Optimizing Diabetes Care Through Listening to Multiple Voices.

This article is adapted from the address Dr. Caballero delivered as the recipient of the American Diabetes Association's Outstanding Educator in Diabetes Award for 2023. He delivered the address in June 2023 during the Association's 83rd Scientific Sessions in San Diego, CA. A webcast of this speech is available for viewing on the DiabetesPro website (https://events.diabetes.org/live/25/page/186).

Implicit or Unconscious Bias in Diabetes Care.

"Implicit bias," also called "unconscious bias," refers to associations outside of conscious awareness that adversely affect one's perception of a person or group. Awareness of implicit bias has been increasing in the realm of diabetes care. Here, the authors highlight several types of unconscious bias on the part of clinicians and patients, including biases based on race, ethnicity, and obesity. They discuss how these biases can negatively affect patient-centered clinical interactions and diabetes care delivery, and they recommend implementation of evidence-based interventions and other health system policy approaches to reduce the potential impact of such biases in health care settings.

Diabetes subgroups and sociodemographic inequalities in Mexico: a cross-sectional analysis of nationally representative surveys from 2016 to 2022.

Background: Differences in the prevalence of four diabetes subgroups have been reported in Mexico compared to other populations, but factors that may contribute to these differences are poorly understood. Here, we estimate the prevalence of diabetes subgroups in Mexico and evaluate their correlates with indicators of social disadvantage using data from national representative surveys. Methods: We analyzed serial, cross-sectional Mexican National Health and Nutrition Surveys spanning 2016, 2018, 2020, 2021, and 2022, including 23,354 adults (>20 years). Diabetes subgroups (obesity-related [MOD], severe insulin-deficient [SIDD], severe insulin-resistant [SIRD], and age-related [MARD]) were classified using self-normalizing neural networks based on a previously validated algorithm. We used the density-independent social lag index (DISLI) as a proxy of state-level social disadvantage. Findings: We identified 4204 adults (median age: 57, IQR: 47-66, women: 64%) living with diabetes, yielding a pooled prevalence of 16.04% [95% CI: 14.92-17.17]. When stratified by diabetes subgroup, prevalence was 6.62% (5.69-7.55) for SIDD, 5.25% (4.52-5.97) for MOD, 2.39% (1.95-2.83) for MARD, and 1.27% (1.00-1.54) for SIRD. SIDD and MOD clustered in Southern Mexico, whereas MARD and SIRD clustered in Northern Mexico and Mexico City. Each standard deviation increase in DISLI was associated with higher odds of SIDD (OR: 1.12, 95% CI: 1.06-1.12) and lower odds of MOD (OR: 0.93, 0.88-0.99). Speaking an indigenous language was associated with higher odds of SIDD (OR: 1.35, 1.16-1.57) and lower odds of MARD (OR 0.58, 0.45-0.74). Interpretation: Diabetes prevalence in Mexico is rising in the context of regional and sociodemographic inequalities across distinct diabetes subgroups. SIDD is a subgroup of concern that may be associated with inadequate diabetes management, mainly in marginalized states. Funding: This research was supported by Instituto Nacional de Geriatría in Mexico.

Individualized HbA1c target selection and achievement in the Multinational Observational Study Assessing Insulin Use (MOSA1c) type 2 diabetes study.

AIM: To identify which individual-, physician-, and the healthcare system-related factors can predict individualized hemoglobin A1c (HbA1c) targets and the likelihood of reaching those targets after initial insulin therapy over a two-year follow-up period. METHODS: Real-world data, including baseline characteristics of people with type 2 diabetes mellitus (T2DM), psychosocial data, and diabetes medication use, collected from the Multinational Observational Study Assessing Insulin Use (MOSA1c) study in 18 countries were analyzed. RESULTS: Overall, 225 of 1194 people with T2DM (18.8%) who received initial insulin therapy for ≥3 months reached HbA1c targets at two-year follow-up; most were likely to be White (64.9%) and perceptions of their relationship with physicians were less positive than those who did not reach HbA1c targets. Higher baseline HbA1c (>8%) was the strongest predictor of being assigned an HbA1c target >7% (odds ratio [OR] 6.06, 95% confidence interval [CI] 3.97, 9.26). A smaller difference between baseline and target HbA1c levels was the strongest predictor of reaching an HbA1c target at two-year follow-up (large vs small difference, OR 0.28, 95% CI 0.17, 0.47). CONCLUSIONS: Several factors were significantly associated with establishing individualized HbA1c targets and reaching these targets. A small proportion of people with T2DM on insulin therapy reached their HbA1c target. Personalized management of glycemic targets necessitates the adoption of multi-factorial strategies, as several factors could influence an individual's glycemic outcome. CLINICALTRIALS. GOV IDENTIFIER: NCT01400971.

Impact of Monthly A1C Values Obtained at Home on Glycemic Control in Patients With Type 2 Diabetes: A Randomized Clinical Trial.

The purpose of this randomized controlled clinical trial was to determine whether an A1C value obtained at home by participants followed by a phone discussion of the result with a clinician would lead to 1) a more rapid and significant decrease in A1C, 2) more effective advancement of diabetes treatment, and 3) improvement in diabetes self-care behaviors. The study included 307 participants with type 2 diabetes, most of whom were of Latino origin. All study participants experienced a statistically significant reduction in mean A1C (control subjects -0.3%, P = 0.04; intervention subjects -0.5%, P = 0.0002), but there was a statistically significant difference in the number of people who achieved a reduction of ≥0.5% by 6 months, favoring the intervention (33.6 vs. 46.7%, P = 0.05).

Genetic Ancestry Markers and Difference in A1c Between African American and White in the Diabetes Prevention Program.

Purpose: HbA1c levels are higher in blacks than non-Hispanic whites (NHWs). We investigated whether genetics could explain this difference in Diabetes Prevention Program (DPP) participants. Methods: We tested (i) genetic variants causing hemoglobinopathies, (ii) a genetic risk score (GRS) based on 60 variants associated with HbA1c from genome-wide association meta-analysis, and (iii) principal component (PC) factors that capture continental ancestry derived from genetic markers distributed across the genome. Results: Of 2658 eligible DPP participants, 537 (20%) self-identified as black and 1476 (56%) as NHW. Despite comparable fasting and 2-hour glucose levels, blacks had higher HbA1c (mean ± SD = 6.2 ± 0.6%) compared with NHWs (5.8 ± 0.4%; P < 0.001). In blacks, the genetic variant causing sickle cell trait was associated with higher HbA1c [ß (SE) = +0.44 (0.08)%; P = 2.1 × 10-4]. The GRS was associated with HbA1c in both blacks and NHWs. Self-identified blacks were distributed along the first PC axis, as expected in mixed ancestry populations. The first PC explained 60% of the 0.4% difference in HbA1c between blacks and NHWs, whereas the sickle cell variant explained 16% and GRS explained 14%. Conclusions: A large proportion of HbA1c difference between blacks and NHWs was associated with the first PC factor, suggesting that unidentified genetic markers influence HbA1c in blacks in addition to nongenetic factors.

A multinational observational study assessing insulin use: Understanding the determinants associated with progression of therapy.

AIMS: To describe global patterns of insulin treatment and to assess the impact of patient, provider, health system and economic influences on treatment decisions for patients with insulin-treated type 2 diabetes (T2D). METHODS: This prospective cohort study of insulin-treated patients with T2D was conducted across 18 countries categorized as high, upper-middle or lower-middle income regions. Information collected from patients included knowledge of diabetes, experiences and interactions with their healthcare provider. Physician information included specialty, practice size, availability of diabetes support services, volume of diabetes patients treated and time spent per patient. Physicians determined an individualized haemoglobin A1c (HbA1c) target for each patient by the start of the study. Changes in T2D therapies and HbA1c were recorded for 2 years. RESULTS: Complete treatment data were available for 2528 patients. Median age was 61 years and median duration of diabetes was 11.4 years. Changes to treatment regimen occurred in 90.0% of patients, but changes were less common in countries with a higher economic status (P < 0.001). Most treatment changes involved insulin, with changes in dose the most common. Overall predictors of change in insulin therapy included younger age, use of any insulin regimen other than basal only, higher mean baseline HbA1c and longer duration of T2D. HbA1c levels remained constant regardless of regional economic status. At baseline, 20.6% of patients were at their HbA1c target; at 2 years this was 26.8%. CONCLUSIONS: Among insulin-treated patients with T2D, treatment changes were common; however, only approximately one-fourth of individuals achieved their HbA1c target.

The "A to Z" of Managing Type 2 Diabetes in Culturally Diverse Populations.

Type 2 diabetes affects racial/ethnic minorities at an alarming rate in the US and in many countries around the world. The quality of health care provided to these groups is often suboptimal, resulting in worse patient-related outcomes when compared to those in mainstream populations. Understanding the complex biological elements that influence the development and course of the disease in high-risk populations is extremely important but often insufficient to implement effective prevention and treatment plans. Multiple factors must be addressed in routine diabetes clinical care. This paper discusses various key factors, organized in alphabetical order. These are acculturation, biology, clinician's cultural awareness, depression and diabetes-specific emotional distress, educational level, fears, group integration, health literacy, intimacy and sexual dysfunction, judging, knowledge of the disease, language, medication adherence, nutritional preferences, other forms of medicine (alternative), perception of body image, quality of life, religion and faith, socio-economic status, technology, unconscious bias, vulnerable groups, asking why?, exercise, "you are in charge" and zip it! Considering these factors in the development of type 2 diabetes prevention and treatment programs will help improve diabetes-related outcomes in culturally diverse populations and reduce health care disparities.

Long-term studies of treatments for type 2 diabetes.

There is a relative lack of long-term data for individual glucose-lowering therapies for the treatment of type 2 diabetes mellitus. A systematic search of published literature reporting data of approximately ≥3 years of follow-up from randomized controlled trials and their extensions was conducted. Trials to evaluate the efficacy and/or safety of glucose-lowering drugs currently approved for the treatment of adults with type 2 diabetes were included. Search results included long-term published data for traditional oral glucose-lowering drugs, insulin, α-glucosidase inhibitors, and incretin-based therapies. In general, results indicated that the short-term risk/benefit profile of these therapies is in line with longer-term evaluations. Individual results from these trials are reviewed in this report. These findings support the use of approved drug classes for longer-term treatment of type 2 diabetes.

Linagliptin plus metformin in patients with newly diagnosed type 2 diabetes and marked hyperglycemia.

OBJECTIVES: Few studies of oral glucose-lowering drugs exist in newly diagnosed type 2 diabetes (T2D) patients with marked hyperglycemia, and insulin is often proposed as initial treatment. We evaluated the oral initial combination of metformin and linagliptin, a dipeptidyl peptidase-4 inhibitor, in this population. METHODS: We performed a pre-specified subgroup analysis of a randomized study in which newly diagnosed T2D patients with glycated hemoglobin A1c (HbA1c) 8.5%-12.0% received linagliptin/metformin or linagliptin monotherapy. Subgroups of baseline HbA1c, age, body-mass index (BMI), renal function, race, and ethnicity were evaluated, with efficacy measured by HbA1c change from baseline after 24 weeks. RESULTS: HbA1c reductions from baseline (mean 9.7%) at week 24 in the overall population were an adjusted mean -2.81% ± 0.12% with linagliptin/metformin (n = 132) and -2.02% ± 0.13% with linagliptin (n = 113); treatment difference -0.79% (95% CI -1.13 to -0.46, P < 0.0001). In patients with baseline HbA1c ≥9.5%, HbA1c reduction was -3.37% with linagliptin/metformin (n = 76) and -2.53% with linagliptin (n = 61); difference -0.84% (95% CI -1.32 to -0.35). In those with baseline HbA1c <9.5%, HbA1c reduction was -2.08% with linagliptin/metformin (n = 56) and -1.39% with linagliptin (n = 52); difference -0.69% (95% CI -1.23 to -0.15). Changes in HbA1c and treatment differences between the linagliptin/metformin and linagliptin groups were of similar magnitudes to the overall population across patient subgroups based on age, BMI, renal function, and race. Drug-related adverse events occurred in 8.8% and 5.7% of linagliptin/metformin and linagliptin patients, respectively; no severe hypoglycemia occurred. CONCLUSION: Linagliptin/metformin combination in newly diagnosed T2D patients with marked hyperglycemia was well tolerated and elicited substantial improvements in glycemic control regardless of baseline HbA1c, age, BMI, renal function, or race. Thus, newly diagnosed, markedly hyperglycemic patients may be effectively treated by combinations of oral agents. CLINICAL TRIAL REGISTRATION: www.clinicaltrials.gov identifier is NCT01512979.

Severe Ketoacidosis (pH ≤ 6.9) in Type 2 Diabetes: More Frequent and Less Ominous Than Previously Thought.

Diabetic ketoacidosis is a life-threatening acute metabolic complication of uncontrolled diabetes. Severe cases of DKA (pH ≤ 7.00, bicarbonate level ≤ 10.0, anion gap > 12, positive ketones, and altered mental status) are commonly encountered in patients with type 1 diabetes and are thought to carry an ominous prognosis. There is not enough information on the clinical course of severely acidotic type 2 diabetes (pH ≤ 6.9) patients with DKA, possibly because this condition is rarely seen in developed countries. In this series, we present 18 patients with type 2 diabetes, DKA, and a pH ≤ 6.9 that presented to a tertiary university hospital over the past 11 years. The objective was to describe their clinical characteristics, the triggering cause, and emphasis on treatment, evolution, and outcomes. The majority of the patients were female (61%). Mean age was 40.66 years (23-59). The patients had been first diagnosed with type 2 diabetes on average 5.27 ± 3.12 years before admission. Glutamic acid decarboxylase (GAD65) antibodies were negative in all patients. The origin of DKA could be attributed to two main causes: treatment omission in 8 (44.4%) patients and infections in 7 (38.8%) patients. The most common symptoms described were general malaise, dyspnea, altered mental status, and abdominal pain. Mean serum glucose on admission was 613.8 ± 114.5 mg/dL. Mean venous pH was 6.84 ± 0.03 with an anion gap of 30.3 ± 2.9 and a venous HCO3 level of 3.62 ± 1.35 mmol/L. All patients had acute renal failure on admission, with a mean serum creatinine of 1.57 ± 0.35 mg/dL compared to 0.55 ± 0.21 mg/dL at discharge. All patients received regular insulin infusion, aggressive fluid repletion, and 12 patients (66%) received bicarbonate infusion. Mean total insulin infusion dose was 181.7 ± 90.4 U (on average 0.14 ± 0.05 U/Kg/h). Mean time on infusion was 24.4 ± 12.6 hours. We recorded no mortality in this case series. Mean in-hospital stay was 5.0 ± 4.1 days. In conclusion, very severe DKA in type 2 diabetes is not uncommon in our population, shares many features with non-very-severe cases of DKA (bicarbonate therapy did not make a difference in mortality), and can be managed following standard published or institutional guidelines.

Cardiorenal metabolic syndrome and cardiometabolic risks in minority populations.

Cardiovascular disease (CVD), including heart disease and stroke, is the leading cause of death in the USA, regardless of self-determined race/ethnicity, and largely driven by cardiometabolic risk (CMR) and cardiorenal metabolic syndrome (CRS). The primary drivers of increased CMR include obesity, hypertension, insulin resistance, hyperglycemia, dyslipidemia, chronic kidney disease as well as associated adverse behaviors of physical inactivity, smoking, and unhealthy eating habits. Given the importance of CRS for public health, multiple stakeholders, including the National Minority Quality Forum (the Forum), the American Association of Clinical Endocrinologists (AACE), the American College of Cardiology (ACC), and the Association of Black Cardiologists (ABC), have developed this review to inform clinicians and other health professionals of the unique aspects of CMR in racial/ethnic minorities and of potential means to improve CMR factor control, to reduce CRS and CVD in diverse populations, and to provide more effective, coordinated care. This paper highlights CRS and CMR as sources of significant morbidity and mortality (particularly in racial/ethnic minorities), associated health-care costs, and an evolving index tool for cardiometabolic disease to determine geographical and environmental factors. Finally, this work provides a few examples of interventions potentially successful at reducing disparities in cardiometabolic health.

Bodily aesthetic ideals among Latinas with type 2 diabetes: implications for treatment adherence, access, and outcomes.

PURPOSE: The purpose of this study was to examine how attitudes and practices related to bodily aesthetic ideals and self-care might inform the engagement of Latinas with type 2 diabetes (T2DM). METHODS: Focus groups were used to collect qualitative data concerning bodily aesthetic ideals and diabetes management, including help-seeking experiences, from Latina women with T2DM (n = 29) receiving care through Latino Diabetes Initiative at the Joslin Diabetes Center. Focus groups were conducted in Spanish, audiotaped, transcribed, and content analyzed. RESULTS: Four main themes emerged: (1) a preference among participants for a larger than average body size, although perceptions of attractiveness were more closely linked to grooming than body size; bodily dissatisfaction centered on diabetes-induced skin changes, virilization, and fatigue rather than weight; (2) diabetic complications, especially foot pain, as a major obstacle to exercise; (3) fatalistic attitudes regarding the inevitability of diabetes and reversal of its complications; and (4) social burdens, isolation, and financial stressors as contributing to disease exacerbation. CONCLUSIONS: Interventions that emphasize reduced body size may be less effective with Latinas who have T2DM than those that emphasize the benefits of exercise and weight loss for skin health, energy levels, and reduced virilization.

Previously unrecognized trends in diabetes consumption clusters in medicare.

OBJECTIVE: To examine the annual cost profiles of Medicare beneficiaries with diabetes to identify patterns in their consumption of benefits. METHODS: Retrospective expenditure data were collected from Medicare records. Beneficiaries with diabetes were grouped into 5 consumption clusters ranging from "crisis consumers" at the high end to "low consumers" at the low end. RESULTS: The percentages of beneficiaries and expenditures for the consumption clusters remained generally constant from year to year. As expected, most of Medicare's budget each year was spent on crisis, heavy, and moderate consumers. However, a notable proportion of low and light consumers from one year go on to become crisis and heavy consumers in subsequent years. A review of total 2001 through 2006 inpatient costs for the year 2000 clusters revealed that 47% of these costs were for year 2000 low and light consumers and only 27% were for year 2000 crisis and heavy consumers. CONCLUSIONS: This analysis revealed previously unrecognized trends, whereby a notable proportion of low and light consumers during one year went on to become crisis and heavy consumers in subsequent years, representing a large proportion of inpatient costs. These findings have important implications for disease management programs, which typically focus intervention efforts exclusively on crisis and heavy consumers.

Food purchasing selection among low-income, Spanish-speaking Latinos.

BACKGROUND: In the U.S., poverty has been linked to both obesity and disease burden. Latinos in the U.S. are disproportionately affected by poverty, and over the past 10 years, the percentage of overweight U.S. Latino youth has approximately doubled. Buying low-cost food that is calorie-dense and filling has been linked to obesity. Low-income individuals tend to favor energy-dense foods because of their low cost, and economic decisions made during food purchasing have physiologic repercussions. Diets based on energy-dense foods tend to be high in processed staples, such as refined grains, added sugars, and added fats. These diets have been linked to a higher risk of obesity, type 2 diabetes, and cardiovascular disease. PURPOSE: This pilot study conducted ethnographic qualitative analyses combined with quantitative analyses to understand grocery shopping practices among 20 Spanish-speaking, low-income Latino families. The purpose was to analyze food selection practices in order to determine the effect of nutrition education on changes in shopping practices to later develop educational tools to promote selection of healthier food options. METHODS: Participants received tailored, interactive, nutrition education during three to five home visits and a supermarket tour. Grocery store receipts for grocery purchases collected at baseline and at the end of the project were analyzed for each family to extract nutritional content of purchased foods. Nutritional content was measured with these factors in mind: quantity, calories, fats, carbohydrates, fiber, protein, and percentage of sugary beverages and processed food. Data were collected in 2010-2011 and analyzed in 2011-2012. RESULTS: After receiving between three and five home-based nutrition education sessions and a supermarket tour over a 6-month period, many families adopted instructions on buying budget-friendly, healthier alternative foods. Findings indicate that participating families decreased the total number of calories and calories per dollar purchased from baseline to post-education (median total calories: baseline, 20,191; post-education, 15,991, p=0.008); median calories per dollar: baseline, 404; post-education, 320, p=0.008). The median grams of carbohydrates per dollar (baseline, 66, post-education, 45) and median calories from processed food (baseline, 11,000, post-education, 7845) were not reduced (p=0.06). CONCLUSIONS: This pilot study demonstrated that grocery shopping practices are an important factor to address in nutrition education among Spanish-speaking, low-income individuals, and that there may be ways to encourage low-income, Latino families to purchase healthier foods. Findings challenged arguments suggesting that such an approach is not possible because of the high cost of healthier foods.

Do older adults aged 60-75 years benefit from diabetes behavioral interventions?

OBJECTIVE: In this secondary analysis, we examined whether older adults with diabetes (aged 60-75 years) could benefit from self-management interventions compared with younger adults. Seventy-one community-dwelling older adults and 151 younger adults were randomized to attend a structured behavioral group, an attention control group, or one-to-one education. RESEARCH DESIGN AND METHODS: We measured A1C, self-care (3-day pedometer readings, blood glucose checks, and frequency of self-care), and psychosocial factors (quality of life, diabetes distress, frustration with self-care, depression, self-efficacy, and coping styles) at baseline and 3, 6, and 12 months postintervention. RESULTS: Both older (age 67 ± 5 years, A1C 8.7 ± 0.8%, duration 20 ± 12 years, 30% type 1 diabetes, 83% white, 41% female) and younger (age 47 ± 9 years, A1C 9.2 ± 1.2%, 18 ± 12 years with diabetes, 59% type 1 diabetes, 82% white, 55% female) adults had improved A1C equally over time. Importantly, older and younger adults in the group conditions improved more and maintained improvements at 12 months (older structured behavioral group change in A1C -0.72 ± 1.4%, older control group -0.65 ± 0.9%, younger behavioral group -0.55 ± 1.2%, younger control group -0.43 ± 1.7%). Furthermore, frequency of self-care, glucose checks, depressive symptoms, quality of life, distress, frustration with self-care, self-efficacy, and emotional coping improved in older and younger participants at follow-up. CONCLUSIONS: The findings suggest that, compared with younger adults, older adults receive equal glycemic benefit from participating in self-management interventions. Moreover, older adults showed the greatest glycemic improvement in the two group conditions. Clinicians can safely recommend group diabetes interventions to community-dwelling older adults with poor glycemic control.

Impact of race/ethnicity on efficacy and safety of two starter insulin regimens in patients with type 2 diabetes: a posthoc analysis of the DURABLE trial.

OBJECTIVE: To explore the impact of race/ethnicity on efficacy and safety of twice-daily insulin lispro mix 75/25 (LM75/25; 75% lispro protamine suspension, 25% insulin lispro) and once daily insulin glargine (GL). DESIGN, SETTING, PATIENTS: More than 2,000 Patients with type 2 diabetes enrolled in the 24-week initiation phase of the DURABLE Trial. MAIN OUTCOME MEASURES: Efficacy and safety variables at endpoint, including hemoglobin A1c (HbA1c), self-monitored plasma glucose (SMPG), and hypoglycemia, in each racial/ethnic group were compared to Caucasians within treatment groups. RESULTS: Asian patients had less (LM75/25: -1.46%, P < .01; GL: -1.25%, P < .01) and Hispanic patients had greater (LM75/25: -2.17%) HbA1c reduction from baseline vs Caucasian patients (LM75/25: -1.84%; GL: -1.78%). Fewer Asian (LM75/25: 20%, P < .001; GL: 22%, P < .001) and Hispanic patients (LM75/25: 40%, P < .01) reached HbA1c target (< 7%) vs Caucasian patients (LM75/25: 53%; GL: 44%). Fasting plasma glucose was similar among groups, postprandial glucose (PPG) with GL was lower for African patients post-breakfast and post-dinner and higher for Asian patients post-lunch. Only PPG with LM75/25 was lower for Hispanic patients post-breakfast. Weight gain was lower in Asian patients (LM75/ 25). Insulin dose was higher for Asian (LM75/25 and GL) and lower for African patients (GL). Hypoglycemia rate was lower for Asian (LM75/25 and GL) and Hispanic patients (LM75/25). CONCLUSIONS: There were significant efficacy and safety differences among racial/ethnic groups in the DURABLE trial. These differences may be important in designing insulin based treatment plans.

The effect of a structured behavioral intervention on poorly controlled diabetes: a randomized controlled trial.

BACKGROUND: Although maintaining nearly normal glycemia delays onset and slows progression of diabetes complications, many patients with diabetes and their physicians struggle to achieve glycemic targets. The best methods to support patients as they follow diabetes prescriptions and recommendations are unclear. METHODS: To test the efficacy of a behavioral diabetes intervention in improving glycemia in long-duration, poorly controlled diabetes, we randomized 222 adults with diabetes (49% type 1) (mean [SD] age, 53 [12] years; mean [SD] disease duration 18 [12] years; mean [SD] hemoglobin A(1c) [HbA(1c)] concentration, 9.0% [1.1%]) to attend (1) a 5-session manual-based, educator-led structured group intervention with cognitive behavioral strategies (structured behavioral arm); (2) an educator-led attention control group education program (group attention control); or (3) unlimited individual nurse and dietitian education sessions for 6 months (individual control). Outcomes were baseline and 3-, 6-, and 12-month postintervention HbA(1c) levels (primary) and frequency of diabetes self-care, 3-day pedometer readings, 24-hour diet recalls, average number of glucose checks, physical fitness, depression, coping style, self-efficacy, and quality of life (secondary). RESULTS: Linear mixed modeling found that all groups showed improved HbA(1c) levels (P < .001). However, the structured behavioral arm showed greater improvements than the group and individual control arms (3-month HbA(1c) concentration changes: -0.8% vs -0.4% and -0.4%, respectively (P = .04 for group × time interaction). Furthermore, participants with type 2 disease showed greater improvement than those with type 1 (P = .04 for type of diabetes × time interaction). Quality of life, glucose monitoring, and frequency of diabetes self-care did not differ by intervention over time. CONCLUSIONS: A structured, cognitive behavioral program is more effective than 2 control interventions in improving glycemia in adults with long-duration diabetes. Educators can successfully use modified psychological and behavioral strategies. TRIAL REGISTRATION: clinicaltrials.gov Identifier: NCT000142922.