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Smartphone being used for the self-management of type 2 diabetes

NIHR Signal Smartphones may help people with diabetes manage their condition better

Published on 28 May 2019

doi: 10.3310/signal-000772

People with type 2 diabetes using smartphone apps or message services feel more confident about their ability to manage their condition, are more likely to engage in self-care activities and have a better quality of life.

Smartphone self-management technologies can be split into two main types: applications where users can record data and view information, and SMS text messages which can act as prompts or reminders. A review of 22 international studies found that smartphones could aid diabetes self-management, but also found wide variation in the results, types of apps used and ways that results were recorded. The underlying trials were rated as low quality.

While the technology seems to have a beneficial effect on diabetes control, reported in all studies, it would be useful to see more detailed information about which apps and message services are most helpful in supporting self-efficacy, and which translate into better control. They may vary widely in content and reliability.

Share your views on the research.

Why was this study needed?

An estimated 4.6 million people in the UK have diabetes (including people not yet diagnosed), and 90% of them have type 2 diabetes. That number doubled between 1998 and 2018. Managing this complex condition is likely to become ever more important for the NHS in years to come.

Self-management through diet, exercise and medication is an important part of diabetes care. Ensuring that people feel empowered to manage their condition and avoid complications is essential.

Any technology that encourages better self-management is likely to be of interest, but the impact of smartphone technology on diabetes self-efficacy, self-care and health-related quality of life has not previously been assessed in a systematic review. This study aimed to review the literature and conduct meta-analyses to assess the potential of smartphone technology on diabetes self-management.

What did this study do?

This systematic review found 26 reports of 22 randomised controlled trials with a total of 2,645 participants. It looked at studies published since smartphones became widely available as a product, from 2007 to 2018, that compared smartphone-based self-management intervention with a usual care control group.

The researchers carried out meta-analyses on reports of self-efficacy, self-care activities and health-related quality of life. They also looked at clinical outcomes, including glycated haemoglobin (HbA1c – a marker of blood glucose over three months), BMI and blood pressure.

Blinding of participants was not possible, which may have led to some overestimation of the self-reported outcomes, such as self-efficacy. However, HbA1c, as an objective measure of control, would be less affected by this risk of bias and so provides clearer evidence of an effect. The underlying trials were rated low quality. Larger, well-designed trials in the UK could refine this estimate for apps used here and be more relevant for the NHS.

What did it find?

  • Researchers found a large effect size in favour of smartphone interventions for measures of self-efficacy (Cohen’s d 0.98, 95% confidence interval [CI] 0.42 to 1.55; six studies, 682 participants) and self-care activities (Cohen’s d 0.90, 95% CI 0.24 to 1.57; three studies, 315 participants).
  • For health-related quality of life, researchers found a small effect size (Cohen’s d 0.26, 95% CI 0.06 to 0.47; three studies, 371 participants) in favour of smartphones, with little variation between studies.
  • The mean difference in HbA1c was -0.55 in favour of the smartphone interventions (95% CI ‑0.6 to ‑0.4; in 22 studies).
  • The researchers found no effect of smartphones on BMI or blood pressure (nine studies).

What does current guidance say on this issue?

NICE guidance from 2015 says adults with type 2 diabetes should be offered “structured education” about their condition. However, the guideline makes no mention of smartphones or other technological aids to education or self-management.

What are the implications?

The research shows that smartphone-based technology has potential to help people better manage their diabetes, but the studies so far are insufficient to recommend any particular technology.

Inconsistent reporting of self-care and self-efficacy outcomes, as well as lack of clarity about the exact nature of the interventions, suggest that more work needs to be done in the UK before smartphone technologies can be widely recommended for self-management here.

Citation and Funding

Aminuddin H B, Jiao N, Jiang Y, Hong J, Wang W. Effectiveness of smartphone-based self-management interventions on self-efficacy, self-care activities, health-related quality of life and clinical outcomes in patients with type 2 diabetes: a systematic review and meta-analysis
Int J Nurs Stud. 2019; Feb 8. doi: 10.1016/j.ijnurstu.2019.02.003. [E-pub ahead of print].

The study was funded by the Ministry of Education, Academic Research Fund Tier 1, in Singapore.

Bibliography

NICE. Type 2 diabetes in adults: management. NG28. London: National Institute for Health and Care Excellence; 2015.

Why was this study needed?

An estimated 4.6 million people in the UK have diabetes (including people not yet diagnosed), and 90% of them have type 2 diabetes. That number doubled between 1998 and 2018. Managing this complex condition is likely to become ever more important for the NHS in years to come.

Self-management through diet, exercise and medication is an important part of diabetes care. Ensuring that people feel empowered to manage their condition and avoid complications is essential.

Any technology that encourages better self-management is likely to be of interest, but the impact of smartphone technology on diabetes self-efficacy, self-care and health-related quality of life has not previously been assessed in a systematic review. This study aimed to review the literature and conduct meta-analyses to assess the potential of smartphone technology on diabetes self-management.

What did this study do?

This systematic review found 26 reports of 22 randomised controlled trials with a total of 2,645 participants. It looked at studies published since smartphones became widely available as a product, from 2007 to 2018, that compared smartphone-based self-management intervention with a usual care control group.

The researchers carried out meta-analyses on reports of self-efficacy, self-care activities and health-related quality of life. They also looked at clinical outcomes, including glycated haemoglobin (HbA1c – a marker of blood glucose over three months), BMI and blood pressure.

Blinding of participants was not possible, which may have led to some overestimation of the self-reported outcomes, such as self-efficacy. However, HbA1c, as an objective measure of control, would be less affected by this risk of bias and so provides clearer evidence of an effect. The underlying trials were rated low quality. Larger, well-designed trials in the UK could refine this estimate for apps used here and be more relevant for the NHS.

What did it find?

  • Researchers found a large effect size in favour of smartphone interventions for measures of self-efficacy (Cohen’s d 0.98, 95% confidence interval [CI] 0.42 to 1.55; six studies, 682 participants) and self-care activities (Cohen’s d 0.90, 95% CI 0.24 to 1.57; three studies, 315 participants).
  • For health-related quality of life, researchers found a small effect size (Cohen’s d 0.26, 95% CI 0.06 to 0.47; three studies, 371 participants) in favour of smartphones, with little variation between studies.
  • The mean difference in HbA1c was -0.55 in favour of the smartphone interventions (95% CI ‑0.6 to ‑0.4; in 22 studies).
  • The researchers found no effect of smartphones on BMI or blood pressure (nine studies).

What does current guidance say on this issue?

NICE guidance from 2015 says adults with type 2 diabetes should be offered “structured education” about their condition. However, the guideline makes no mention of smartphones or other technological aids to education or self-management.

What are the implications?

The research shows that smartphone-based technology has potential to help people better manage their diabetes, but the studies so far are insufficient to recommend any particular technology.

Inconsistent reporting of self-care and self-efficacy outcomes, as well as lack of clarity about the exact nature of the interventions, suggest that more work needs to be done in the UK before smartphone technologies can be widely recommended for self-management here.

Citation and Funding

Aminuddin H B, Jiao N, Jiang Y, Hong J, Wang W. Effectiveness of smartphone-based self-management interventions on self-efficacy, self-care activities, health-related quality of life and clinical outcomes in patients with type 2 diabetes: a systematic review and meta-analysis
Int J Nurs Stud. 2019; Feb 8. doi: 10.1016/j.ijnurstu.2019.02.003. [E-pub ahead of print].

The study was funded by the Ministry of Education, Academic Research Fund Tier 1, in Singapore.

Bibliography

NICE. Type 2 diabetes in adults: management. NG28. London: National Institute for Health and Care Excellence; 2015.

Effectiveness of smartphone-based self-management interventions on self-efficacy, self-care activities, health-related quality of life and clinical outcomes in patients with type 2 diabetes: A systematic review and meta-analysis

Published on 5 March 2019

Aminuddin, H. B.,Jiao, N.,Jiang, Y.,Hong, J.,Wang, W.

Int J Nurs Stud , 2019

OBJECTIVES: To review the evidence and determine the effectiveness of smartphone-based self-management interventions on self-efficacy, self-care activities, health-related quality of life, glycated hemoglobin, body mass index (BMI), and blood pressure (BP) levels of adults with type 2 diabetes mellitus . METHODS: A systematic search of five databases (PubMed, Embase, Cochrane, CINAHL and Scopus) was conducted. Studies published in English from January 2007 to January 2018 were considered. Only randomized controlled trials (RCTs) of smartphone-based self-management interventions for patients with type 2 diabetes mellitus that reported any of the study outcomes were included. Two reviewers independently screened the studies, extracted data and assessed the quality of the studies. Meta-analyses were conducted for the different study outcomes. RESULTS: A total of 26 articles, consisting of 22 studies with 2645 participants, were included in the review. The results from meta-analysis on the studies revealed that as compared to control group, participants received smartphone-based self-management intervention had better self-efficacy with large effect size of 0.98 (P < 0.001), self-care activities with effect size of 0.90 (P < 0.001), health related quality of life with effect size of 0.26 (p=0.01), and lower glycated hemoglobin (pooled MD=-0.55; p<0.001). Subgroup analyses were also conducted for self-efficacy as significant heterogeneity was present among the studies. The effects on BMI and BP were not statistically significant. CONCLUSIONS: Smartphone-based self-management interventions appear to have beneficial effects on self-efficacy, self-care activities and health-relevant outcomes for patients with type 2 diabetes mellitus. However, more research with good study design is needed to evaluate the effectiveness of smartphone-based self-care interventions for T2DM.

Expert commentary

Self-management education for people with type 2 diabetes is highly cost-effective and are recommended by most international guidelines, including NICE. However, uptake of these programmes has been low overall. To scale up these programmes, a number of technology-based programmes have been evaluated.

This systematic review and meta-analysis of smartphone-based self-management education found that the programmes improve self-efficacy, self-care activities, health-related quality of life and glycaemic control.

However, the studies varied greatly in terms of their quality and the interventions used. Unfortunately, there were no studies from the UK. Applicability of this systematic review is uncertain.

Kamlesh Khunti, Head of Department and Professor of Primary Care Diabetes and Vascular Medicine, Diabetes Research Centre, University of Leicester, Leicester General Hospital

The commentator is part of a group who developed the DESMOND Programme and the Let's Prevent Prevention of Diabetes Programme, and digital platforms for these programmes.