Augmenting Diabetes Care & Self-Management: What can digital health offer?

Abstract

Background: The main recommendations for people living with diabetes are: optimally adhere to glucose lowering medications, frequently monitor their blood glucose levels, regularly engage in physical activity, and avoid the consumption of an unhealthy diet. Suboptimal adherence to these recommendations is associated with experiencing poor glycemic control which results in micro- and macro-vascular complications, poor quality of life, and a higher risk of premature death. Therefore, patients with diabetes require an evidence-based medical treatment coupled with effective self-management interventions to maintain a healthy lifestyle and increase disease management capability. Digital health has a strong potential to improve patient outcomes by facilitating diabetes self-management education and personalizing clinical, behavioral, and self-management goals. This dissertation discusses the role of digital health for improving diabetes self-management and outcomes. More broadly, the main aspects of digital health solutions and what it may offer to healthcare and public health, in general, are also discussed. Methods: A systematic review and meta-analysis was conducted to determine the effectiveness of digital interventions for improving glycemic control in persons with poorly controlled type 2 diabetes. Multivariable meta-regression was also used to identify the effective components of digital interventions. Three meta-analytic methods, namely, Analysis of Covariance (ANCOVA), Simple Analysis of Change Scores (SACS) and Simple Analysis of Final Values (SAFV) were used to compare the effectiveness of digital interventions. In addition, two empirical studies were conducted to identify popular diabetes application (apps) and investigate the role of diabetes mobile app use for glycemic control and self-care behavior among the digital community of persons with diabetes. Facebook groups, targeted Facebook advertisements (ads) and diabetes-specific patient forums were used to collect data from 1682 respondents. Results: A statistically significant reduction of glycated haemoglobin (HbA1c) levels favoring participants of digital interventions was found after pooling the effect estimates. This was confirmed by all of the three different meta-analytic methods although there was a slight difference in the estimates and their confidence intervals. Higher baseline HbA1c-levels and Behavior Change Techniques (BCTs), such as ‘problem solving’ and ‘self-monitoring outcomes of behaviour’, were significantly associated with reduced HbA1c-level. More than half of the respondents with type 1 (n=549, 52.2%) and more than one-third of those with type 2 diabetes (n=210, 33.3%) reported using diabetes apps for self-management. One hundred forty-five different diabetes apps were reported by respondents. Of these apps, “mySugr” was the most popular app. Continuous glucose monitor (CGM) apps, such as “Dexcom”, “Freestyle Libre”, and “Xdrip+”, were also popular, particularly among respondents with type 1 diabetes. The use of diabetes apps for self-management was associated with reduced the odds of experiencing hyperglycaemia in persons with type 2 diabetes (by 37%, AOR = 0.63(95% confidence interval (CI): 0.41 - 0.96)). In both persons with type 1 and type 2 diabetes, the use of diabetes apps for self-management was also independently associated with an increased cumulative self-care behavior scores. Conclusions: The results of this dissertation indicate that digital health augments diabetes self-management and is associated with improving clinical (HbA1c, hyperglycaemia and hypoglycaemia) and behavioral (self-care behavior) outcomes. Hence, it looks reasonable to endorse the use of diabetes apps for self-management. However, to date, many of these apps are faulty and only a small minority of them meets clinical recommendations for diabetes care. Clinicians should therefore consider prescribing evidence-based and regulatory body-approved diabetes apps. National and international regulatory bodies need to further regulate diabetes apps and ensure clinical safety and effectiveness.