When does personalized feedback make a difference? A narrative review of recent findings and their implications for promoting better diabetes self-care

Determinants of physical activity in newly diagnosed obstructive sleep apnea patients: testing the health action process approach

This study aims to identify the determinants associated with physical activity (PA) behavior in newly diagnosed obstructive sleep apnea (OSA) patients by applying the Health Action Process Approach (HAPA) with a longitudinal design. Anthropometric and clinical (OSA severity, subjective somnolence, use of continuous positive airway pressure (CPAP)) variables, the determinants of physical activity specified in the HAPA (motivational self-efficacy, outcome expectancies, risk perception, intention, maintenance self-efficacy, action planning, coping planning, social support), as well as physical activity behavior were assessed using a longitudinal (T1 and T2) design in a sample of 57 OSA patients in routine care. Applying regression analyses, regarding the motivation phase, the amount of explained variance in intention was 77% and 39% of the variance in physical activity. In the motivational phase, motivational self-efficacy, risk perception and outcome expectancies were associated with intention. In the volitional phase, physical activity at T1 and social support (family) were related with physical activity at T2. In conclusion, the assumptions of HAPA were partially found in the context of newly diagnosed OSA patients. This study provided additional evidence regarding the role of motivational self-efficacy, outcome expectancies and risk perception during motivational phase, and highlighted the important role of social support from the family in the PA in this population.

Can a Basic Management App Paired With A Glucose Meter Help Reduce Glucose Levels Among Adults With Type 2 Diabetes? The REALL Study

OBJECTIVE

Evaluations of technology to help adults manage type 2 diabetes (T2D) have yielded mixed results. We analyzed the effectiveness of a free app linked to a glucose meter to study reductions in glucose levels over time among a self-selected sample of adults with T2D.

RESEARCH DESIGN AND METHODS

Adults with T2D >12 months, >21 years, ability to read English (insulin using-IU and non-insulin using-NIU) who independently elected to pair their CONTOUR NEXT ONE meter with the CONTOUR DIABETES App were invited to participate. Glucose data from baseline to 16 weeks were uploaded to the cloud (N = 461). Assessment of diabetes distress, medication taking, quality of life, and hypoglycemia concerns occurred at baseline, six, and 16 weeks.

RESULTS

Findings indicated a significant decrease in weekly glucose levels over time: baseline mean = 169 (62.0) (9.4 mmol/L; 3.44); 16-week mean = 146.5 (36.0) (8.1 mmol/L; 2.0) (P < .001), with no IU and NIU differences. Largest reductions occurred during the first six weeks, with no later rebound effects. Significant, though modest, improvements in global quality of life (P = .03), hypoglycemia concerns (P = .01), and diabetes distress (P < .001) occurred over 16 weeks.

CONCLUSIONS

Making an App for monitoring glucose easily available for download with a glucose meter can be helpful for self-selected adults with T2D. Effective utilization assumes that users are sufficiently motivated and engaged, are comfortable and trusting of the technology, and have sufficient knowledge of how to make use of the glucose data.

Fukushima study for Engaging people with type 2 Diabetes in Behaviour Associated Change (FEEDBACK): study protocol for a cluster randomised controlled trial

BACKGROUND

The growing burden of type 2 diabetes mellitus (T2DM) and the rising cost of healthcare worldwide make it imperative to identify interventions that can promote sustained self-management behaviour in T2DM populations while minimising costs for healthcare systems. The present FEEDBACK study (Fukushima study for Engaging people with type 2 Diabetes in Behaviour Associated Change) aims to evaluate the effects of a novel behaviour change intervention designed to be easily implemented and scaled across a wide range of primary care settings.

METHODS

A cluster randomised controlled trial (RCT) with a 6-month follow-up will be conducted to evaluate the effects of the FEEDBACK intervention. FEEDBACK is a personalised, multi-component intervention intended to be delivered by general practitioners during a routine diabetes consultation. It consists of five steps aimed at enhancing doctor-patient partnership to motivate self-management behaviour: (1) communication of cardiovascular risks using a 'heart age' tool, (2) goal setting, (3) action planning, (4) behavioural contracting, and (5) feedback on behaviour. We aim to recruit 264 adults with T2DM and suboptimal glycaemic control from 20 primary care practices in Japan (cluster units) that will be randomly assigned to either the intervention or control group. The primary outcome measure will be the change in HbA1c levels at 6-month follow-up. Secondary outcome measures include the change in cardiovascular risk score, the probability to achieve the recommended glycaemic target (HbA1c <7.0% [53mmol/mol]) at 6-month follow-up, and a range of behavioural and psychosocial variables. The planned primary analyses will be carried out at the individual level, according to the intention-to-treat principle. Between-group comparisons for the primary outcome will be analysed using mixed-effects models. This study protocol received ethical approval from the research ethics committee of Kashima Hospital, Fukushima, Japan (reference number: 2022002).

DISCUSSION

This article describes the design of a cluster RCT that will evaluate the effects of FEEDBACK, a personalised, multicomponent intervention aimed at enhancing doctor-patient partnership to engage adults with T2DM more effectively in self-management behaviour.

TRIAL REGISTRATION

The study protocol was prospectively registered in the UMIN Clinical Trials Registry (UMIN-CTR ID UMIN000049643 assigned on 29/11/2022). On submission of this manuscript, recruitment of participants is ongoing.

How Frequently and for How Long Do Adults With Type 2 Diabetes Use Management Apps? The REALL Study

OBJECTIVE

The objective of the study is to identify predictors of utilization of a type 2 diabetes (T2D) management App over time for insulin users (IUs) and noninsulin users (NIUs).

RESEARCH DESIGN AND METHODS

We followed over 16 weeks a national sample of unselected T2D adults who independently elected to download and pair a CONTOUR DIABETES App with their CONTOUR NEXT ONE glucose meter. App use and frequency of glucose testing were recorded. Baseline surveys recorded participant demographic, disease status, distress, medication taking, and views of technology to predict utilization.

RESULTS

Mean age was 51.6 years (108 IUs; 353 NIUs), 48% were female, time with diabetes was 6.9 years, and self-reported HbA1c was 8.1% (36.3 mmol/mol). Mean duration of App use was 85.4 days and 40% stopped using the App before 16 weeks. Continuous users were older and reported higher distress, better medication taking, and more positive attitudes toward technology (all P < .01). IUs tested more frequently than NIUs, but frequency and intensity of testing decreased markedly for both groups over time. More predictors of App use frequency and testing occurred for NIUs than IUs: older age, higher HbA1c, lower distress, more medication taking (all P < .05).

CONCLUSIONS

App use and testing decreased markedly over time. Variations in the predictors of frequency of App use suggest that the utilization of mobile technologies requires a tailored approach that addresses the specific needs of individual users, compared with adopting a one-size-fits-all strategy, and that IUs and NIUs may require very different strategies of customization.

The AH-HA! Project: Transforming Group Diabetes Self-Management Education Through the Addition of Flash Glucose Monitoring

Background: The majority of individuals referred to diabetes self-management education and support (DSMES) programs do not access this resource. Of those who do, attrition is high, with anecdotal reports pointing to the didactic and impersonal nature of these programs contributing to low utilization and completion rates. In an effort to develop a more engaging form of DSMES for adults with type 2 diabetes (T2D), we constructed a nondidactic "discovery learning"-based DSMES program centered on real-time flash glucose monitoring (FGM). Methods: In this single-arm pilot study, 35 adults with T2D duration 1-5 years, ages 21-75 years, not using insulin and HbA1c ≥8.0% were introduced to FGM and participated in five weekly group sessions. DSMES content was personalized, emerging from the concerns and questions arising from participants' FGM discoveries. The primary outcome was glycemic change as assessed by blinded FGM at baseline and month 3. Secondary outcomes included psychosocial and behavioral measures. Results: There was a significant gain in percentage time in range (% TIR) 70-180 mg/dL from baseline (55%) to month 3 (74%), and a parallel drop-in percentage time above range (TAR) >180 mg/dL from 44% to 25% (Ps = 0.01). Overall well-being rose significantly (P = 0.04), whereas diabetes distress showed a nonsignificant drop. Participants reported improvements in healthy eating (P < 0.001) and physical activity, although the latter did not reach statistical significance. Conclusions: These findings support a new approach to DSMES, a method that integrates FGM with a highly interactive and engaging patient-driven "discovery learning" approach to education.

An individualized mobile health intervention to promote physical activity in adults with obstructive sleep apnea: An intervention mapping approach

Objective

Combining continuous positive airway pressure with physical activity (PA) might be a promising strategy to treat obstructive sleep apnea (OSA). This article describes how intervention mapping (IM) can guide the development, content, and mechanisms of action of a mobile application to promote PA in adults with OSA.

Methods

To develop the program, the IM approach was followed. This article presents the first three steps of IM to develop a mixed intervention (with interventionists and a digital application) aiming to: (1) assess patients' health problems and needs in a literature review to determine their expectations and perceived facilitators and barriers to PA behavior change and thus select the determinants of behavior; (2) formulate the expected intervention outcomes and objectives to be met to achieve the overall program goals; and (3) select and implement the behavior change techniques (BCTs) to achieve the change objectives.

Results

The literature review identified the relevant determinants (e.g., self-efficacy, coping, planning, and habit) of PA behavior using the health action process approach and multiprocess action control. These results were used to specify the program outcomes for PA adapted to physical, psychological, and social parameters. Overall, 11 performance objectives and 30 change objectives were defined. Lastly, BCTs and practical applications were identified.

Conclusions

The study provides a theoretical and methodological basis for researchers and practitioners given the current paucity of evidence-based PA interventions for adults with OSA. It addresses the lack of BCTs (framing and prompts/cue techniques) and meaningful behavioral determinants (identity and habit) in most interventions.

The Role of Retrospective Data Review in the Personal Use of Real-Time Continuous Glucose Monitoring: Perceived Impact on Quality of Life and Health Outcomes

Background: To explore whether regularly reviewing one's own retrospective continuous glucose monitoring (CGM) data might be linked with perceived quality of life (QoL) and glycemic benefits. Methods: Adults with type 1 diabetes (N = 300) or insulin-using type 2 diabetes (N = 198) using the Dexcom G5 Mobile or G6 Real-Time CGM (RT-CGM) system and receiving the weekly CLARITY summary report of their glucose data completed a survey exploring their use of the report and its perceived value and impact on QoL and glycemic outcomes. Regression analyses examined whether personal use of the report was associated with QoL, perceived glycemic outcomes, and RT-CGM metrics. Results: The majority reported that receiving and viewing the report contributed to improved hypoglycemic confidence (75.9%) and overall well-being (50.0%), reduced diabetes distress (59.3%-74.1%), and helped to improve A1C (73.1%) and reduce problems with hypoglycemia (61.8%) and chronic hyperglycemia (73.1%). Regularly reviewing the report with family or friends (positive predictor) and doing nothing with the report's information (negative predictor) were independently associated with QoL and perceived glycemic outcomes. Surprisingly, both predictors were also associated with poorer glycemic control (e.g., greater % time above range >180). Conclusions: These findings suggest that receiving a weekly RT-CGM summary report may contribute to QoL and health benefits, especially if the individual chooses to actively review and make use of the report's findings and openly reviews the findings with family or friends. Prospective studies are needed to more precisely determine how retrospective RT-CGM data summaries can best be presented and utilized effectively by adults with diabetes to enhance health outcomes.

A Telehealth Diabetes Intervention for Rural Populations: Protocol for a Randomized Controlled Trial

Background

Diabetes self-management education and support (DSMES) is a crucial component of diabetes care associated with improved clinical, psychosocial, and behavioral outcomes. The American Association of Diabetes Care and Education Specialists, the American Diabetes Association, and the American Academy of Family Physicians all recommend DSMES yet accessing linguistically and culturally appropriate DSMES is challenging in rural areas. The Diabetes One-Day (D1D) program is an established DSMES group intervention that has not been adapted or evaluated in rural communities.

Objective

The specific aims of this paper are (1) to adapt the existing D1D program for use in rural communities, called rural D1D (R-D1D); and (2) to conduct a patient-level randomized controlled trial to examine the effects of R-D1D and standard patient education, guided by the Reach, Effectiveness, Adoption, Implementation, and Maintenance framework.

Methods

This is a protocol for a pilot type II hybrid implementation-effectiveness trial of a culturally adapted virtual DSMES program for rural populations, R-D1D. We will use Boot Camp Translation, a process grounded in the principles of community-based participatory research, to adapt an existing DSMES program for rural populations, in both English and Spanish. Participants at 2 rural primary care clinics (4 cohorts of N=16 plus care partners, 2 in English and 2 in Spanish) will be randomized to the intervention or standard education control. The evaluation is guided by the Reach, Effectiveness, Adoption, Implementation, and Maintenance framework. Patient-level effectiveness outcomes (hemoglobin A_1c, diabetes distress, and diabetes self-care behaviors) will be assessed using patient-reported outcomes measures and a home A_1c test kit. Practice-level and patient-level acceptability and feasibility will be assessed using surveys and interviews.

Results

This study is supported by the National Institute of Nursing. The study procedures were approved, and the adaptation processes have been completed. Recruitment and enrollment started in July 2021.

Conclusions

To our knowledge, this will be the first study to evaluate both effectiveness and implementation outcomes for virtually delivered DSMES, culturally adapted for rural populations. This research has implications for delivery to other rural locations where access to specialty diabetes care is limited.

Trial Registration

ClinicalTrials.gov NCT04600622; https://clinicaltrials.gov/ct2/show/NCT04600622

International Registered Report Identifier (IRRID)

DERR1-10.2196/34255

Socio-cognitive determinants affecting insulin adherence/non-adherence in late adolescents and young adults with type 1 diabetes: a systematic review protocol

Objective

This systematic review aims to investigate the key socio-cognitive determinants associated with adherence/non-adherence to insulin treatment in late adolescents and young adults in the age range of 17–24 years with T1D.

Methods

A pre-specified search strategy will be used to search for studies in the electronic databases and citation indexes: PubMed, EMBASE, Web of Science, and PsycINFO. Two researchers will screen the title and the abstract independently, then will read and critically appraise the full text of each included study. A third independent reviewer will resolve disagreements in data extraction until consensus. Data will be extracted using the Population, Exposure, Outcomes, Study characteristics framework. Study selection will follow the updated guideline for reporting systematic reviews (PRISMA 2020) and will take place from 15 October 2021 to 1 January 2022. The methodological quality and risk of bias of the observational studies will be assessed by the JBI Critical Appraisal Checklist for Cohort and JBI Critical Appraisal Checklist for Analytical Cross Sectional Studies.

Results

A qualitative narrative synthesis will present the characteristics and the quality of studies and the outcomes of concern.

Conclusion

Based on the contemporary literature, this review will synthesize the evidence on the socio-cognitive determinants associated with adherence/non-adherence to insulin treatment in late adolescents and young adults in the age range of 17–24 years with T1D. The findings will help design patient-centered interventions to promote adherence to insulin in this age group, guide patients’ consultations and diabetes self-management education (DSME) programs.

Protocol registration: PROSPERO ID: CRD42021233074.

A Network Analysis of the Association Between Depressive Symptoms and Patient Activation Among Those With Elevated Cardiovascular Risk

Background

Network analysis provides a new method for conceptualizing interconnections among psychological and behavioral constructs.

Objective

We used network analysis to investigate the complex associations between depressive symptoms and patient activation dimensions among patients at elevated risk of cardiovascular disease.

Methods

This secondary analysis included 200 patients seen in primary care clinics. Depressive symptoms were assessed using the 21-item Beck Depression Inventory. Patient activation was measured using the 13-item Patient Activation Measure. Glasso networks were constructed to identify symptoms/traits that bridge depressive symptoms and patient activation and those that are central within the network.

Results

“Self-dislike” and “confidence to maintain lifestyle changes during times of stress” were identified as important bridge pathways. In addition, depressive symptoms such as “punishment feelings,” “loss of satisfaction,” “self-dislike,” and “loss of interest in people” were central in the depressive symptom–patient activation network, meaning that they were most strongly connected to all other symptoms.

Conclusions

Bridge pathways identified in the network may be reasonable targets for clinical intervention aimed at disrupting the association between depressive symptoms and patient activation. Further research is warranted to assess whether targeting interventions to these central symptoms may help resolve other symptoms within the network.

Exploring the Discursive Emphasis on Patients and Coaches Who Participated in Technology-Assisted Diabetes Self-management Education: Clinical Implementation Study of Health360x

BACKGROUND

A critical unmet need for underserved patients with diabetes is regular access to sufficient support for diabetes self-management. Although advances in digital technologies have made way for eHealth applications that provide a scalable path for tailored interventions for self-management of chronic conditions, health and digital literacy has remained an obstacle to leveraging these technologies for effective diabetes self-management education. Studies have shown that the availability of coaches helps to maintain engagement in internet-based studies and improves self-efficacy for behavior change. However, little is known about the substances involved in these interactions.

OBJECTIVE

This study aims to compare the content of conversations between patient-coach pairs that achieved their self-management goals and those that did not. The context is a clinical implementation study of diabetes self-management behavior change using Health360x within the practices of the Morehouse Choice Accountable Care Organization in the Atlanta metro area. Health360x is a coach-assisted consumer health information technology designed to support self-management skills acquisition and behavior among underserved, high-risk patients with diabetes.

METHODS

We provide a novel analysis of the discursive emphasis on patients and coaches. We examined transcripts of visits using a structural topic model to estimate topic content and prevalence as a function of patient and coach characteristics. We compared topics between patient-coach pairs that achieved diabetes-related self-management goals and those who did not. We also estimated a regression in which utterances are the units, the dependent variable is the proportion of an utterance that is about a given topic, and the independent variables are speaker types and explored other themes.

RESULTS

Transcripts from 50 patients who were recruited and consented, starting in February 2015, were analyzed. A total of 44 topics were estimated for patient-coach pairs that achieved their intended health goals and 50 topics for those who did not. Analysis of the structural topic model results indicated that coaches in patient-coach pairs that were able to achieve self-management goals provided more contextual feedback and probed into patients' experience with technology and trust in consumer information technologies. We also found that discussions around problem areas and stress, support (β_Coach=.015; P<.001), initial visits (β_Coach=.02; P<.001), problems with technology (β_Coach=.01; P<.001), health eating goals (β_Coach=.01; P=.04), diabetes knowledge (β_Coach=.02; P<.001), managing blood sugar (β_Coach=.03; P<.001), and using Health360x (β_Coach=.003; P=.03) were dominated by coaches.

CONCLUSIONS

Coach-facilitated, technology-based diabetes self-management education can help underserved patients with diabetes. Our use of topic modeling in this application sheds light on the actual dynamics in conversations between patients and coaches. Knowledge of the key elements for successful coach-patient interactions based on the analysis of transcripts could be applied to understanding everyday patient-provider encounters, given the recent paradigm shift around the use of telehealth.

Including the Public in Public eHealth: The Need for Community Participation in the Development of State-Sponsored COVID-19-Related Mobile Apps

The COVID-19 pandemic has overwhelmed health care systems worldwide, particularly in underresourced communities of color with a high prevalence of pre-existing health conditions. Many state governments and health care entities responded by increasing their capacity for telemedicine and disease tracking and creating mobile apps for dissemination of medical information. Our experiences with state-sponsored apps suggest that because many of these eHealth tools did not include community participation, they inadvertently contributed to widening digital health disparities. We propose that, as eHealth tools continue to expand as a form of health care, more attention needs to be given to their equitable distribution, accessibility, and usage. In this viewpoint collaboratively written by a minority-serving community-based organization and an eHealth academic research team, we present our experience participating in a community advisory board working on the dissemination of the COVID Alert NY mobile app to illustrate the importance of public participation in app development. We also provide practical recommendations on how to involve community representatives in the app development process. We propose that transparency and community involvement in the process of app development ultimately increases buy-in, trust, and usage of digital technology in communities where they are needed most.

Game Plan-a Brief Web-Based Intervention to Improve Uptake and Use of HIV Pre-exposure Prophylaxis (PrEP) and Reduce Alcohol Use Among Gay and Bisexual Men: Content Analysis

Background

HIV pre-exposure prophylaxis (PrEP) has considerable potential for reducing incidence among high-risk groups, such as gay, bisexual, and other men who have sex with men (GBM). However, PrEP’s effectiveness is closely linked with consistent use, and a variety of individual-level barriers, including alcohol use, could impede optimal uptake and use. Web-based interventions can encourage medication adherence, HIV prevention behaviors, and responsible drinking and may help support PrEP care, particularly in resource-limited settings.

Objective

We previously developed a web application called Game Plan that was designed to encourage heavy drinking GBM to use HIV prevention methods and reduce their alcohol use and was inspired by brief motivational interventions. This paper aims to describe the web-based content we designed for integration into Game Plan to help encourage PrEP uptake and consistent use among GBM. In this paper, we also aim to describe this content and its rationale.

Methods

Similar to the original site, these components were developed iteratively, guided by a thorough user-centered design process involving consultation with subject-matter experts, usability interviews and surveys, and user experience surveys.

Results

In addition to Game Plan’s pre-existing content, the additional PrEP components provide specific, personal, and digestible feedback to users about their level of risk for HIV without PrEP and illustrate how much consistent PrEP use could reduce it; personal feedback about their risk for common sexually transmitted infections to address low-risk perceptions; content challenging common beliefs and misconceptions about PrEP to reduce stigma; content confronting familiar PrEP and alcohol beliefs; and a change planning module that allows users to select specific goals for starting and strategies for consistent PrEP use. Users can opt into a weekly 2-way SMS text messaging program that provides similar feedback over a 12-week period after using Game Plan and follows up on the goals they set.

Conclusions

Research preliminarily testing the efficacy of these components in improving PrEP outcomes, including uptake, adherence, sexually transmitted infection rates, and alcohol use, is currently ongoing. If supported, these components could provide a scalable tool that can be used in resource-limited settings in which face-to-face intervention is difficult.

Progression to unscheduled hospital admissions in people with diabetes: a qualitative interview study

BACKGROUND

People with diabetes often have difficulty maintaining optimal blood glucose levels, risking progressive complications that can lead to unscheduled care. Unscheduled care can include attending emergency departments, ambulance callouts, out-of-hours care, and non-elective hospital admissions. A large proportion of non-elective hospital admissions involve people with diabetes, with significant health and economic burden.

AIM

To identify precipitating factors influencing diabetes-related unscheduled hospital admissions, exploring potential preventive strategies to reduce admissions.

DESIGN & SETTING

Thirty-six people with type 1 (n = 11) or type 2 (n = 25) diabetes were interviewed. They were admitted to hospital for unscheduled diabetes-related care across three hospitals in Scotland, Northern Ireland, and the Republic of Ireland. Participants were admitted for peripheral limb complications (n = 17), hypoglycaemia (n = 5), hyperglycaemia (n = 6), or for comorbidities presenting with erratic blood glucose levels (n = 8).

METHOD

Factors precipitating admissions were examined using framework analysis.

RESULTS

Three aspects of care influenced unscheduled admissions: perceived inadequate knowledge of diabetes complications; restricted provision of care; and complexities in engagement with self-care and help-seeking. Limited specialist professional knowledge of diabetes by staff in primary and community care, alongside inadequate patient self-management knowledge, led to inappropriate treatment and significant delays. This was compounded by restricted provision of care, characterised by poor access to services - in time and proximity - and poor continuity of care. Complexities in patient engagement, help-seeking, and illness beliefs further complicated the progression to unscheduled admissions.

CONCLUSION

Dedicated investment in primary care is needed to enhance provision of and access to services. There should be increased promotion and earlier diabetes specialist team involvement, alongside training and use of technology and telemedicine, to enhance existing care.

Factors associated with engagement and adherence to a low-energy diet to promote 10% weight loss in patients with clinically significant non-alcoholic fatty liver disease

Objective

Clinical guidelines recommend weight loss to manage non-alcoholic fatty liver disease (NAFLD). However, the majority of patients find weight loss a significant challenge. We identified factors associated with engagement and adherence to a low-energy diet (LED) as a treatment option for NAFLD.

Design

23 patients with NAFLD enrolled in a LED (~800 kcal/day) were individually interviewed. Transcripts were thematically analysed.

Results

14/23 patients achieved ≥10% weight loss, 18/23 achieved ≥7% weight loss and 19/23 achieved ≥5% weight loss. Six themes were generated from the data. A desire to achieve rapid weight loss to improve liver health and prevent disease progression was the most salient facilitator to engagement. Early and significant weight loss, accountability to clinicians and regular appointments with personalised feedback were facilitators to engagement and adherence. The desire to receive positive reinforcement from a consultant was a frequently reported facilitator to adherence. Practical and emotional support from friends and family members was critically important outside of the clinical setting. Irregular working patterns preventing attendance at appointments was a barrier to adherence and completion of the intervention.

Conclusions

Engagement and adherence to a LED in patients with NAFLD were encouraged by early and rapid weight loss, personalised feedback and positive reinforcement in the clinical setting combined with ongoing support from friends and family members. Findings support those identified in patients who completed a LED to achieve type 2 diabetes remission and highlight the importance of behaviour change support during the early stages of a LED to promote adherence.

Effectiveness of smartphone application-based self-management interventions in patients with type 2 diabetes: A systematic review and meta-analysis of randomized controlled trials

AIMS

To synthesize evidences on smartphone application-based intervention and determine its effectiveness on glycaemic control, self-management behaviours, psychological well-being, quality of life and cardiometabolic risk factors.

DESIGN

A systematic review and meta-analysis of randomized controlled trials (RCTs).

DATA SOURCES

Major English and Chinese electronic databases were searched from January 2008 to January 2021, including PubMed, Web of Science, Embase, Cochrane Central Register of Controlled Trials, Google Scholar, China National Knowledge Infrastructure (CNKI), Wanfang and Sinomed.

REVIEW METHODS

RCTs were screened and selected if they used smartphone applications to support patients in the self-management of diabetes. Data extraction and methodological assessment were performed by two reviewers independently. Meta-analysis was performed to pool the intervention effect on outcomes of interest using RevMan 5.3.

RESULTS

Across 19 included trials involving 2585 participants, smartphone application-based interventions were associated with a clinically and statistically significant reduction of glycated haemoglobin (HbA1c). Beneficial effects were also observed in participants' behavioural performance, especially in medication adherence. Intervention effects on psychological status, quality of life and cardiometabolic risk factors were nonsignificant. Subgroup analysis showed interactive approach with medium frequency or flexible facilitator-patient interaction induced a larger effect on HbA1c reduction. Besides, patients with baseline HbA1c ≥9% benefited more than those with HbA1c <9% from the use of smartphone applications.

CONCLUSIONS

Smartphone application-based diabetes self-management intervention could optimize patients' glycaemic control and enhance participants' self-management performance. Further endeavour is required to examine the long-term effects and cost-effectiveness of smartphone application-based intervention before promoting the adoption and dissemination of such intervention.

IMPACT

This review supports the potential of smartphone application-based intervention as effective approach to optimize glycaemic control and promote self-management engagement among patients with type 2 diabetes. Suggestions for future research and practice are provided and discussed.

Testing patient-informed approaches for visually depicting the hemoglobin A1c value to patients with poorly controlled diabetes: a randomized, controlled trial

Background

Patients’ understanding of the hemoglobin A1c (HbA1c) has been linked to better diabetes care outcomes (glycemic control, self-care). This is concerning given low documented rates of HbA1c understanding. In this non-blinded, randomized trial, we compared two formats for communicating the HbA1c, selected based on input from people with diabetes, to standard presentation to assess their impact on participants’ glycemic control and diabetes-related perceptions.

Methods

To design the tested formats, we interviewed 25 patients with diabetes and reviewed a range of possible formats, including color-based scales and graphs. The interviews were recorded, transcribed, and subjected to thematic analysis. Synthesizing interviewees’ feedback, we selected two formats, one using a combination of words and colors (Words) and one using a color-coded graph (Graph), for further evaluation. We then randomized adults with poorly controlled diabetes to receive mailed information on their current diabetes control in one of three ways: 1) standard lab report (control), 2) Words format, or 3) Graph format. The primary outcome was HbA1c change at 6 months. Also examined were changes in participants’ diabetes-related perceptions and choice of participation incentive.

Results

Of the 234 enrolled participants, 76.9% were Black, and their median baseline HbA1c was 9.1% (interquartile range 8.4–10.4). There were no between-arm differences in HbA1c change (− 1.04% [SD 2.2] Control vs. -0.59% [SD 2.0] Words vs. -0.54% [SD 2.1] Graph, p > 0.05 for all comparisons). Participants in the Words arm had an increase in the accuracy of their perceptions of diabetes seriousness (p = 0.04) and in the number of participants reporting a diabetes management goal (p = 0.01).

Conclusions

The two patient-informed communication formats did not differentially impact glycemic control among adults with inadequately controlled diabetes. However, a significant proportion of participants in the Words arm had an increase in the accuracy of their perception of diabetes seriousness, a potential mediating factor in positive diabetes-related behavioral changes. With increasing use of patient-facing online portals, thoughtfully designed approaches for visually communicating essential, but poorly understood, information like the HbA1c to patients have the potential to facilitate interpretation and support self-management.

Clinical trial registration

Prospectively registered as NCT01886170.

Psychosocial Aspects of Diabetes Technology: Adult Perspective

The success of diabetes technologies depends on the attitudes and behavior of the individuals who choose to adopt them. Real-time continuous glucose monitoring, continuous subcutaneous insulin infusion, and sensor-augmented pump systems may positively affect diabetes-related quality of life (QOL), although the influence on QOL outcomes seems to be modest and the results from randomized controlled trials are limited and controversial. In contrast, more consistently positive QOL-related responses are apparent from observational data. The newer generations of devices hold the promise for more strongly enhancing diabetes-related QOL. Appropriate training and ongoing support are likely to be the key to successful uptake.

Tolerability and acceptability of real-time continuous glucose monitoring and its impact on diabetes management behaviours in individuals with Type 2 Diabetes - A pilot study

INTRODUCTION

Emerging evidence suggests us of real-time continuous glucose monitoring systems (RT-CGM), can assist to improve glucose control in Type 2 Diabetes (T2D) treatment, however the impact of these devices on patients' stress levels and behaviour is poorly understood. This study aimed to examine the effects of RT-CGM on tolerance and acceptability of device wear, stress and diabetes management and motivation to change.

METHODS

Twenty adults (10 men, 10 women) with T2D (aged 60.6 ± 8.4 years, BMI 34.2 ± 4.7 kg/m²), were randomised to a low-carbohydrate lifestyle plan whilst wearing a RT-CGM or an 'offline-blinded' (Blinded-CGM) monitoring system continuously for 12 weeks. Outcomes were glycaemic control (HbA1c), weight (kg) perceived stress scale (PSS), CGM device intolerance, acceptability, motivation to change and diabetes management behaviour questionnaires.

RESULTS

Both groups experienced significant reductions in body weight (RT-CGM -7.4 ± 4.5 kg vs. Blinded-CGM -5.5 ± 4.0 kg) and HbA1c (-0.67 ± 0.82% vs. -0.68 ± 0.74%). There were no differences between groups for perceived stress (P = 0.47) or device intolerance at week 6 or 12 (both P > 0.30). However, there was evidence of greater acceptance of CGM in the RT-CGM group at week 12 (P = 0.03), improved blood glucose monitoring behaviour in the RT-CGM group at week 6 and week 12 (P ≤ 0.01), and a significant time x group interaction (P = 0.03) demonstrating improved diabetes self-management behaviours in RT-CGM.

CONCLUSION

This study provides preliminary evidence of improved behaviours that accompany RT-CGM in the context of diabetes management and glucose self-monitoring. RT-CGM may provide an alternative approach to glucose management in individuals with T2D without resulting in increased disease distress.

Living with type 1 diabetes as experienced by young adults

AIM

Describe young adults` (19-30 years) experiences of living with Type 1 Diabetes (T1D).

BACKGROUND

Young adulthood is characterized by adaption to adult roles, gradual separation from parental support and leaving the parental home. Living with T1D in young adulthood raises challenges and concerns.

DESIGN

This study has a qualitative design.

METHODS

Semistructured interviews with 12 young adults living with T1D for 3-14 years, analysed with qualitative content analysis.

RESULTS

The analysis revealed contradictory ways of handling the illness, as is illuminated in two main categories (a) and five subcategories (b). Handling the situation and dealing with different opinions (a), (b) managing daily life, emotional roller coaster and general attitudes, own views and apprehensions, ignorance and lack of motivation. Most participants were motivated, had knowledge and were in control of their long-term illness. Planning and structure were an essential part of their daily life. The participants were anxious about losing control of their bodies, the situation, die or be a burden to other people.

Effect of ecological momentary assessment, goal-setting and personalized phone-calls on adherence to interval walking training using the InterWalk application among patients with type 2 diabetes-A pilot randomized controlled trial

OBJECTIVES

The objective was to investigate the feasibility and usability of electronic momentary assessment, goal-setting and personalized phone-calls on adherence to a 12-week self-conducted interval walking training (IWT) program, delivered by the InterWalk smartphone among patients with type 2 diabetes (T2D).

METHODS

In a two-arm pilot randomized controlled trial (Denmark, March 2014 to February 2015), patients with T2D (18-80 years with a Body Mass Index of 18 and 40 kg/m2) were randomly allocated to 12 weeks of IWT with (experimental) or without additional support (control). The primary outcome was the difference between groups in accumulated time of interval walking training across 12 weeks. All patients were encouraged to use the InterWalk application to perform IWT for ≥90 minute/week. Patients in the experimental group made individual goals regarding lifestyle change. Once a week inquiries about exercise adherence was made using an ecological momentary assessment (EMA). In case of consistent self-reported non-adherence, the patients would receive a phone-call inquiring about the reason for non-adherence. The control group did not receive additional support. Information about training adherence was assessed objectively. Usability of the EMA was assessed based on response rates and self-reported satisfaction after 12-weeks.

RESULTS

Thirty-seven patients with T2D (66 years, 65% female, hemoglobin 1Ac 50.3 mmol/mol) where included (n = 18 and n = 19 in experimental and control group, respectively). The retention rate was 83%. The experimental group accumulated [95%CI] 345 [-7, 698] minutes of IWT more than the control group. The response rate for the text-messages was 83% (68% for males and 90% for females). Forty-one percent of the experimental and 25% of the control group were very satisfied with their participation.

CONCLUSION

The combination inquiry about adherence using EMA, goal-setting with the possibility of follow-up phone calls are considered feasible interventions to attain training adherence when using the InterWalk app during a 12-week period in patients with T2D. Some uncertainty about the effect size of adherence remains.

TRIAL REGISTRATION

Clinicaltrials.gov NCT02089477.

Mobile Momentary Assessment and Biobehavioral Feedback for Adolescents with Type 1 Diabetes: Feasibility and Engagement Patterns

BACKGROUND

Integration of momentary contextual and psychosocial factors within self-management feedback may provide more specific, engaging, and personalized targets for problem solving.

METHODS

Forty-four youth ages 13-19 with type 1 diabetes (T1D) were provided a Bluetooth meter and completed the 30-day protocol. Participants were randomized to "app + meter" or "meter-only" groups. App + meter participants completed mealtime and bedtime assessment each day. Assessments focused on psychosocial and contextual information relevant for self-management. Graphical feedback integrated self-monitored blood glucose (SMBG), insulin, and Bluetooth-transmitted blood glucose data with the psychosocial and contextual data. App + meter participants completed an interview to identify data patterns.

RESULTS

The median number of momentary assessments per participant was 80.0 (range 32-120) with 2.60 per day. By 2 weeks participants had an average of 40.77 (SD 12.23) assessments. Dose-response analyses indicated that the number of app assessments submitted were significantly related to higher mean daily SMBG (r = -0.44, P < 0.05) and to lower% missed mealtime SMBG (r = -0.47, P < 0.01). Number of feedback viewing sessions was also significantly related to a lower% missed mealtime SMBG (r = -0.44, P < 0.05). Controlling for baseline variables, mixed-effects analyses did not indicate group × time differences in mean daily SMBG. Engagement analyses resulted in three trajectory groups distinguished by assessment frequencies and rates of decline. Engagement group membership was significantly related to gender, mean daily SMBG, and HbA1c values.

CONCLUSIONS

Momentary assessment combined with device data provided a feasible means to provide novel personalized biobehavioral feedback for adolescents with T1D. A 2-week protocol provided sufficient data for self-management problem identification. In addition to feedback, more intensive intervention may need to be integrated for those patients with the lowest self-management at baseline.

What interventions are used to improve exercise adherence in older people and what behavioural techniques are they based on? A systematic review

OBJECTIVES

To conduct a systematic review of interventions used to improve exercise adherence in older people, to assess the effectiveness of these interventions and to evaluate the behavioural change techniques underpinning them using the Behaviour Change Technique Taxonomy (BCTT).

DESIGN

Systematic review.

METHODS

A search was conducted on AMED, BNI, CINAHL, EMBASE, MEDLINE and PsychINFO databases. Randomised controlled trials that used an intervention to aid exercise adherence and an exercise adherence outcome for older people were included. Data were extracted with the use of a preprepared standardised form. Risk of bias was assessed with the Cochrane Collaboration's tool for assessing risk of bias. Interventions were classified according to the BCTT.

RESULTS

Eleven studies were included in the review. Risk of bias was moderate to high. Interventions were classified into the following categories: comparison of behaviour, feedback and monitoring, social support, natural consequences, identity and goals and planning. Four studies reported a positive adherence outcome following their intervention. Three of these interventions were categorised in the feedback and monitoring category. Four studies used behavioural approaches within their study. These were social learning theory, socioemotional selectivity theory, cognitive behavioural therapy and self-efficacy. Seven studies did not report a behavioural approach.

CONCLUSIONS

Interventions in the feedback and monitoring category showed positive outcomes, although there is insufficient evidence to recommend their use currently. There is need for better reporting, use and the development of theoretically derived interventions in the field of exercise adherence for older people. Robust measures of adherence, in order to adequately test these interventions would also be of use.

PROSPERO REGISTRATION NUMBER

CRD42015020884.

Effectiveness of remote feedback on physical activity in persons with type 2 diabetes: A systematic review and meta-analysis of randomized controlled trials

Objectives

The objective of this systematic review and meta-analysis was to examine the effectiveness of remote feedback intervention compared with standardized treatment on physical activity levels in persons with type 2 diabetes. Further, to investigate the influence of the length of intervention, number of contacts, study size, delivery of feedback, and preliminary face-to-face sessions.

Methods

A systematic literature search was conducted in May 2017, with a priori defined eligibility criteria: randomized controlled trials investigating remote feedback interventions in adult persons with type 2 diabetes, using physical activity as outcome. The effect size was calculated as standardized mean difference (SMD) and was pooled in a meta-analysis using a random-effects model. Meta-regression analyses were performed to examine if the observed effect size could be attributed to study- or intervention characteristics using these as covariates.

Results

The literature search identified 4455 articles of which 27 met the eligibility criteria. The meta-analysis including a total of 4215 participants found an overall effect size in favour of remote feedback interventions compared to standardized treatment, SMD = 0.33 (95% CI: 0.17 to 0.49), I2 = 81.7%). Analyses on study characteristics found that the effect on physical activity was only influenced by study size, with a larger effect in small studies.

Conclusion

Adding remote feedback to standardized treatments aimed at increasing physical activity in persons with type 2 diabetes showed a small to moderate additional increase in physical activity levels. Systematic review registration: PROSPERO CRD42016033479.

A Comprehensive Evaluation of a Novel Color Range Indicator in Multiple Blood Glucose Meters Demonstrates Improved Glucose Range Interpretation and Awareness in Subjects With Type 1 and Type 2 Diabetes

AIMS

We previously demonstrated that people with type 2 diabetes (T2DM) can improve their ability to categorize blood glucose (BG) results into low, in range, or high glycemic ranges after experiencing a color range indicator (CRI or ColorSure™ Technology) in a single meter. This study examined whether a CRI was effective in people with type 1 (T1) or T2DM when used in 3 glucose meters.

METHODS

A total of 179 subjects (139 T2DM and 40 T1DM) classified BG values as low, in range, or high based on individual current knowledge. Subjects then experienced the CRI which showed whether different BG values were low, in range, or high. After CRI interaction, subjects repeated the classification.

RESULTS

Following interaction with the CRI, subjects significantly improved their ability to categorize BG results into low, in range, and high glycemic ranges by 27.9% (T2DM) and 27.2% (T1DM) (each P < .001). Improvement was not accompanied by an increase in time spent categorizing results. There was no difference in classification ability between subjects with T1 or T2DM. There was also no correlation between HbA1c, numeracy level, test frequency, or duration of diabetes and the ability to correctly classify results. Subjects agreed the CRI feature helped them easily interpret glucose values and improved their awareness of glucose ranges.

CONCLUSION

Interaction with a CRI improved the ability of subjects with T1 and T2DM to interpret and categorize BG values into recommended glycemic ranges, irrespective of the glucose meter providing the CRI insights.