Teaching diabetes self-management ‘basic survival skills'

Diabetes self-management education is cost-efficient and can improve A1c levels “far greater” than the effect required to approve a new drug for the disease. Smartphones, health coaches and educators are part of the new paradigm to help patients.

There's a cost-efficient, effective treatment for diabetes that is significantly underused in the United States today, both in and outside of the hospital.

“We know that it can dramatically improve hemoglobin A1c. In fact, the reduction shown in meta-analysis is far greater than what's required to approve a drug by the FDA,” endocrinologist and ACP Member Robert Gabbay, MD, PhD, told attendees at the American Diabetes Association (ADA) annual meeting, held in Philadelphia in June.

Photo by Stockbyte
Photo by Stockbyte

Dr. Gabbay, who is director of the Penn State Hershey Diabetes Institute in Pennsylvania, was talking about diabetes self-management education, an intervention that can range from the basics of how to test blood sugar to assistance with reshaping a whole diet and lifestyle.

Teaching diabetes on the phone

A room, a desk, a book—these are the typical tools of education. But the latest in diabetes self-management education requires none of these accoutrements.

“Cell phones are emerging as a fantastic platform for personal health and wellness applications,” Lena Mamykina, PhD, assistant professor of biomedical informatics at Columbia University in New York, told American Diabetes Association meeting attendees.

To help manage diabetes, today's smartphones can keep records (of blood glucose measurements or food consumed, for example) input by the patient, or even track data on their own, such as sensing movement when a person is exercising. They can also provide social support and communication.

The last of these was the focus of a recent study led by Dr. Mamykina. A group of diabetic patients under age 65 were enrolled in in-person diabetes education classes and given smartphones. Using the phones, they were encouraged to send data frequently to a diabetes educator, including blood glucose results (measured and transmitted via a Bluetooth attachment) and meals (photographed or described in e-mail or voice notes).

The educator remotely provided advice to the patients, on what might be a good choice for breakfast, for example, and answered specific questions. After five months, the researchers compared the smartphone patients to a group that had received only the diabetes education classes.

The smartphone group was significantly more likely to think that diabetes was theirs to control (as opposed to having an external locus of control). “When they had a chance to very clearly see how their behaviors impact their glucose readings, it put them more in a position of asserting themselves and taking responsibility,” said Dr. Mamykina. “Interestingly, the quality of life [for those patients] went down...The fact that you are in charge of your health is not always a very positive discovery.”

More positively, researchers also discovered that the interactions between patients and educators fit into a pattern of problem-solving and coaching. Much of this work could potentially be handled by an automated system instead of a trained educator, Dr. Mamykina hypothesized. “What we're hoping to do is replicate the same process just with our application, without an educator,” she said. A trial of this “mobile diabetes detective” will begin next year.

However, some of the study's participants might not be comfortable with such a system. Although no one over 65 was included in the study, some still reported discomfort with the provided smartphone. “I was really afraid I would break something,” one patient said.

Such patients might be better suited to a lower-tech program such as that instituted by the University of California, San Francisco (UCSF). Researchers there developed a program for mostly non-English-speaking patients of several safety net clinics who had poorly controlled diabetes. Patients didn't even have to have a cell phone to participate; a landline would do.

“You receive a weekly call which has some automated questions,” explained Margaret Handley, PhD, MPH, an associate professor of epidemiology and biostatistics at UCSF. “It'll ask you questions like, ‘How many days in the last seven days have you checked your blood sugar?’”

Based on patients' responses, the phone system might play a prerecorded narrative in their native languages. “Something like ‘Your problem sounds like what Mrs. Jones was experiencing when she forgets to take her diabetes medicines. She came up with a strategy to help her remember’ and we give an example. We worked a lot with patients to come up with those narratives,” said Dr. Handley.

If a patient's responses are significantly out of line with her goals (for example, missing doses on three or more days), a health coach would call the patient within 24 hours. “The [health coach's] discussion really focused on action plans and motivational interviewing and a lot of times didn't really even address that particular trigger directly. Most patients had several triggers and the conversation might flow to what were the challenges in that week,” Dr. Handley said.

The program resulted in improved satisfaction, communication, functional status and even exercise among the involved patients, as well as other benefits. “We came across a lot of potential adverse events, particularly among patient who didn't have good English skills,” she said. The health coaches noticed misunderstandings of medication regimens, for example.

The program was also found to be so cost-effective that the local Medicaid provider adopted it. Most of the participants in that follow-up program spoke Spanish or C