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Man receiving text messages for self management of diabetes

NIHR Signal Text messages improve diabetes self-management and blood sugar control

Published on 4 September 2018

doi: 10.3310/signal-000640

In adults with poorly controlled diabetes, text messages offering advice and support can improve self-management and blood sugar control.

This trial included 366 adults with type 1 or type 2 diabetes in New Zealand. An automated system delivered individually tailored text messages to participants over a nine-month period to support self-management of blood sugar. The control group received usual care, comparable to that in the UK.

The text message group had a small reduction in blood sugar levels. Although the levels remained above target levels in both groups, the reduction is still likely to help reduce complications. The text message service was well-received by participants with almost all willing to recommend the intervention to others. However, the costs of the intervention were not reported.

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Why was this study needed?

There are 3.8 million people in the UK with diabetes. About 90% of these have type 2 diabetes. It is estimated that the cost of diabetes and its complications to the NHS is £9.8 billion per year. Good blood glucose control can help prevent complications and is central to the management of diabetes. This is measured by a blood test called HbA1c which indicates the average blood glucose over the previous two or three months. For people with diabetes, the target HbA1c is usually below 48mmol/mol.

There is growing interest in the use of tools such as mobile phones in the self-management of diabetes to prevent complications. This randomised controlled trial examined the effectiveness of a text message-based intervention designed to support people in self-management of their diabetes.

What did this study do?

The SMS4BG (self-management support for blood glucose) trial randomised 366 adults with poorly controlled type 1 or type 2 diabetes (HbA1c 65mmol/mol or more) to receive either text messages in addition to usual care or usual care alone. The texts were individually tailored to motivate participants to engage in behaviours relating to diabetes management.

The text messages were sent from an automated management system. The participants could choose the frequency and content of the messages. The system also enabled them to submit their blood glucose readings and monitor these over time through graphs.

This trial included a high proportion of ethnic minorities and took place in New Zealand, which may limit applicability to the UK. One funder of this study was involved in the development of the texting service which may introduce bias in favour of the intervention.

What did it find?

At nine months, compared with baseline:

  • HbA1c had reduced by more in the group receiving text message support than in the control group (adjusted mean difference −4.2mmol/mol, 95% confidence interval −7.3 to −1.2).
  • The average HbA1c levels in both groups remained higher than the target. The intervention group HbA1c reduced from 86 to 78mmol/mol. The control group HbA1c reduced from 83 to 79mmol/mol.
  • A decrease in HbA1c was observed in 75% of intervention participants compared with 59% of control participants.
  • Of 21 secondary outcomes that were assessed, improvements were seen in four: frequency of foot care, perceived overall diabetes support, self-reported health status, and how often people perceive they have symptoms related to diabetes.
  • Participants reported high levels of satisfaction with the text messaging program with 95% identifying it as being useful and 97% willing to recommend it to others.

What does current guidance say on this issue?

NICE guidelines for management of type 1 and type 2 diabetes recommend the monitoring of HbA1c at three to six-month intervals. Adults with either type of diabetes are usually advised to aim for a target HbA1c of 48mmol/mol (6.5%) or lower. Adults with type 2 diabetes on medication that can cause low blood sugar (hypoglycaemia) should aim for 53mmol/mol.

Structured education programmes are recommended in both type 1 and 2 diabetes focusing on diet, lifestyle, and adherence to drug treatment. However, the guidelines do not specify how the education is best delivered or the role of mobile technology.

What are the implications?

Text message support appears to be a safe, well received, and modestly effective adjunct to standard care for patients with poorly controlled diabetes. However, the HbA1c 4.2mmol/mol difference between the groups was small and did not reach the pre-set 5.5mmol/mol clinically meaningful difference by the researchers. Nevertheless, any improvement is likely to help reduce the risk of complications.

There is increasing interest and investment in UK programmes applying mobile technology to the prevention and management of diabetes and other chronic diseases.

Uncertainties remain around the long-term benefits of such interventions, their cost-effectiveness, their use in overcoming health care inequalities, and the optimal content and frequency of their messages. 

Citation and Funding

Dobson R, Whittaker R, Jiang Y, et al. Effectiveness of text message based, diabetes self-management support programme (SMS4BG): two arm, parallel randomised controlled trial. BMJ. 2018;361:k1959. 

Development of the SMS4BG was funded by Waitemata District Health Board. The trial was funded by the Health Research Council of New Zealand in partnership with the Waitemata District Health Board and Auckland District Health Board. This was associated with the Research Partnerships for New Zealand Health Delivery initiative.  Funding was also provided by the New Zealand Ministry of Health. The funding agencies were not involved with the analysis of study results or in the writing of the manuscript.

Bibliography

Diabetes UK. The cost of diabetes. London: Diabetes UK; 2014.

NHS website. Diabetes. London: Department of Health; reviewed 2016.

NICE. Type 2 diabetes in adults: management. NG28. London: National Institute for Health and Care Excellence; 2016.

NICE. Type 1 diabetes in adults: diagnosis and management. NG17. London: National Institute for Health and Care Excellence; 2015.

Why was this study needed?

There are 3.8 million people in the UK with diabetes. About 90% of these have type 2 diabetes. It is estimated that the cost of diabetes and its complications to the NHS is £9.8 billion per year. Good blood glucose control can help prevent complications and is central to the management of diabetes. This is measured by a blood test called HbA1c which indicates the average blood glucose over the previous two or three months. For people with diabetes, the target HbA1c is usually below 48mmol/mol.

There is growing interest in the use of tools such as mobile phones in the self-management of diabetes to prevent complications. This randomised controlled trial examined the effectiveness of a text message-based intervention designed to support people in self-management of their diabetes.

What did this study do?

The SMS4BG (self-management support for blood glucose) trial randomised 366 adults with poorly controlled type 1 or type 2 diabetes (HbA1c 65mmol/mol or more) to receive either text messages in addition to usual care or usual care alone. The texts were individually tailored to motivate participants to engage in behaviours relating to diabetes management.

The text messages were sent from an automated management system. The participants could choose the frequency and content of the messages. The system also enabled them to submit their blood glucose readings and monitor these over time through graphs.

This trial included a high proportion of ethnic minorities and took place in New Zealand, which may limit applicability to the UK. One funder of this study was involved in the development of the texting service which may introduce bias in favour of the intervention.

What did it find?

At nine months, compared with baseline:

  • HbA1c had reduced by more in the group receiving text message support than in the control group (adjusted mean difference −4.2mmol/mol, 95% confidence interval −7.3 to −1.2).
  • The average HbA1c levels in both groups remained higher than the target. The intervention group HbA1c reduced from 86 to 78mmol/mol. The control group HbA1c reduced from 83 to 79mmol/mol.
  • A decrease in HbA1c was observed in 75% of intervention participants compared with 59% of control participants.
  • Of 21 secondary outcomes that were assessed, improvements were seen in four: frequency of foot care, perceived overall diabetes support, self-reported health status, and how often people perceive they have symptoms related to diabetes.
  • Participants reported high levels of satisfaction with the text messaging program with 95% identifying it as being useful and 97% willing to recommend it to others.

What does current guidance say on this issue?

NICE guidelines for management of type 1 and type 2 diabetes recommend the monitoring of HbA1c at three to six-month intervals. Adults with either type of diabetes are usually advised to aim for a target HbA1c of 48mmol/mol (6.5%) or lower. Adults with type 2 diabetes on medication that can cause low blood sugar (hypoglycaemia) should aim for 53mmol/mol.

Structured education programmes are recommended in both type 1 and 2 diabetes focusing on diet, lifestyle, and adherence to drug treatment. However, the guidelines do not specify how the education is best delivered or the role of mobile technology.

What are the implications?

Text message support appears to be a safe, well received, and modestly effective adjunct to standard care for patients with poorly controlled diabetes. However, the HbA1c 4.2mmol/mol difference between the groups was small and did not reach the pre-set 5.5mmol/mol clinically meaningful difference by the researchers. Nevertheless, any improvement is likely to help reduce the risk of complications.

There is increasing interest and investment in UK programmes applying mobile technology to the prevention and management of diabetes and other chronic diseases.

Uncertainties remain around the long-term benefits of such interventions, their cost-effectiveness, their use in overcoming health care inequalities, and the optimal content and frequency of their messages. 

Citation and Funding

Dobson R, Whittaker R, Jiang Y, et al. Effectiveness of text message based, diabetes self-management support programme (SMS4BG): two arm, parallel randomised controlled trial. BMJ. 2018;361:k1959. 

Development of the SMS4BG was funded by Waitemata District Health Board. The trial was funded by the Health Research Council of New Zealand in partnership with the Waitemata District Health Board and Auckland District Health Board. This was associated with the Research Partnerships for New Zealand Health Delivery initiative.  Funding was also provided by the New Zealand Ministry of Health. The funding agencies were not involved with the analysis of study results or in the writing of the manuscript.

Bibliography

Diabetes UK. The cost of diabetes. London: Diabetes UK; 2014.

NHS website. Diabetes. London: Department of Health; reviewed 2016.

NICE. Type 2 diabetes in adults: management. NG28. London: National Institute for Health and Care Excellence; 2016.

NICE. Type 1 diabetes in adults: diagnosis and management. NG17. London: National Institute for Health and Care Excellence; 2015.

Effectiveness of text message based, diabetes self management support programme (SMS4BG): two arm, parallel randomised controlled trial

Published on 19 May 2018

Dobson, R.,Whittaker, R.,Jiang, Y.,Maddison, R.,Shepherd, M.,McNamara, C.,Cutfield, R.,Khanolkar, M.,Murphy, R.

Bmj Volume 361 , 2018

OBJECTIVE: To determine the effectiveness of a theoretically based and individually tailored, text message based, diabetes self management support intervention (SMS4BG) in adults with poorly controlled diabetes. DESIGN: Nine month, two arm, parallel randomised controlled trial. SETTING: Primary and secondary healthcare services in New Zealand. PARTICIPANTS: 366 participants aged 16 years and over with poorly controlled type 1 or type 2 diabetes (HbA1c >/=65 mmol/mol or 8%) randomised between June 2015 and November 2016 (n=183 intervention, n=183 control). INTERVENTIONS: The intervention group received a tailored package of text messages for up to nine months in addition to usual care. Text messages provided information, support, motivation, and reminders related to diabetes self management and lifestyle behaviours. The control group received usual care. Messages were delivered by a specifically designed automated content management system. MAIN OUTCOME MEASURES: Primary outcome measure was change in glycaemic control (HbA1c) from baseline to nine months. Secondary outcomes included change in HbA1c at three and six months, and self efficacy, diabetes self care behaviours, diabetes distress, perceptions and beliefs about diabetes, health related quality of life, perceived support for diabetes management, and intervention engagement and satisfaction at nine months. Regression models adjusted for baseline outcome, health district category, diabetes type, and ethnicity. RESULTS: The reduction in HbA1c at nine months was significantly greater in the intervention group (mean -8.85 mmol/mol (standard deviation 14.84)) than in the control group (-3.96 mmol/mol (17.02); adjusted mean difference -4.23 (95% confidence interval -7.30 to -1.15), P=0.007). Of 21 secondary outcomes, only four showed statistically significant improvements in favour of the intervention group at nine months. Significant improvements were seen for foot care behaviour (adjusted mean difference 0.85 (95% confidence interval 0.40 to 1.29), P<0.001), overall diabetes support (0.26 (0.03 to 0.50), P=0.03), health status on the EQ-5D visual analogue scale (4.38 (0.44 to 8.33), P=0.03), and perceptions of illness identity (-0.54 (-1.04 to -0.03), P=0.04). High levels of satisfaction with SMS4BG were found, with 161 (95%) of 169 participants reporting it to be useful, and 164 (97%) willing to recommend the programme to other people with diabetes. CONCLUSION: A tailored, text message based, self management support programme resulted in modest improvements in glycaemic control in adults with poorly controlled diabetes. Although the clinical significance of these results is unclear, the findings support further investigation into the use of SMS4BG and other text message based support for this patient population. TRIAL REGISTRATION: Australian New Zealand Clinical Trials Registry ACTRN12614001232628.

Expert commentary

Technology is being used more and more by people with diabetes. Previous research shows that text messaging can help bring glucose levels into the target range and this study’s results are broadly consistent with earlier studies.

So what insights does this study bring? It is a large study including a diverse group of people with diabetes. The researchers struggled to recruit to this study, perhaps reflecting the rapid advances in technologies, which are moving on faster than trials can be conducted. Nevertheless, as New Zealand has a similar healthcare service to the UK with similar challenges in managing diabetes, the findings are relevant to people with diabetes and healthcare professionals in the UK.

Richard IG Holt, Professor in Diabetes and Endocrinology, University of Southampton