The Role of Technology and the Improvement of Compliance with Diabetes Mellitus

by Arica Jones BSN, RN (MSN student, Troy University)

Technology for Diabetes

Scholarly, peer-reviewed articles and studies published within the past five years were examined to determine the current state of technology for diabetes, as well as its effectiveness. The research found that the combination of modern technology and education has a profound effect on glycemic control and is very promising for improving the overall health of patients. Studies have heavily incorporated cell phone usage and mobile applications to enhance patient health by encouraging personal involvement in their care, which could ultimately lead to better patient outcomes.

Dobson, R., Carter, K., Cutfield, R., Hulme, A., Hulme, R., McNamara, C., Maddison, R., Murphy, R., Shepherd, M., Strydom, J., & Whittaker, R. (2015). Diabetes text message self-management support program (SMS4BG): A pilot study. JMIR Mhealth Uhealth, 3(1), 32. https://doi.org/10.2196/mhealth.3988

Dobson et al. conducted a non-randomized pilot study designed to implement a mobile health intervention to control glycemic issues among the population in Auckland, New Zealand. Forty-two consenting participants, with type 1 or type 2 diabetes, participated over a three-month period. The self-management support for blood glucose (SMS4BG) program was created to offer mobile health solutions for the complications of poor glycemic control. In this study, poorly controlled diabetes was defined as having a hemoglobin A1c of 8.6% or greater. Inclusion criteria included possessing a mobile phone, being ages 17-69, and being able to read English. The participants were referred from healthcare providers at primary healthcare practices, secondary care hospitals, and a community-based organization.

The study affirmed that mobile health would be beneficial to diabetes management due to the high percentage of the population that own a mobile device. The study consisted of modules that could be customized by the participant. They could receive anywhere from 30 text messages to 461 text messages during the study. The core module sent two text messages per month and covered topics such as diabetes education and stress management. Participants could also choose to receive additional information, such as smoking cessation tips and glucose check reminders. Thirty-four of the 42 participants opted into the glucose reminders, which ranged in frequency from once per week to four times per day. The glucose reminder messages allowed participants to reply with their blood glucose levels, which were then displayed on a graph for tracking over time.

Thirty-nine of the 42 subjects participated in the post-study follow-up. A telephone interview showed that 100% of participants felt the program was useful, and 97% stated they would recommend the program to others. The study resulted in an average improvement of hemoglobin A1c to 7.1%. Although this study consisted of a small sample size, it is still beneficial due to its patient satisfaction rating and overall patient outcome.

Garg, S. K., Shah, V. N., Akturk, H. K., Beatson, C., & Snell-Bergeon, J. K. (2017). Role of mobile technology to improve diabetes care in adults with type 1 diabetes: The remote-T1D study iBGStar® in type 1 diabetes management. Diabetes Therapy, 8(4), 811-819. https://doi.org/10.1007/s13300-017-0272-5

Garg et al. conducted a study to determine if mobile technology could lower the hemoglobin A1c in people with type 1 diabetes. The particular device that was used in this study was the iBGStar®, which is a blood glucose meter. This device is unique because it attaches to a smartphone and is able to report data directly to the physician. This device can also be used in conjunction with the Diabetes Manager app, which enables it to function as a personal glucometer. Garg et al. also assessed the fear of hypoglycemia before and after the study through a participant questionnaire.

The study was conducted over a six-month period as stratified block randomization that consisted of 100 participants who were divided into two groups: a control group and an intervention group. The control group was given an Accu-Chek Nano® meter, while the intervention group was provided with the iBGStar®, an iPhone, and the Diabetes Manager app. Additionally, all of the participants were provided with a Dexcom Seven Plus CGM sensor. All participants were educated on the use of their assigned device and glucose logbooks. They were instructed to check their blood glucose levels at least three times per day during this six-month period, and they were not allowed to use their own CGMs or take acetaminophen, as this would alter the analysis. The intervention group’s device was set up to send an alert to the patient’s provider if the blood glucose level was below 60 or above 300 at any time.

The Results of the Study

The results of the study were measured after three months and six months. Although both groups showed a decrease in their hemoglobin A1c, there was a substantial decrease among the intervention group at the six-month assessment. Garg et al. also reassessed the fear of hypoglycemia at the end of the study, but they saw no significant difference between the initial scores and the final ones. Over 85% of the participants in the intervention group were pleased with the iBGStar® apparatus. They found it to be more convenient and user friendly than traditional devices. This study shows how mobile technology can improve compliance among those with diabetes. A great deal of non compliance comes from not checking blood glucose levels. This study implemented routine checks of blood glucose levels, which made the participants more conscientious of their results. This, in turn, can promote the start of healthy behaviors.

Gunawardena, K. C., Jackson, R., Robinett, I., Dhaniska, L., Jayamanne, S., Kalpani, S., & Muthukuda, D. (2019). The influence of the smart glucose manager mobile application on diabetes management. Journal of Diabetes Science and Technology, 13(1), 75-81. https://doi.org/10.1177/1932296818804522

This randomized controlled study focused on the population of Sri Lanka and its prevalence of diabetes mellitus. The country has seen a 13% increase in cell phone usage among the population over the last five years. This prompted Gunawardena et al. to implement their innovative, technology-based study to determine if a smartphone app could positively impact those with diabetes. The focus of the smart glucose manager (SMG) app was to provide consistent feedback, which was believed to have a profound effect on lowering hemoglobin A1c. The features of the app included daily reminders to perform glucose checks, to administer insulin and other medications, to eat, and to exercise. The highlights of the app were the abilities for users to store blood glucose levels to be graphed over time and to receive feedback from medical professionals.

The study consisted of 67 participants between the ages of 18 and 80 years old with a hemoglobin A1c of 8.0% or higher who also possessed an Android phone. Exclusion criteria included those who were pregnant, on dialysis, had cognitive impairment, or with steroid-induced diabetes. All participants had their A1c and BMI checked after three months and six months. The control group consisted of 32 participants who were encouraged to continue their daily diabetes management routine. The intervention group comprised 35 individuals with access to the SMG app.

The study was deemed successful as both groups showed a significant decrease in A1c during the first three months. However, only the intervention group continued to show a reduction in A1c beyond that. This study is beneficial because it shows the positive effects of technology on the self-management of diabetes.

Hou, C., Carter, B., Hewitt, J., Francisa, T., & Mayor, S. (2016). Do mobile phone applications improve glycemic control (HbA1c) in the self-management of diabetes? A systematic review, meta-analysis, and GRADE of 14 randomized trials. Diabetes Care, 39(11), 2089-2095. https://doi.org/10.2337/dc16-0346

The Purpose of the Study

The purpose of this study was to determine if smartphone applications could successfully lower and control hemoglobin A1c and improve the self-management of diabetes. Hou et al. reviewed 14 previous studies that included 1,360 total participants. The 14 studies were selected from five databases using the keywords cellphones, mobile applications, and diabetes mellitus. The search was narrowed further to only include those studies whose participants were over the age of 18, had type 1 or type 2 diabetes, and did not already use an app for diabetes management. Four of the studies comprised 509 individuals and examined type 1 diabetes, while the remainder focused on type 2 diabetes in 851 people. A total of 12 apps were reviewed in the study: three of which were used for type 1 diabetes, and nine were used for type 2 diabetes. The apps for type 1 diabetes were geared toward the calculation of insulin based upon blood glucose levels, while the apps for type 2 diabetes centered on the self-management of blood glucose levels and providing feedback on the self-monitored data. Although there was little to no difference in the A1c among the participants with type 1 diabetes, there was significant success in reducing the A1c levels of the individuals with type 2 diabetes.

Despite the study’s limitations, it still demonstrated that technology can effectively control glycemic levels and hemoglobin A1c. Further research is needed to determine the full impact of technology, but the results provide much hope for the future of diabetes management.

Miremberg, H., Ben-Ari, T., Betzer, T., Raphaeli, H., Gasnier, R., Barda, G., Bar, J., & Weiner, E. (2018). The impact of a daily smartphone-based feedback system among women with gestational diabetes on compliance, glycemic control, satisfaction, and pregnancy outcome: A randomized controlled trial. American Journal of Obstetrics and Gynecology, 218(4), 453. https://doi.org/10.1016/j.ajog.2018.01.044

This study was implemented to determine if a daily smartphone-based feedback system could help control glycemic levels and improve patient compliance among pregnant women with gestational diabetes. The population of the study consisted of 120 participants divided into two groups: the control group attended a bi-weekly clinic visit, and the intervention group had an app installed on their smartphone. During the initial visit, the participants were educated by a nutritionist and a dietician on the proper dietary approaches for their condition, and they were also shown how to use a glucometer. They were instructed to check their blood glucose levels four times per day. An exercise regimen was also established to aid in the improvement of blood glucose levels. Other pregnancy routines were followed, such as blood pressure monitoring, urinalyses, and non-stress tests. All of the participants received the same care, with the exception of the smartphone app for those individuals in the intervention group.

This app allowed the participants to log their daily blood glucose levels and receive daily feedback on these readings. They were able to communicate with providers within the app for dietary suggestions and to make provisions for insulin therapy. At the last prenatal visit, participants were given a questionnaire to determine their satisfaction with the smartphone app. The intervention group showed increased compliance, lower blood glucose levels, and lower insulin therapy use than the control group.

This study proves that the incorporation of technology can help improve compliance among patients with diabetes. Although this study focused on pregnant women with gestational diabetes, the intervention can be applied to non-pregnant patients with type 1 and type 2 diabetes as well. The main concern making an app like this affordable for the consumer.

Conclusion

Although DM continues to be a daunting disease, astronomical advances for its management have been made since its discovery. Technology is constantly evolving and improving, but continued efforts must be made to reduce the costs of monitoring equipment and medications. This disease is only partly to blame for the current health condition of our population. As healthcare workers, we are responsible for staying up to date with current technology and research so that we can provide better care for our patients and enable them to have a healthy future. Understanding the inconveniences patients suffering from DM face in their daily maintenance routines, applying technological applications to mitigate those factors, and working with researchers and developers to reduce out-of-pocket expenses for patients are the best ways to encourage DM compliance and achieve positive patient outcomes.