\u003ehttps://doi.org/10.4310/sii.2010.v3.n1.a7\u003c/a\u003e.\u003c/li\u003e\n\u003cli\u003eB. P\u0026eacute;tr\u0026eacute;, R. Gagnayre, V. De Andrade, O. Ziegler, and M. Guillaume, \u0026ldquo;From therapeutic patient education principles to educative attitude: the perceptions of health care professionals\u0026mdash;a pragmatic approach for defining competencies and resources,\u0026rdquo; Patient Preference and Adherence, vol. 11, pp. 603\u0026ndash;617, 2017.\u003c/li\u003e\n\u003cli\u003eJ. Beck, D. A. Greenwood, L. Blanton et al., \u0026ldquo;2017 national standards for diabetes self-management education and support,\u0026rdquo; Diabetes Care, vol. 40, no. 10, pp. 1409\u0026ndash;1419, 2017.\u003c/li\u003e\n\u003cli\u003eH. Riemenschneider, S. Saha, S. van den Broucke et al., \u0026ldquo;State of diabetes self-management education in the European Union member states and non-EU countries: the diabetes literacy project,\u0026rdquo; Journal of Diabetes Research, vol. 2018, Article ID 1467171, 10 pages, 2018.\u003c/li\u003e\n\u003cli\u003eM. M. Funnell, T. L. Brown, B. P. Childs et al., \u0026ldquo;National standards for diabetes self-management education,\u0026rdquo; Diabetes Care, vol. 33, Supplement 1, pp. S89\u0026ndash;S96, 2010.\u003c/li\u003e\n\u003c/ol\u003e"}],"fulltextSource":"","fullText":"","funders":[],"hasAdminPriorityOnWorkflow":false,"hasManuscriptDocX":true,"hasOptedInToPreprint":true,"hasPassedJournalQc":"","hasAnyPriority":false,"hideJournal":true,"highlight":"","institution":"","isAcceptedByJournal":false,"isAuthorSuppliedPdf":false,"isDeskRejected":"","isHiddenFromSearch":false,"isInQc":false,"isInWorkflow":false,"isPdf":false,"isPdfUpToDate":true,"isWithdrawnOrRetracted":false,"journal":{"display":true,"email":"[email protected]","identity":"researchsquare","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":true,"externalIdentity":"","sideBox":"","snPcode":"","submissionUrl":"/submission","title":"Research Square","twitterHandle":"researchsquare","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"","reportingPortfolio":"","inReviewEnabled":false,"inReviewRevisionsEnabled":true},"keywords":"Educational, Chronic, Care Model, Diabetic Patients","lastPublishedDoi":"10.21203/rs.3.rs-47906/v1","lastPublishedDoiUrl":"https://doi.org/10.21203/rs.3.rs-47906/v1","license":{"name":"CC BY 4.0","url":"https://creativecommons.org/licenses/by/4.0/"},"manuscriptAbstract":"\u003cp\u003eBackground \u003c/p\u003e\u003cp\u003eLack of knowledge and understanding about diabetes are important barriers to cure. Treatment of diabetes alone without education is not sufficient. Nowadays, health education could reach us on mobiles. \u003c/p\u003e\u003cp\u003eAim\u0026nbsp;\u0026nbsp;\u0026nbsp;\u0026nbsp;\u0026nbsp;\u0026nbsp;\u003c/p\u003e\u003cp\u003eOur aim is how to make advice-giving becomes a system to treat our patients. The theme of this study is diabetes education. And to know how far the prompt well-structured education could affect the clinical status and the quality of life of a poorly controlled diabetic patients. \u003c/p\u003e\u003cp\u003eMethods\u003c/p\u003e\u003cp\u003e702 patients with type 1 diabetes were followed for 2 years (2017, 2018), by condensed friendly education and training sessions. Our activities were mainly through direct individual approach and social media, structured in the form of visits. The study was done in a specialized clinics of diabetes (SDC) in a tertiary university hospital. We evaluated the clinical status, psychological, sociocultural and satisfaction of the patients, pre and post education. We assessed our patients at the beginning of the study, throughout, and at the time of discharge. Quantitative and qualitative data were compared statistically by paired t test and chi-square test at 0.05 level of significance. \u0026nbsp;\u0026nbsp;\u003c/p\u003e\u003cp\u003eResults\u003c/p\u003e\u003cp\u003e96.7% of our patients were completely satisfied by what they have achieved through this project. The average HbA1C become less than eight in 54% of patients. Patients with HbA1C 8-9%, BP \u0026lt;140/80, and LDL \u0026lt;3.36 mmol/l, were 46%, 51% and 79% respectively. The average blood pressure for 56% of patients was 132/77. The average LDL level among 71% of patients was 2.25. 27% of patients had average discharged HbA1c of 7.3. Net promotor score of SDC was 85%, were promotors, passives and detractors were 87.8%, 9.5% and 2.8% respectively. P value \u0026lt;0.05\u003c/p\u003e\u003cp\u003eConclusion \u003c/p\u003e\u003cp\u003eEducation self-management support programs are cost-effective and superior to usual care. Education programs were more effective in lowering HbA1c. Attendees finding it valuable and enjoyable.\u003c/p\u003e","manuscriptTitle":"Impact of Educational Chronic Care Model on Diabetic Patients: A Prospective Cohort Study","msid":"","msnumber":"","nonDraftVersions":[{"code":1,"date":"2020-08-03 21:19:28","doi":"10.21203/rs.3.rs-47906/v1","editorialEvents":[{"type":"communityComments","content":0}],"status":"published","journal":{"display":true,"email":"[email protected]","identity":"researchsquare","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":true,"externalIdentity":"","sideBox":"","snPcode":"","submissionUrl":"/submission","title":"Research Square","twitterHandle":"researchsquare","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"","reportingPortfolio":"","inReviewEnabled":false,"inReviewRevisionsEnabled":true}}],"origin":"","ownerIdentity":"f53e36f6-ee9a-4fa1-bc2c-7204d8519643","owner":[],"postedDate":"August 3rd, 2020","published":true,"recentEditorialEvents":[],"rejectedJournal":[],"revision":"","amendment":"","status":"posted","subjectAreas":[{"id":236050,"name":"Endocrinology \u0026 Metabolism"}],"tags":[],"updatedAt":"2021-05-13T23:56:59+00:00","versionOfRecord":[],"versionCreatedAt":"2020-08-03 21:19:28","video":"","vorDoi":"","vorDoiUrl":"","workflowStages":[]},"version":"v1","identity":"rs-47906","journalConfig":"researchsquare"},"__N_SSP":true},"page":"/article/[identity]/[[...version]]","query":{"redirect":"/article/rs-47906","identity":"rs-47906","version":["v1"]},"buildId":"cBFmMYwuxLRRLfASyISRj","isFallback":false,"isExperimentalCompile":false,"dynamicIds":[84888],"gssp":true,"scriptLoader":[]}